Diagnostic Tests for Neonatal Jaundice
Neonatal Jaundice Tests: Book Excerpts
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Neonatal Jaundice Diagnosis: Book Excerpts
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JAUNDICE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The basic workup includes a CBC, sedimentation rate, reticulocyte count, red cell fragility test, urinalysis, chemistry panel, VDRL test, EKG, a chest x-ray, and flat plate of the abdomen.
If infectious hepatitis is suspected, a hepatitis profile, febrile agglutinins, Monospot test, cytomegalic virus antibody titer, and leptospirosis antibody titer should be done. If lupoid hepatitis is suspected, a test for antinuclear antibodies and a smooth muscle antibody should be done.
If hemochromatosis is suspected, a serum iron, iron-binding capacity, and ferritin should be done.
If hemolytic anemia is suspected, serum haptoglobins, hemoglobin electrophoresis, and sickle cell preparations may be done.
If obstructive jaundice is suspected, then gallbladder ultrasound should be done to rule out gallstones, and a CT scan of the abdomen may be done to look for GI neoplasm. An upper GI series may assist in finding a primary neoplasm in the GI tract.
ERCP or percutaneous transhepatic cholangiography will assist in determining whether there is definitely obstructive jaundice and whether it is due to a surgically resectable lesion. Peritoneoscopy can also be helpful. An exploratory laparotomy will probably be necessary regardless of whether one performs the above tests. Cholangiopancreatography and endoscopic ultrasonography are two newer methods that may be used to evaluate the biliary tree and pancreatic ducts, especially when a neoplasm is suspected.
Hepatocellular jaundice will often require a needle biopsy of the liver to pin down the diagnosis. Antimitochondrial antibodies will need to be ordered to screen for biliary cirrhosis. An alpha 1-fetoprotein will help diagnose hepatocellular carcinoma. By the time you have reached this point, you have gone to considerable expense in the diagnostic workup. It would be much more prudent to ask for a gastroenterology consultation before ordering all these expensive diagnostic tests.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Jaundice:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Documenting a history of the patient’s jaundice is critical in determining its cause. Begin by asking the patient when he first noticed the jaundice. Does he also have pruritus, clay-colored stools, or dark urine? Ask about past episodes or a family history of jaundice. Does he have nonspecific signs or symptoms, such as fatigue, a fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, weight loss, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations? Ask about alcohol use and a history of cancer or liver or gallbladder disease. Has the patient lost weight recently? Also, obtain a drug history. Ask about a history of hepatitis, gallstones, or liver or pancreatic disease.
Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn’t affect the sclera. Inspect the patient’s skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops as well as crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient’s mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Jaundice [Icterus]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Documenting a history of the patient’s jaundice is critical in determining its cause. Begin by asking the patient when he first noticed the jaundice. Does he also have pruritus, clay-colored stools, or dark urine? Ask about past episodes or a family history of jaundice. Does he have nonspecific signs or symptoms, such as fatigue, fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, weight loss, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations? Ask about alcohol use and a history of cancer or liver or gallbladder disease. Has the patient lost weight recently? Also, obtain a drug history. Ask about a history of hepatitis, gallstones, or liver or pancreatic disease.
Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn’t affect the sclera. Inspect the patient’s skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops. For all patients, auscultate for crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient’s mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function. (See Differential diagnosis: Jaundice, pages 462 and 463.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Jaundice:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The physical examination should focus on the following: Eyes should be examined for icterus or Kayser-Fleischer rings, which are copper-colored rings suggestive of Wilson’s disease. Heart and lung examination revealing S3 gallop or rales is suggestive of congestive heart failure, which leads to passive liver congestion. Ascites, hepatosplenomegaly, venous hum, and tenderness on abdominal examination points to portal hypertension and indicates liver cirrhosis (Chapters 9.2 and 9.9). Suspect pancreatic carcinoma when a nontender, palpable mass is found on upper abdominal examination. Signs of cirrhosis include excoriations, spider nevi, caput medusa, Dupytren’s contracture, gynecomastia, and palmar erythema. Delirium, drowsiness, asterixis, and tremor occur with liver failure.
Testing
A. Laboratory tests. Laboratory assays measure bilirubin as indirect (unconjugated) and direct (conjugated) fractions. An elevated indirect bilirubin level is consistent with overproduction of bilirubin or decreased uptake, transport, or conjugation by the hepatocyte. Elevation of direct bilirubin points to decreased excretion or transport by the biliary system (3). Transaminase levels (aspartate aminotransferase and alanine aminotransferase) increase from hepatocellular necrosis or inflammation from the release of aspartate aminotransferase from lysed hepatocytes. Hepatocyte damage and cholestasis increase alkaline phosphatase levels. γ-Glutamyl transpeptidase levels increase in cholestasis and alcohol abuse. Pancreatitis, pancreatic carcinoma, or common bile duct stones elevate amylase levels. With hepatocellular damage, coagulation studies can be prolonged. Antimitochondrial antibodies are present in primary biliary cirrhosis. Hepatitis B serologic tests are summarized in Table 9.8. Hepatitis A IgM antibody detects acute stage hepatitis A and IgG detects chronic stage hepatitis A. Anti-hepatitis C virus indicates hepatitis C infection. Hepatitis D only occurs with hepatitis B infection and is detected by anti-hepatitis D (4).
