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Jaundice

  • Approach

    • Biliary obstruction: direct hyperbilirubinemia, marked ALP elevation (4x normal)
      • extrahepatic: RUQ pain, duct dilation
      • intrahepatic: drug, liver disease
    • Hepatocellular injury: ALT, AST elevation, mild ALP elevation
      • marked elevation: acute hepatitis (viral, toxic, ischemic), acetaminophen, drug reaction
      • mild-moderate elevation (up to 8x normal): chronic hepatitis, chronic liver disease
    • Conjugation issue: indirect hyperbilirubinemia
    • Non liver issue
      • hemolysis: indirect hyperbilirubinemia
      • muscle injury: elevated ALT, AST and CK
      • other cases of elevated transaminase: celiac disease, thyroid disease, adrenal insufficiency
      • bone disease: elevated ALP
      • pregnancy: placental ALP
  • Initial labs

    • bilirubin, direct and indirect
    • CBC with smear
    • AST, ALT, ALP
  • Specific labs

    • acetaminophen level, toxicology
    • hepatitis panel
    • autoimmune panel, anti transglutaminase, TSH
    • liver biopsy
  • Hemolysis ddx (high unconjugated bili, low Hct)

    • sickle cell
    • thalassemia
    • G6PD (sulfa drugs, TMP-SMZ)
    • spherocytosis
    • PNH
    • DIC
    • TTP/HUS
    • HDN (neonate)
    • autoimmune hemolytic anemia
    • malaria
    • babesia
  • Conjugation ddx (high unconjugated bili, normal Hct)

    • Gilbert's
    • Crigler-Najjar
    • physiologic (newborn)
    • drugs (new meds)
  • Biliary obstruction ddx (light colored stool, high conjugated bili)

    • gallstone
    • gallbladder cancer
    • pancreatitis
    • pancreatic cancer
    • PBC
    • PSC (PMH of UC)
    • cholangiocarcinoma
    • cholestasis of pregnancy
    • Dubin Johnson
    • Rotor's syndrome
    • drugs (new meds)
  • Liver failure ddx (high AST, ALT)

    • cirrhosis
    • hepatitis
    • HCC
    • drugs (acetaminophen, new meds)
  • Peds ddx

    • physiologic, cephalohematoma, breast feeding failure, breast milk jaundice, galactosemia, HDN, sepsis, meningitis
  • Other ddx

    • sepsis
  • HPI

    • onset
    • aggravates, alleviates
    • location
  • ROS

    • fever, weight loss
    • rash
    • neuro: headache
    • cardio, pulm: chest pain, dyspnea
    • GI: abdominal pain, nausea, vomiting, diarrhea, acholic stool
  • PMH

    • blood disorders
    • hemoglobinopathies
    • ulcerative colitis
  • FH

    • blood disorders
    • hemoglobinopathies
  • SH

    • foreign travel
    • new meds
  • Meds

    • new meds
    • acetaminophen
  • Allergies

  • Px

    • vitals
    • gen impression, mental status
    • skin: rash, jaundice
    • HEENT: cephalohematoma in kids
    • cardio
    • pulm
    • abd: organomegaly, mass, tenderness, rebound

  • Print | Citations

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