Jaundice resident survival guide

Jaundice Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Synonyms and keywords:

Overview

The classic definition of Jaundice is a serum bilirubin level higher than 2.5 to 3 mg per dL (42.8 to 51.3 μper L) in conjunction with a clinical picture of yellow skin and sclera. Bilirubin metabolism takes place in three phases; "prehepatic", "intrahepatic", and "posthepatic". The causes of jaundice can be classified under these categories by measuring total bilirubin and its conjugated and unconjugated levels determine where is the dysfunction of bilirubin metabolism.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Ascending cholangitis
• Life threatening cause 2
• Life threatening cause 3

Common Causes

of acute Jaundice[2]

• Gilbert syndrome
• Alcoholic hepatitis
• Viral hepatitis
• Obstructive Jaundice due to Choledocholithiasis or Malignancy
• Decompensated chronic liver disease

of chronic progressive Jaundice

• Cirrhosis
• Pancreatic cancer

Diagnosis

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Characterize the jaundice duration and frequency ❑ Duration: short versus long ❑ Frequency: episodic vesus constant

Ask about assoaciated symptoms ❑ Abdominal pain (episodic or constant) ❑ Abdominal distension ❑ Fever ❑ Clay colored stool ❑ Dark urine ❑ Weight gain or loss ❑ Anorexia ❑ Dyspepsia ❑ Arthralgia ❑ Myalgia ❑ Back pain ❑ Rash ❑ Confusion

Inquire about ❑ Past medical history ❑ Blood disorder ❑ Liver diseases ❑ biliary diseases ❑ Pancreatic disease ❑ Cardiac disease ❑ Infectious disease ❑ HIV ❑ Malaria ❑ Etc ❑ Family history of ❑ Hemolytic anemias ❑ Congenital hyperbilirubinemia ❑ Wilson disease ❑ Medication history ❑ Parentral exposure ❑ Blood transfusion ❑ Iv drug abuse ❑ Recent travel history ❑ Social history ❑ Excess alcohol intake ❑ Sexual history

Examine the patient General Appearance ❑ Check for: ❑ Pale skin (hemolysis/cancer/cirrhosis) ❑ Gross weight loss (cancer/severe malabsorption) ❑ Fetor hepaticus ❑ Flapping tremor (impending hepatic coma) Skin exam ❑ Check for: ❑ Scratch marks ❑ Melanin pigmentation ❑ Xanthoma of eyelids (chronic cholestasis) ❑ Signs of liver disease: spider nevi, palmar erythema ❑ Bruising, purpuric spots, clotting defects due to thrombocytopenia of cirrhosis Cariac exam ❑ Check JVP (right sided heart failure) full abdominal exam ❑ Size and consistency of liver and spleen ❑ A grossly enlarged nodular liver or an obvious abdominal mass suggests malignancy ❑ Small liver can be seen in (severe hepatitis/cirrhosis) ❑ An enlarged tender liver could be due to: ❑ Viral hepatitis ❑ Alcoholic hepatitis ❑ An infiltrative process such as amyloidosis ❑ Acutely congested liver secondary to right-sided heart failure) ❑ Check gall bladder area if it is tender ❑ Positive murphy sign due to choledocholithiasis ❑ Palpable, visibly enlarged GB can be due to pancreatic ca ❑ Splenomegaly can be seen in hemolytic states, Hodgkin’s lymphoma, portal hypertension ❑ Ascites due to cirrhosis/abdominal malignancy caput medosa Extremity examination ❑ Ankle edema due to: ❑ cirrhosis ❑ IVC obstruction due to hepatic or pancreatic malignancy

Order ❑ Blood tests ❑ CBC ❑ Total Bilirubin ❑ Conjugated or unconjugated bilirubin ❑ Metabolic panel ❑ LFT ❑ INR ❑ Urine ❑ Bilirubin ❑ Urobilinogen

Isolated unconjugated hyperbilirubinemia

Isolated conjugated hyperbilirubinemia

Unconjugated & conjugated hyperbilirubinemia

❑Inquire about Any recent trauma hematoma blood transfusion

❑Dubin-Johnson syndrome ❑Rotor syndrome

With Liver enzyme changes

with ↑ INR,↓ Alb,↓ PLt

If none of them

If ⇈AST/ALT out of proportion to ALK-P

If ⇈Alk-P out of proportion to AST/ALT

Suggestive of Cirrhosis Additional tests Hepatitis serology Iron panel Abdominal Ultrasound Workup for Automimmune hepatitis, NAFLD,Hemochromatosis & other causes of cirrhosis