B. Diagnostic imaging has limited uses. Plain films of the abdomen rarely provide useful information. Cholelithiasis or pancreatic mass are best detected by ultrasound. Magnetic resonance imaging or computed tomography scans are used to examine the liver, pancreas, biliary tree, and suspected obstruction not identified by ultrasound. Hepatoiminodiacetic acid scanning is useful in a patient with suspected acute cholecystitis. Percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are used if obstructive jaundice is suspected to show the cause, location, and extent of involvement (5).
C. Other tests. Percutaneous liver biopsy is not indicated in the routine workup of jaundice but may prove useful in diagnosing the cause of jaundice when the above-mentioned tests are inconclusive. Iron levels are increased in hemochromatosis. Copper levels are increased in Wilson’s disease.
Diagnostic assessment
The patient’s history and associated symptoms guide the initial differential diagnosis of jaundice. Physical examination further narrows the causative choices and analysis of hepatic enzyme levels and viral serologies should confirm the initial diagnosis. Imaging studies play a limited role, except in suspected cases of malignancy or biliary obstruction.
Most patients have acute viral hepatitis as the cause of jaundice. Consultation is indicated when testing is inconclusive, when a surgical cause is suspected, or as needed for treatment.
References
1. Scharschmidt BF, Goldberg HI, Schmid R. Approach to the patient with cholestatic jaundice. N Engl J Med 1983;308:1515.
2. Lucas WB, Chuttani R. Pathophysiology and current concepts in the diagnosis of obstructive jaundice. Gastroenterologist 1995;3:105–118.
3. Fevery J, Blanckaert N. What can we learn from analysis of serum bilirubin?
J Hepatol 1986;2:113–121.
4. Bakerman S. ABC’s of interpretive laboratory data, 3rd ed. Myrtle Beach, SC: Interpretive Data, Inc., 1994:279–286.
5. Barloon TJ, Bergus GR, Weissman AM. Diagnostic imaging to identify the cause of jaundice. Am Fam Physician 1996;54:556–562.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Jaundice:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Jaundice becomes clinically apparent when the bilirubin level reaches 2 to 2.5 mg/dL. Scleral elastin has a high affinity for bilirubin, and with a white background, it is a sensitive indicator of jaundice. Biliary obstruction gives a greenish skin tint due to accumulation of biliverdin. Hemolysis gives a lemon-yellow tint when observed in natural light. An orange-yellow color is more consistent with hepatocellular disease. Pseudojaundice may be found in black patients with pigmented sclera, with carotinemia, with uremia (a sallow yellowish pallor), and with quinacrine (a yellow-green color).
Dark urine with green foam confirms a conjugated hyperbilirubinemia and excludes hemolysis or a conjugating defect. Unconjugated bilirubin is tightly bound to albumin, which prevents glomerular filtration.
Courvoisier law states: “In a jaundiced patient, a palpable gallbladder indicates that the jaundice is not due to stones.” Painless jaundice usually suggests a gradual process, as is found in intrahepatic cholestasis. The liver in this case is usually enlarged, smooth, and nontender. A patient with hepatocellular disease appears more ill than one with obstruction. Fluctuating jaundice occurs with gallstones, ampullary carcinoma, or toxins.
Anorexia, nausea, vomiting, or weight loss within 2 weeks of the appearance of jaundice suggests acute hepatitis or gallstones. Appearance more than 2 weeks prior suggests malignant biliary obstruction, chronic hepatitis, or toxin exposure (e.g., alcohol). Generalized pruritus suggests biliary obstruction, either extrinsic due to tumor, or canalicular due to drug-induced intrahepatic cholestasis.
