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Cathy McDermott

on 12 February 2013

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Transcript of Jaundice

Jaundice! What IS Jaundice?? How Do You Work it Up? Bilirubin Etiologies of Jaundice You Treat the Underlying Etiology! symptoms of Jaundice the yellow-orange bile pigment formed by breakdown products of heme rings, usually from metabolized RBCs By the way:
Why does it matter? Jaundice is a yellowish pigmentation of the skin, the membranes over the eyes, and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood).

{The term jaundice comes from the French word jaune, meaning yellow.} Yellow discoloration of the skin, especially on the palms and the soles, but not of the sclera or mucous membranes, is due to carotenemia —aka pseudojaundice, a harmless condition that is important to differentiate from jaundice. (also known as icterus) First Tests to Order & Why 1. serum total and indirect bilirubin
2. LFTs: AST, ALT, ALP, Alb
-->assess where the process is ocurring

if unconjugated: CBC, retic, haptoglobin, LDH, & smear to evaluate for hemolysis

if conjugated: assess LFTs for cause

- AST & ALT - hepatocellular injury
- Alk Phos & GGT - cholestasis
- Hepatitis panel - viral hepatitis
- ANA, Sm muscle, liver-kidney microsomal antibodies - autoimmune hep How Do You Treat it? References 1. Roche, Sean P, and Rebecca Kobos. "Jaundice in the adult patient." American family physician 69.2 (2004):299-304.
2.The assessment of jaundice in adults: Tests, imaging, differential diagnosis
Danielle Kruger, RPA-C, MS Ed June 02, 2011 JAAPA
3. Winger, James, and Aaron Michelfelder. "Diagnostic approach to the patient with jaundice." Primary care 38.3 (2011):469-82. for the utterly confused Bili Metabolism Pre-hepatic: formed in the spleen from the breakdown of heme (80%), and from ineffective erythropoesis and breakdown of muscle & cytochromes (20%)

Then, transported to the liver for conjugation & excretion

Intra-hepatic: in hepatocytes, it is conjugated with a sugar and becomes soluble in aqueous bile

Then, transported through biliary system to gallbladder

Post-hepatic: metabolized by gut flora into urobilinogen; some is excreted in stool as stercobilin, some reabsorbed into portal circulation, the rest passes into systemic circulation, filtered by kidneys and excreted in urine The conjunctiva of the eye are one of the first tissues to change color as bilirubin levels rise in jaundice. This often erroneously referred to as scleral icterus. However, the sclera themselves are not "icteric" (stained with bile pigment) but rather the conjunctival membranes that overlie them. The yellowing of the "white of the eye" is thus more properly termed conjunctival icterus. unconjugated bilirubin is fat-soluble and can cross the blood-brain barrier or enter a placenta - this is bad!

it is highly neurotoxic, accumulating in gray matter of the CNS, causing potentially irreversible neuro damage or even death (this is why unconjugated hyperbilirubinemia in babies is so dangerous) Physical Exam signs of chronic liver disease:
- ascites
- caput medusae
- edema
- gynecomastia
- palmar erythema
- portal HTN
- r-sided pleural effusion
- r-sided heart failure
- spider angioma
- testicular atrophy
- varices Why Does it Happen? Imaging Ultrasound is the most sensitive imaging technique for detecting biliary stones.

CT scanning more sensitive for liver and pancreatic parenchymal disease.

(Although neither modality is good at delineating intraductal stones)

ERCP, MRCP and PTC if necessary Liver Biopsy Liver biopsy can be helpful in determining cause of hepatocellular injury, particularly in diagnosing autoimmune hepatitis or biliary tract disorders (e.g., primary biliary cirrhosis, primary sclerosing cholangitis). Handy Flow-Chart Take-Home! FYI... FYI... by Cathy McDermott Also! In case you forgot:
conjugated = direct
unconjugated = indirect Pathophys hemolytic v. hepatocellular v. cholestatic

pre-hepatic: mostly unconjugated
intra-hepatic: either or mixed
post-hepatic: mostly conjugated unconjugated:

impaired uptake
impaired conjugation conjugated:

dysfunction of hepatocytes
impaired excretion
of bile ducts
reflux from biliary system
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