❑Check Hb,LDH,Haptoglobin,Rectic count

Hepatocellular pattern

Cholestatic pattern

Abnormal

Normal

Additional work-up for specific diseases Viral hepatitis serology(e.g. HAV,HBV,HCV) Toxicology screen Acetaminophen level Cereuloplasmin if patient<40 years of age Autoantibodies(ANA,Anti-sm,LKM,...) Ferritin & TIBC HbA1c Pregnancy test a1-antitrypsin ❑Consider work-up for rare cases Liver biopsy if results negative

Ultrasound

Start workup of hemolytic anemia with blood smear & coombs

❑ Gilbert syndrome ❑ Crigler-Najjar syndrome

Consider following based on the results: ❑ Viral hepatitis ❑ NAFLD(Non-alcoholic liver disease) ❑ Alcoholic liver disease ❑ Metabolic/genetic diseases Hereditary hemochromatosis Wilson's disease Alpha-1 antitrypsin deficiency ❑ Drug-induced and supplemental-induced injury Acetaminophen,kavakava ❑ Pregnancy AFLP,HELLP ❑ Autoimmune hepatitis

Bile ducts dialted

Bile ducts not dilated

❑ Sickle cell disease ❑ Hereditary spherocytosis ❑G6PD deficiency ❑ Medications effect ❑ Immune-mediated hemolysis

CT ERCP

Additional test for Intrahepatic cholestasis Hepatitis serology Autoantibodies for autoimmune hepatitis Review drugs MRCP/Liver biopsy

❑ CBD stones Biliray stricture Worms/flukes Cholangiocarcinoma

Extrahepatic sources: Pancreatic cancer

Consider following based on the results: Primary biliary cirrhosis PSC Drugs TPN Sepsis Infiltrative diseases: Sarcoidosis Amyloidosis Malignancy

Treatment

Based on the liver function tests and CBC,patients with Jaundice will typically fall into one of 3 categories.

Jaundice

Managment of isolated unconjugated hyperbilirubinemia If no eveidence of hemolytic anemia consider Gilbert syndrome OR Crigler-Najjar type I, II  Work-up and detect the cause of hemolysis, if low Hb,High LDH,Low haptoglobulin, and reticulocytes present  G6PD deficiency - mostly recover on its own,if progresses to hemolytic anaemia, oxygen therapy or blood transfusion may be required.Avoid of precipitants and etiological factors  Spherocytosis ,phototherapy and/or exchange transfusion for infants, Folic acid for maaintaing erythropoiesis.Splenectomy is the definitive treatment  Sickle cell anemia reduce pain and prevent complications, blood transfusions and supplemental oxygen, as well as a bone marrow transplant.  Immune related hemolysis – corticosteroids, folic acid is main line of treatment  Parasitic Infections like malaria are treated with antimalarial drugs like chloroquine, artesunate, lumefantrine,amodiaquine  Ineffective erythropoiesis- iron and folic acid & B12 supplementation, repeated blood transfusions

Managment of isolated conjugated hyperbilirubinemia

Unconjugated & Conjugated hyperbilirubinemia managment

Hepatocellular pattern,⇈AST/ALT out of proportion to ALK-P Treatment depends on causes  Hepatitis A :mostly self limiting  Hepatitis B treated with antiviral medications  Hepatitis C is treated with interferons Other Viral infections like EBV, CMV, HSV are treated with Antiviral medications Alcohl hepatitis: Alcohol abstinence,glucocorticoids, pentoxifylline  Wilson"s disease:chelating agents such as D-penicillamine  Drug toxicity treatment(e.g. Acteaminophen, Isoniazid Primary biliary cholangitis management  Auroimmune hepatitis  enviromental toxin:kavakava

Cholestatic pattern managment,⇈ Alk-P out of proportion to AST/ALT,predominantly conjugated

Managment of cirrhosis,Predominantly conjugated,↑ INR,↓ Alb,↓ PLt

Dilated Bile ducts

Non-dilated Bile ducts

MELD Score

Consider Intrahepatic injury

>15

<15

CBD stones Stricture/choldochal cyst

Solid mass(Extrahepatic)

Consider reffering patient to a transplant center

Preoperative biliary decompression (ERCP or PTC) Cholecystectomy endoscopic stenting,surgery excision of cyst

If resectable,fit for surgery If unresecatable,pallative therapy

Compensated Cirrhosis Mangament Alochol abstinence Antiviral medications for viral hepatitis avoidance of hepatotoxic medications vaccination

Decompensated Cirrhosis Managment(with complications) Managment of complications: Varices,Asciets,Hepatorenal syndrome,Hepatic encephalopathy

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References