hyperbilirubinemia
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Etiology
unconjugated hyperbilirubinemia
- overproduction of bilirubin
- hemolysis
- intravascular: DIC
- extravascular: hemoglobinopathy, G6PD deficiency, autoimmune hemolytic anemia
- bilirubin rarely increases above 4 mg/dL (except neonatal jaundice)
- ineffective erythropoiesis
- hematoma
- blood transfusions
- hemolysis
- decreased hepatic uptake
- prolonged fasting
- sepsis
- hereditary unconjugated hyperbilirubinemia
- Gilbert's syndrome (jaundice during times of stress)[4]
- Crigler-Najjar syndrome, type I
- Crigler-Najjar syndrome, type II
- pharmacologic agents
- chloramphenicol: neonatal hyperbilirubinemia
- vitamin K: neonatal hyperbilirubinemia
- 5-beta-pregnane-3-alpha, 20-alpha-diol: breast milk jaundice
- physiologic jaundice of the newborn is secondary to inefficient uptake of bilirubin by immature hepatocytes
- neonatal jaundice
conjugated hyperbilirubinemia
- inherited disorders
- Dubin-Johnson syndrome
- Rotor syndrome
- recurrent (benign) intrahepatic cholestasis
- hepatocellular diseases
- viral hepatitis:
- most common cause of jaundice in young adults
- serum unconjugated bilirubin 0-20 mg/dL
- serum transaminases 10-50 times upper limit of normal
- hepatitis A, hepatitis B, hepatitis C, hepatitis E, Epstein Barr virus, Cytomegalovirus
- alcoholic hepatitis
- ischemic hepatitis
- serum transaminase 100 times upper limit of normal
- cirrhosis: 1/3 of jaundice in patients age 30-60 years
- alcoholic cirrhosis - most common etiology in US
- hepatitis B - most common etiology worldwide
- cardiac cirrhosis
- alpha-1 antitrypsin deficiency
- hemochromatosis
- Wilson's disease
- malignancy: hepatocellular, metastatic
- abscesses: pyogenic, amebic
- granulomatous infiltration of the liver
- toxoplasmosis
- Pneumocystis carinii
- Echinococcus
- viral hepatitis:
- biliary diseases
- biliary cirrhosis: primary, secondary
- primary sclerosing cholangitis
- gallstone disease
- cholangiocarcinoma & ampullary carcinoma
- biliary atresia in neonate
- pancreatic disease
- pancreas-related stricture of the common bile duct
- tumor of the head of the pancreas
- pharmacologic agents
- drug-induced hepatitis:
- amoxicillin clavulanate (most common)
- isoniazid (INH), NSAIDs, Bactrim, zidovudine (AZT), acetaminophen
- drug-induced cholestasis:
- perchlorperazine, haloperidol (Haldol), estrogens, androgens, rifampin, allopurinol, sulfonylurea, chlorpromazine
- drug-induced hepatitis:
- sepsis
- postoperative jaundice
- galactosemia in neonate
- cholestatic jaundice of pregnancy
- helminth infection: Clonorchis, Ascaris
Clinical manifestations
- jaundice
- symptoms associated with specific etiologies
- manifestations of cirrhosis
- manifestations of biliary obstruction
- manifestations of hepatocellular dysfunction
- Kayser-Fleischer rings in Wilson's disease
- edema associated with cardiac cirrhosis
- weight loss
Laboratory
- complete blood count (CBC)
- liver profile
- increased serum alkaline phosphatase 3X upper limit of indicates biliary obstruction
- increased serum transaminases 5X upper limit of normal indicates hepatocellular dysfunction
- prothrombin time
- tests for viral hepatitis (hepatitis serology)
- special studies as indicated
Diagnostic procedures
- endoscopic retrograde cholangiopancreatography (ERCP)
- invasive procedure
- provides specimen for cytology (suspected malignancy)
- therapeutic modality:
- removal of common bile duct stone
- stent placement
- sphincterotomy
Radiology
- abdominal ultrasound in all cases of suspected biliary obstruction
- abdominal CT
Management
- general measures
- control itching
- phenobarbital 60-180 mg/day may reduce serum bilirubin
- abstinence from alcohol
- treatment of underlying cause
- obstructive jaundice is treated surgically
- Wilson's disease is treated with penicillamine
- hemochromatosis is treated with phlebotomy
- interferon is occasionally used to treat chronic hepatitis B & hepatitis C
More general terms
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 830.
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 361-62, 371-73
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 253
- ↑ 4.0 4.1 NEJM Knowledge+ Gastroenterology