Ascites with jaundice is an ominous sign, signifying decompensated cirrhosis with portal hypertension or malignancy with liver metastases. In portal hypertension, veins are engorged radially away from the umbilicus. In inferior vena cava obstruction, flow occurs upward over the abdominal wall. A harsh hepatic bruit may occur with malignancy, alcoholic hepatitis, or hemangioma. Splenomegaly without hepatomegaly occurs with hemolysis or portal vein occlusion.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Jaundice:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn’t affect the sclerae. Inspect the patient’s skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops. For all patients, auscultate for crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient’s mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Jaundice:
Diagnostic Approach: Unconjugated Hyperbilirubinemia
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Most commoncauses of neonatal unconjugated hyperbilirubinemia are physiologic jaundiceand breast-feeding–related jaundice.Diagnostic tests should be performedinNeonateswho become clinically jaundiced during first 24 hrs of lifeTerm bottle-fed infants whose maximumserum bilirubin exceeds 12 mg/dLTerm breast-fed infants whose maximumserum bilirubin exceeds 15 mg/dLPreterm infants Certain tests should be performed initially:Maternal andinfant blood groups and Rh typesUnconjugated and conjugated serum bilirubinCBC and differentialReticulocyte countDirect Coombs testAnalysis of blood smear If jaundice persists, red cell G6PDactivity and T4 and TSH levels should bedetermined.If diagnosis remains uncertain, moreextensive studies for rarer forms of hemolytic disease and enzymeassay for uridine diphosphate glucuronyl transferase activity shouldbe considered. Tests for hepatocellular disease need to be performedonly when there is significant increase in conjugated bilirubin.In infancy and childhood, most commoncause of unconjugated hyperbilirubinemia is hemolytic anemia [see Chap. 45, Pallor (Anemia)].
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Jaundice [Icterus]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Documenting a history of the patient's jaundice is critical in determining its cause. Begin by asking the patient when he first noticed the jaundice. Does he also have pruritus, clay-colored stools, or dark urine? Ask about past episodes or a family history of jaundice. Does he have nonspecific signs or symptoms, such as fatigue, a fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, weight loss, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations? Ask about alcohol use and a history of cancer or liver or gallbladder disease. Has the patient lost weight recently? Also, obtain a drug history. Ask about a history of hepatitis, gallstones, or liver or pancreatic disease.
Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn't affect the sclera. Inspect the patient's skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops as well as crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient's mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Jaundice - Case 15-4: 6-Week-Old Girl:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 37.0°C; RR, 32/min; HR, 136 bpm; BP, 88/60 mm Hg
Weight, 4.1 kg (10th to 25th percentile); length, 56 cm (25th to 50th
percentile)
On examination, the infant was resting quietly in her mother's arms and was observed to have a mild “muddy” jaundice in her face. She was nondysmorphic and normocephalic, with an open,
flat fontanel. Scleral icterus was pleasant. There was no nasal discharge or
flaring. The oropharynx was clear, with moist mucous membranes. The lung and
cardiac examinations were normal. Her abdomen was soft and nondistended, and a
smooth, firm liver edge palpable 2 cm below the right costal margin. The
genitourinary, extremity, and neurologic examinations were all normal.
IV. Diagnostic Studies
The complete blood count revealed the following: 6,900 WBCs/mm3 (43% segmented neutrophils and 48% lymphocytes); hemoglobin, 9.2 g/dL; and
332,000 platelets/mm
3. Total bilirubin was 9.5 mg/dL, and the direct bilirubin concentration was 8.4
mg/dL. ALT and AST were 267 and 288 U/L, respectively. Albumin was 3.2 g/dL,
and the alkaline phosphatase was 641 U/L. Serum electrolytes, BUN, creatinine,
and glucose were normal. Calcium was also normal. Urinanalysis revealed a
specific gravity of 1.015 and 1+ blood but no nitrites, leukocyte esterase,
protein, or urobilinogen.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Jaundice - Case 15-6: 5-Week-Old Girl:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
T, 37.2°C; RR, 28/min; HR, 120 bpm; BP, 80/56 mm Hg
Weight, 3.35 kg (5th percentile); length, 51 cm; head circumference, 36 cm
The infant appeared small but comfortable in her father's lap. She had an open, flat fontanel and a broad forehead; equal and round
pupils; and scleral icterus. The oropharynx was clear with moist mucous
membranes. Respirations were clear and unlabored. Cardiac examination revealed
a II/VI systolic murmur that was loudest at the left sternal border; the rate,
rhythm, and distal pulses were all normal. Her abdomen was soft and
nondistended, with a smooth liver edge palpable 3 cm below the right costal
margin; no spleen or other masses were appreciated. The genitourinary,
extremity, and neurologic examinations were all normal.
IV. Initial Diagnostic Studies
A complete blood count revealed the following: 16,700 WBCs/mm3 (31% segmented neutrophils and 61% lymphocytes); hemoglobin, 9.6 g/dL; and
625,000 platelets/mm
3. The BUN and creatinine concentrations were 26 and 1.1 mg/dL, respectively.
Serum electrolytes were normal. The total bilirubin concentration was 11.0
mg/dL; unconjugated and conjugated bilirubin were 8.0 and 3.1 mg/dL,
respectively. The remainder of the hepatic function panel was as follows: ALT,
190 U/L; AST, 94 U/L; albumin, 3.0 mg/dL; and alkaline phosphatase, 450 U/L.
Blood and urine cultures were obtained and were negative. Evaluations for
toxoplasmosis, rubella, cytomegalovirus, and HIV were also negative.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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