24. Jaundice Flashcards
Where is bilirubin conjugated?
liver
Where does bilirubin come from?
heme products
lots from RBC
small portion myoglobin and maturing erythroid cells
What is heme oxidized to prior to bilirbuin?
biliverdin
Where does unconjugated bilirubin go?
passively taken into hepatocytes
udnergoes glucouronidation
becomes conjugated
then secreted into biliary system and emptied into gut –> urobilinogen (reabsorbed to urine) and stercobiligin (feces)
remaining conjug bili then deconjug and back to portal sys to be taken up by hepatocytes
What level is clinical jaundice noted?
2.5mg/dL
Why do eyes and skin show jaundice?
high albumin []
What 3 ways can physiology of bile be altered?
1)over production of heme
2) failure of hepatocyte to take up conjugate and secrete bilirubin
3) obstruction of biliary secretion into intestine
What increases the neurotoxcity of unconjugated hyperbili?
hemolysis
hypoalbuminemia
acidemia
drugs bind competitively to albumin
3 major ddx categories for jaundice patients?
disorders of hemolysis
liver injury, dsyfunction or cholestasis
biliary obstruction
Key hx questions in patients with jaundice
HEPATITIS-viral prodrome
IATRO- recent/remote bl products, occupational exposure, travel
ETOH- liver disease, etoh/ivdu, pregnancy, cv disease
TOX- toxic/therapeutic ingestion
DIRECT -biliary tract surgery, fever, abdo pain, changes to urine or stool, malignancy/w loss/night sweats,trauma
PE specifics for pt with jaundice
mental status
abdo tender/liver size
hepatomegaly
skin: petechiae, purpura, caput medusae, spider angiomata, ascites, pulsatile mass
Extra lab tests for specific situations in pt with jaundice
ammonia if AMS preesnt
LDH and haptoglobin if considering hemolysis
pregnancy
tox screen
List ddx for 6 causes of hepatocellular/cholestatic processes causing jaundice
viral hepatitis
fulmainent hepatic failure
alcohol hepatitis (AST >ALT)
ischemia
toxins
autoimm disease
HELLP
DDX of jaundice with normal transaminases, alk phos, pt/ptt, n or reduced hb/hematocrit
elevated ldh and low haptoglobin
hemolytic disorder
hematoma reabsorption
gilbert syndrome (inadq hepatic conjug of bilirubin)
Name 6 causes of obstructive jaundice
choledocho
intrinsic bile duct dis: cholangitis, aids cholangiopathy, strictures, neoplasm
extrinsic biliary compression
neoplasm (pancr/liver)
Dx of SBP
presence of more than 250 poly- morphonuclear (PMN) cells per cubic millimeter of ascitic fluid
SAAG value >1.1g/dL - what does this mean clinically?
low albumin level in ascitic fluid and therefore transudative –> portal HTN
SAAG value <1.1g/dL - what does this mean clinically?
higher albumin level in ascitis fluid and therefore exudative fluid
sle, pancreatitis
Causes of portal htn causing jaundice?
cirrhosis
liver failure
HF
What is best imaging for looking for obstruction in hepatic, portal or splenic veins
u/s with doppler
MC 2 causes of biliary obstruction
biliary stones
benign/malignant stenoses
Acute hepatic failure triad
jaundice
encephalopathy INR >1.5
Charcot’s triad
fever
ruq pain
jaundice
cholangitis
reynold’s pentad
fever
ruq pain
jaundice
hypotension
ams
asc cholangitis
portal v thrombosis aka
budd chiari syndrome
1000s club for transaminases - causes?
HELLP
eclampsia
budd chiari
ischemia
viral hepatitis
autoimmune
tylenol OD/overdose to liver
SBP med choice
IV third- generation cephalosporin (e.g., cefotaxime 2 g IV, ceftriaxone 2 g IV). Patients with SBP should receive an albumin infusion (initial dose 25% 1.5g/kg IV), as it has been shown to reduce the risk for mortality and hepatorenal syndrome.
Name 5 causes of fulminant hepatic failure that would be considered critical diagnosis of jaundice
toxin
virus
etoh
ischemia
reye syndrome
name 5 emergent diagnoses of jaundice from hepatic in nature
Hepatitis of any cause with confusion, bleeding, or coagu- lopathy
Wilson disease
Primary biliary cirrhosis
Autoimmune hepatitis
Liver transplant rejection
Infiltrative liver disease
Drug induced (isoniazid, phenytoin, acetaminophen, ritona- vir, halothane, sulfonamides)
Toxin ingestion or exposure
Name one critical dx from biliary system and one emergent?
cholangitis
bile duct obstr - stone/inflamm/stricture/neoplasm
Name 2 critical dx of jaundice from systemic cause
sepsis
heatstroke
Name 3 emergent causes of jaundice due to systemic disease
sarcoid
amyloid
gvhd
list 2 nonemergent systemic causes of jaundice
post traumatic hematoma reabsorp
tpn
cv critical causes of jaundice - list 3
obstructing aaa
budd chiari synd
severe HF
cv emergent causes of jaundice - list 2
r sided HF
veno occlusive disease
hem-onc critical cause of jaundice - list 1
transfusion reaction
hem-on emergent causes of jaundice - list 5
hemolytic anemia
massive malign infiltation
inborn error of metabolism
pancreatitic head tumor
metastatic disease
name 2 reproductive causes of jaundice - critical dx
preeclampsia, hellp
acute fatty liver of pregnancy
Name an emergent cause of jaundice in pregnancy and nonemergent
hyperemesis gravardum
cholestasis of pregnancy
What signs/symptoms/labs to consider immediate transfer to a liver specialist
acute hepatitis with elevated INR or encephalopathy
Which jaundice pt require hospitalization?
new-onset jaundice and transaminase levels approaching 1000 IU/L, bilirubin approaching 10 mg/dL, or any evidence of coag- ulopathy, as these laboratory abnormalities suggest significant hepatic dysfunction.
biliary stone disease
choledocho, gallstones in cbd
cholangitis
If >5L of ascitic fluid removed, how much IV albumin repletion?
for ea litre removed, 6-8g albumin
Name the 3 categories and their parts of the Tokyo Guidelines for Dx of Acute cholangitis
a. sys: fever, wbc, elevated crp
b. cholestasis: jaundice, abn LFT
c. imaging: biliary dilatation, stricture, stone, stent
