Jaundice

Jaundice: Excerpt from In a Page: Signs and Symptoms

Yellow skin pigmentation caused by elevated serum bilirubin level is termed jaundice. Bilirubin is the major breakdown product of hemoglobin that is released from dying or damaged erythrocytes. The normal serum bilirubin is less than 1 mg/dL, less than 5% of which is present in conjugated form. Jaundice cannot be detected until the bilirubin level rises above 2 mg/dL.

Differential Diagnosis

• Viral hepatitis
  –Fatigue, anorexia, fever, nausea, vomiting, dark urine, light-colored (acholic) loose stools, RUQ pain, hepatomegaly, and/or pruritis

• Alcoholic hepatitis
  –Associated with fever, leukocytosis, and AST:ALT ratio >2

• Nonalcoholic steatohepatitis or nonalchoholic fatty liver disease
  –Associated with obesity, diabetes, hyperlipidemia and medications

• Cholecystitis
  –RUQ pain, fever, leukocytosis
  –Female, fertile, fat, forty
  –Murphy's sign: Pain upon palpation of the
  gallbladder while taking a deep breath

• Drugs and toxins
  –Acetaminophen, alcohol, estrogens, isoniazid, chlorpromazine, erythromycin, nitrofurantoin, rifampin

• Gilbert's syndrome
  
  –Decreased conjugation of bilirubin, especially with dehydration, fasting, infection

• Liver infiltration
  –Amyloidosis, lymphoma, sarcoidosis, tuberculosis

• Cholangitis
  –Charcot's triad of fever, RUQ pain, and jaundice

• Autoimmune hepatitis
  –May mimic viral hepatitis
  –Females >> males, often 10–30 years old
  –Associated with autoimmune disease
  (e.g., RA, UC, Sjögren's syndrome, thyroiditis)

Workup and Diagnosis

• History and physical examination
  –Duration, associated symptoms (e.g., abdominal pain, constitutional symptoms, pruritis), history of alcohol use or hepatotoxic medications, and/or personal/family history of liver disease
  –Jaundice is best seen in the periphery of ocular conjunctivae and oral mucous membranes
  –Yellow skin discoloration may occur with elevated serum carotene level without scleral icterus
  –Evaluate for hepatomegaly, splenomegaly, palpable gallbladder, and signs of chronic liver disease (e.g., gynecomastia, testicular atrophy, palmar erythema, spider telangiectasias)

• Initial laboratory evaluation includes total and unconjugated (indirect) bilirubin (cannot detect jaundice until serum bilirubin >2 mg/dL), AST, ALT, alkaline phosphatase (elevated with hepatocellular damage or cholestasis), albumin, HIV and hepatitis serologies (if risk factors present), reticulocyte count, LDH, haptoglobin (hemolysis), prothrombin time (to evaluate synthetic liver dysfunction or vitamin K deficiency), ANA (autoimmune hepatitis), and possibly antimitochondrial antibodies (primary biliary cirrhosis)
• Abdominal ultrasound or CT scan to evaluate for biliary obstruction, dilated ducts, pancreatic mass, or gallstones
• ERCP if extrahepatic obstruction on imaging tests
• Liver biopsy is generally not necessary

Treatment

• Discontinue and avoid potentially hepatotoxic medications
• Supportive care for viral hepatitis
• Rehydrate/refeed for Gilbert's syndrome
• Consider steroids in fulminant alcoholic hepatitis
• Cholecystectomy or ERCP with stone removal for obstructing gallstones
• Treat underlying causes of hemolysis or other disorders
• Antibiotics for cholangitis, sepsis
• Hydroxyurea and folate for sickle cell disease, prevent crises by adequate hydration, vaccinating against diseases, and try to prevent other infections

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Hepatoma

• Back to disease: Hepatoma: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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• Hepatomegaly (In A Page: Pediatric Signs and Symptoms)
• Jaundice in Infants – Direct (In A Page: Pediatric Signs and Symptoms)
• Jaundice in Infants – Indirect (In A Page: Pediatric Signs and Symptoms)
• HEPATOMEGALY (Differential Diagnosis in Primary Care)
• JAUNDICE (Differential Diagnosis in Primary Care)

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