Jaundice Flashcards
What is bilirubin conjugated and where is it secreted?
Bilirubin is conjugated in the liver and secreted in the biliary system.
What leads to the deposition of bilirubin in the skin?
Inadequate processing or secretion of bilirubin by the liver.
What happens to heme within the reticuloendothelial system?
Heme is oxidized to biliverdin, which is then converted to bilirubin.
What is the difference between unconjugated and conjugated bilirubin?
Unconjugated bilirubin is indirect and not water-soluble, while conjugated bilirubin is direct and water-soluble.
What is the normal serum bilirubin concentration level for jaundice to be evident?
Jaundice is typically not evident until the total serum bilirubin concentration rises above 2.5 mg/dL.
What are the three principal areas where bile metabolism may be altered?
- Overproduction of heme products
- Failure of hepatocyte to uptake, conjugate, or secrete bilirubin
- Obstruction of biliary secretion
What can unconjugated bilirubin that is not bound to albumin potentially cause?
Adverse neurologic effects ranging from subtle developmental abnormalities to encephalopathy or death.
True or False: Conjugated bilirubin is neurotoxic.
False.
What are the three major diagnostic categories to consider in jaundice?
- Disorders of hemolysis
- Liver injury, dysfunction, or cholestasis
- Biliary obstructive disorders
What symptoms may accompany jaundice?
- Asymptomatic
- Pruritus
- Malaise
- Nausea
- Abdominal pain
What does new-onset painless jaundice typically indicate?
A neoplasm involving the head of the pancreas.
What skin findings can suggest chronic liver disease?
- Angiomas
- Excoriations from pruritus
- Caput medusae
What does a palpable gallbladder suggest?
Chronic cholestasis or malignancy.
What laboratory tests are helpful in evaluating hemolysis disorders?
- Reticulocyte count
- Peripheral blood smear
- Haptoglobin
- Lactate dehydrogenase (LDH)
What is the significance of serum gamma-glutamyl transpeptidase (GGT) in liver dysfunction?
Serum GGT rises in parallel with alkaline phosphatase in liver disease.
What is the first choice of imaging study for biliary obstruction?
Ultrasonography.
What are critical features to consider in patients with jaundice in the ED?
- Altered level of consciousness
- Hypotension
- Fever with abdominal pain
- Active bleeding
What does the triad of jaundice, encephalopathy, and coagulopathy indicate?
Acute hepatic failure.
What should be administered for suspected spontaneous bacterial peritonitis (SBP)?
An IV third-generation cephalosporin and albumin infusion.
What can elevated alkaline phosphatase with elevated direct bilirubin suggest?
Extrinsic biliary obstruction.
What is the empirical treatment for acetaminophen toxicity?
N-acetylcysteine (NAC) therapy.
What therapy is discussed in relation to acetaminophen toxicity?
N-acetylcysteine (NAC) therapy.
What potential benefit does NAC offer in non-acetaminophen induced acute liver failure?
Mortality benefit.
What factors should be considered for NAC initiation?
Relative safety of NAC and high morbidity of acute liver failure.
What conditions warrant admission in the absence of liver failure?
Encephalopathy, coagulopathy, or unstable vital signs.
What laboratory abnormalities suggest significant hepatic dysfunction?
- New-onset jaundice
- Transaminase levels approaching 1000 IU/L
- Bilirubin approaching 10 mg/dL
- Evidence of coagulopathy.
What is the management approach for patients with uncomplicated cholecystitis?
- Intravenous fluids
- Antibiotics
- Parenteral analgesics
- Antiemetics.
What imaging techniques should be considered for patients with choledocholithiasis?
- Ultrasound
- CT with IV contrast.
What symptoms suggest ascending cholangitis?
- Fever
- Abdominal pain
- Obstructive jaundice.
What is the necessary management for patients with ascending cholangitis?
- Antibiotics
- Intravenous fluids.
- Biliary drainage.
What is the recommended approach for biliary drainage?
Endoscopic, percutaneous, or open surgical approaches.
What should be considered for patients with extrahepatic obstructive jaundice without cholangitis?
Admission and drainage.
What type of obstructions can ERCP be therapeutic for?
Benign obstructions, such as gallstones or strictures.
What is essential for managing patients with anemia and jaundice?
Hematology consultation.
What can alter glucose and ammonia metabolism?
Hepatocellular injury
Laboratory testing for blood glucose or ammonia levels may be important in the setting of altered mental status.
Does the degree of elevation in serum ammonia correlate directly with hepatic encephalopathy?
No
The degree of elevation in serum ammonia does not correlate directly with the level of hepatic encephalopathy.
What can cause elevated ammonia levels apart from liver issues?
Gastrointestinal bleeding
This is due to the conversion of excess nitrogen load from blood into ammonia by intestinal bacteria.
What test may be helpful in select patients with elevated ammonia levels?
Fecal guaiac testing
This test may help identify gastrointestinal bleeding as a cause of elevated ammonia levels.
When should ascitic fluid analysis be considered?
In patients with new-onset ascites or established ascites with new complaints
Complaints may include fever, worsening abdominal pain, gastrointestinal bleeding, hepatic encephalopathy, hypotension, or renal failure.
What initial screening tests are typically sufficient for ascitic fluid analysis?
Cell count and differential, ascitic fluid albumin and total protein concentration
These tests help assess the condition of the ascitic fluid.
What should be performed if spontaneous bacterial peritonitis (SBP) is suspected?
Gram stain and culture of ascitic fluid
These tests help confirm the diagnosis of SBP.
What is diagnostic for SBP in ascitic fluid?
More than 250 polymorphonuclear (PMN) cells per cubic millimeter
This cell count indicates the presence of SBP.
Is a negative ascitic fluid Gram stain sufficient to exclude SBP?
No
A negative Gram stain is insufficiently sensitive; treatment should continue until cultures result.
What should be considered if SBP is suspected?
Blood cultures
Blood cultures help identify any systemic infection.
What does the serum ascites albumin gradient (SAAG) help determine?
The etiology of ascites
SAAG assists in narrowing the differential diagnosis.
How is the SAAG value calculated?
By subtracting the albumin level of ascitic fluid from the serum albumin level
This value helps classify the type of ascitic fluid.
What SAAG value indicates transudative fluid often found in portal hypertension?
SAAG value ≥ 1.1 g/dL
This value corresponds to a relatively low albumin level in ascitic fluid.
What are some causes of portal hypertension?
- Cirrhosis
- Liver failure
- Heart failure
These conditions can lead to increased pressure in the portal venous system.
What SAAG value indicates exudative fluid potentially found in conditions like lupus or pancreatitis?
SAAG value < 1.1 g/dL
This value corresponds to a comparatively higher albumin level in ascitic fluid.
Initial approach to patient with Jaundice
Obstructive process flowchart
Hepatocellular/Cholestatic process flowchart
Hematologic process flowchart
Clinical stages of Hepatic Encephalopathy
Critical and emergenct Ddx for Jaundice
Tokyo guidelines for cholangitis
