jaundice - dr. jessica nelson
TRANSCRIPT
Bilirubin
Aspartate Aminotransferase
Alanine Transaminase
International Normalized Ratio
Gamma-glutamyl Transpeptidase
Alkaline Phosphatase
Ammonia
Albumin
Product of heme catabolism
Metabolized in the liver
Conjugated vs. Unconjugated
Patterns of elevation
How high can they go?
Slight to moderate
Moderate to high
Very high
Hemolysis
Fatty liver
Metastatic disease
Pancreatitis
Medications
How high can they go?
Slight to moderate
Moderate to high
Very high
Chronic hepatitis
Skeletal muscle
MI
Mononucleosis
Alcoholic cirrhosis
How high can they go?
Slight to moderate
Moderate to high
Very high
Muscle trauma
Acute viral hepatitis
Toxic hepatitis
Ischemic hepatitis
How can ratios help?
AST/ALT = 1
AST/ALT <1
AST/ALT >2
Hepatocellular damage
Viral hepatitis
Ischemia
Toxic hepatitis
How can ratios help?
AST/ALT = 1
AST/ALT <1
AST/ALT >2
Alcoholic hepatitis
Hepatocellular injury
Active cirrhosis
Tylenol overdose
Medication
Marker of synthetic function
Liver produces:
Factors 1, 2, 5, 7, 8, 9, 10, and 11
Protein C and Protein S
Antithrombin
Correlation with clinical outcome
Albumin
Protein synthesized by the liver
Marker of malnutrition
Do we care about it?
Sort of….but not today
A 23 year old male with a history of G6PD
presents with diffuse abdominal pain and
vomiting for two days.
He comes in now because of dark urine,
yellow eyes and breathlessness for the past
few hours.
HR 124 Bp 110/30 RR 28 O2 88% T 100.4°F
Pale male in mild distress, eyes are icteric
RRR, lungs clear, abdomen soft, extremity rash
Labs
HgB 6 /μL
WBC 5 μL
Platelets 15 μL
LDH 400 U/L
Haptoglobin 20 mg/dL
Reticulocyte count 4%
Bilirubin total: 5 mg/dL
Labs
HgB 6 /μL
WBC 5 μL
Platelets 15 μL
LDH 400 U/L
Haptoglobin 20 mg/dL
Reticulocyte count 4%
Bilirubin total: 5 mg/dL
○ Direct bilirubin?
Mom leaves to park the car.
When interviewed alone, the patient starts
to cry and tells you she doesn’t want to live
anymore.
With further questioning, she talks about a
fight with her boyfriend and admits to taking
some pills later that night…
With further questioning, she talks about a
fight with her boyfriend and admit to taking
some pills later that night…2 days ago.
Bp 110/70 HR 120 RR 18 T 37.2 O2 98%
Alert, quiet with poor eye contact, tearful.
Faint jaundice, RRR, CTAB, mild RUQ tenderness.
AST 1500 U/L
ALT 2000 U/L
INR 3 IU
Bili 8 mg/dL
Alk Phos 250 UL
Acetaminophen <1mg/mL
CBC, BMP, UA, U preg
RUQ US?
AST 1500 U/L
ALT 2000 U/L
INR 3 IU Bili 8 mg/dL
Alk Phos 250 UL
Acetaminophen <1mg/mL
CBC, BMP, UA, U preg
RUQ US?
44 year old male with a history of DM2 and
HTN presents with a 1-month history of
fatigue, nausea, and progressive jaundice.
He denies alcohol, drug abuse, blood
transfusion, or recent international travel.
Bp 140/85 HR100 RR14 T 37.5 O2 99%
Alert, no distress, overall thin
Scleral icterus and jaundiced skin
RRR, CTAB, abd distended but soft with no tenderness
References
Hasler WL, Owyang C. Chapter 290. Approach to the Patient with Gastrointestinal Disease. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.
O'Mara SR, Gebreyes K. Chapter 83. Hepatic Disorders, Jaundice, and Hepatic Failure. Tintinalli'sEmergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
http://lifeinthefastlane.com/investigations/liver-function-tests/
http://jaundicepictures.com/Jaundiced.php
http://emedicine.medscape.com