Jaundice. Michael Ornes

Transcription

1 Jaundice Michael Ornes

2 Definitions Jaundice: hyperbilirubinemia leading to yellow discoloration of the skin Icterus: hyperbilirubinemia leading to yellow discoloration of the sclera Usually undetectable on physical exam until bili > 2.0

3 Unconjugated hyperbilirubinemia Increased production Impaired hepatic uptake Impaired hepatic conjugation

4 Conjugated hyperbilirubinemia Extrahepatic cholestasis or obstruction Intrahepatic cholestasis or obstruction Hepatocellular injury

5 Jaundice medical Massive hemolysis emergencies Clostridium perfingens sepsis Falciparum malaria Ascending cholangitis Fulminant hepatic failure Unconjugated hyperbilirubinemia in the newborn

6 History Medications, alcohol, drug use Hepatitis risk factors Past abdominal (especially biliary) surgery Family history of hyperbilirubinemia HIV status Travel history Toxic exposure

7 Current symptoms Ascending cholangitis RUQ pain fever and or chills Viral hepatitis RUQ pain malaise anorexia myalgias

8 Physical exam findings Enlarged palpable gall bladder Ascites Spider angiomata Splenomegaly Gynecomastia Hyperpigmentation Kayser Fleischer ring Xanthoma

9 Laboratory Liver transaminases: AST less specific than ALT and GGT Alkaline phosphatase: can derive from bone or other sources; other rarely used tests can help confirm source INR Albumin

10 Other studies Viral hepatitis serologies Antimitochondrial antibodies(pbc) Work-up for IBD if signs or symptoms suggestive (PSC) Anti-smooth muscle antibody, ANCA, anti-lkm-1 (autoimmune hepatitis) Iron studies (hemachromatosis) Ceruloplasmin (Wilson s disease) Alpha-1-antitrypsin activity May need liver biopsy (NAFLD, etc)

11 Imaging Ultrasound CT MRCP ERCP Percutaneous transhepatic cholangiography

12 36 year old female Healthy previous to acute onset of RUQ abdominal pain 3 days ago with radiation to epigastrium and back that developed after fatty meal Vitals: T 38.4, HR 105, BP 105/55 Abdominal tenderness especially RUQ Icteric, jaundice

13 Data WBC 14.5 with bands AST 345 ALT 455 Alk Phos 245 Bilirubin 4.3 Lipase 367 Ultrasound of the abdomen showed common bile duct to be 13 mm, gallstones present in the gallbladder and possible pancreatic inflammation

14 Ascending cholangitis Bacterial infection (often E. coli, Klebsiella, Enterobacter, Enterococcus, or anaerobes) Associated with obstruction Treatment Antibiotics Relieve obstruction

15 45 year old Healthy previous to a farm injury to his ankle with a deep laceration resulting in possible vascular injury One day later he develops a fever, progressive severe pain in his ankle with blisters and change in the color of the skin over the ankle and jaundice diffusely

16 Data WBC 20.8 with bands Hemoglobin 10.8 Haptoglobin 10 (low) LDH 557 (high) Bilirubin 3.9 Direct 0.6 Indirect 3.3 Blood culture positive with gram positive bacilli

17 Clostridium perfingens Myonecrosis (gas gangrene) Toxin induced shock Toxin induced hemolysis Multiorgan failure Treatment Antibiotics Emergent surgical debridement

18 32 year old Healthy prior to acute onset of headache Family history of intermittent jaundice, but no personal history of jaundice Diagnosed with subarachnoid hemorrage No abdominal pain, nausea, or vomiting Bilirubin 3.6 Direct 0.6 Indirect 3.0

19 Data AST 34 ALT 27 Alk phos 76 LDH 65 (normal) Hemoglobin 12.5 Coomb s negative Bilirubin normalizes without diagnosis

20 Gilbert syndrome Inherited disorder of UDPglucuronosyltransferase activity Benign Often presents during illness especially if bilirubin production increases

21 75 year old History of cigarette use (75 pack-year) Diabetes Mellitus type II Recent unintentional weight loss Feels depressed Some diarrhea Change in skin color to yellow-orange

22 Exam and data Palpable mass RUQ mildly tender AST 55 ALT 45 Alk phos 345 Bilirubin 14.6 Direct 9.4 Indirect 5.2

23 Pancreatic carcinoma Diagnosed by CT guided biopsy Can have elevated CA 19-9 ERCP may be needed to make diagnosis In high suspicion cases with a possible resectable tumor, referal to a hepatobiliary and pancreatic surgeon for exploratory laparotomy should be considered