Based on the information provided: A. Gamma-glutamyl transpeptidase is indicated to further evaluate liver function. B. Hepatitis A serologies are indicated to evaluate for possible acute viral hepatitis. D. Hepatitis B and C serologies are indicated to evaluate for possible viral hepatitis. E. Prothrombin time is indicated to check for possible coagulopathy due to liver dysfunction. Tests C (anti-mitochondrial antibodies) would not be indicated based on the information provided. So the correct answers are: A, B, D, E.

1. APPROACH TO JAUNDICE
IN EMERGENCY MEDICINE
DR,.S.MADHURA GEETHA,
JUNIOR RESISDENT,
EMERGENCY MEDICINE
DEPARTMENT,
GMCK,KANNUR.

2. CONTENTS
 DEFINITION
 PATHOPHYSIOLOGY
 DIAGNOSTIC APPROACH
 SIGNS AND SYMPTOMS
 ANCILLARY TEST
 APPROACH TO JAUNDICE IN
EMERGENCY MEDICINE
 MANAGEMENT
 DISPOSITION

3. DEFINITION
 Jaundice is the clinical manifestation
of elevated serum bilirubin, which
arises through the metabolism of
hemoglobin. Elevated bilirubin occurs
 when: (1) increased bilirubin is
produced due to hemolysis,
 (2) liver dysfunction prevents
conjugation of bilirubin,
 (3) an obstruction prevents secretion
of bilirubin into the intestines.

5. JAUNDICE
 Total serum bilirubin concentration
rises above 2.5 mg/dL.

7. SIGNS AND SYMPTOMS
 few symptoms that can help narrow the
differential diagnosis.
 jaundice with abdominal pain suggests
biliary obstruction or significant hepatic
inflammation
 New-onset painless jaundice is the
classic presentation for a neoplasm
involving the head of the pancreas.
 ascites,mental status changes,
increasing confusion, or frank altered
mental status-hepatic encephalopathy.

8.  Examination of the skin and the abdomen
is particularly helpful in narrowing the
differential diagnosis.
 Starts apparently in sublingually,
conjunctiva, or on the hard palate.
 Cutaneous findings of chronic liver
disease include angiomas, excoriations
from pruritus, or caput medusa.
 Neurological examination-hepatic
encephalopathy.

9. Abdominal examination
 VISUAL INSPECTION.
 A distended or protuberant abdomen can
indicate the presence of ascites

10. PALPATION
 Enlarged liver non tender
Tender malignancy
hepatic inflammation
engorgement caused by biliary
obstruction.
 Non palpable liver-cirrhosis.
 Splenomegaly –portal
hypertension,malignancy,hemolysis.

11. LIVER FUNCTION TEST
 BILIRUBIN
 TRANSAMINASES-AST,ALT.
 Γ-GLUTAMYL TRANSPEPTIDASE
 ALKALINE PHOSPATASE
 LACTATE DEHYDROGENASE
 AMMONIA
 PROTHROMBIN TIME
 ALBUMIN
 VIRAL MARKERS.
 URINE-BILIRUBIN AND
UROBILINOGEN.
ALCOHOL
ACUTE LIVER
INJURY
obstruction
hemoltyic
Functional
enzymes

12. Hemolytic jaundice

13. Hepatic
jaundice

15. Obstructive
jaundice

18.  ASCITIC FLUID ANALYSIS should be
considered in patients with new-onset ascites,
or in those with established ascites but new
complaint such as fever, worsening abdominal
pain, gastrointestinal bleeding, hepatic
encephalopathy, hypotension, or renal failure.
 Screening-cell count,albumin,total protein
concentration.
 Gram stain and culture of ascitic fluid should be
performed if spontaneous bacterial peritonitis
(SBP) is suspected.
>250 polymorph nuclear
cells per cubic mm of
ascitic fluid.

21. SPONTANEOUS BACTERIAL
PERITONITIS
 Diffuse abdominal pain,fever nd
tenderness

22. HEPATIC
ENCEPHALOPATHY
 accumulation of nitrogenous waste
products normally metabolized by the
liver.
 Hepatic encephalopathy is a common
complication after transjugular
intrahepatic portosystemic shunt.
 diagnosis of exclusion

23. Diagnosis of exclusion
 end-stage liver disease -coagulopathic -
spontaneous or traumatic intracranial
hemorrhage
 hypoglycemia and nutritional encephalopathy's
such as Wernicke-Korsakoff syndrome.
 Cirrhotic patients - diuretics -hyper- or
hyponatremia.
 Altered mental status -decreased hepatic
clearance of drugs -benzodiazepines and
opiates.
 Renal failure, meningitis, and sepsis -cirrhotic
patient -hepatic encephalopathy.
Elevated
serum

24.  Lactulose is the current mainstay of therapy for
hepatic encephalopathy.
 Lactulose is given PO or PR. The oral dose is
20 grams diluted in a glass of water, fruit juice,
or carbonated drink. For rectal administration,
dilute 300 mL of syrup with 700 mL of water or
normal saline. The enema should be retained
for 30 minutes.
 Antibiotics including rifaximin, neomycin,
vancomycin, and metronidazole have been
suggested as a second-line therapy for hepatic
encephalopathy. These agents work by
reducing intestinal flora.

25. JAUNDICE
ENCEPHALOPATY
COAGULOPATHY(IN
R >1.5)
TRANSAMINASE
S >15*UPPER
LIMIT OF
NORMAL OR AST
>10001U/L

26. Fever, abdominal pain,
and obstructive
jaundice

27. CHOLANGITIS
CHARCOT TRAID
RUQ
PAIN,FEVER,JAUNDI
CE
CHARCOT TRAID
PLUS HYPOTENSION
AND
AMS=REYNOLDS
PENTAD
IV FLUIDS,IV ANTIBIOTICS,
BILIARY DRAINAGE.

28. EMPIRICAL MANGEMENT
 IV CANNULA
 IV FLUIDS
 ANTIEMETICS
 COAGULOPATHY-FFP AND PACKED
RED BLOOD CELLS
 SBP(SPONTANEOUS BACTERIAL
PERITONITIS)-
 IV THIRD GENERATION
CEPHALOSPORINS.
ALBUMIN INFUSION(INITIAL
DOSE 25% 1.5g/KG IV)
BETA BLOCKERS

30.  Acetaminophen(paracetamol toxicity)-N-
acetylcysteine(NAC)

31. Ascitic fluid tapping
 In the setting of large volume
paracentesis characterized by greater
than 5 L of ascitic fluid removed, IV
albumin repletion should be
considered to prevent circulatory
compromise with 6 to 8 g albumin
administered IV for each liter of ascitic
fluid removed

32. Biliary ….
 Patients with uncomplicated
cholecystitis should receive
intravenous fluids, antibiotics,
parenteral analgesics, and antiemetic
as needed, with subsequent
hospitalization.
 IMMEDIATE CHOLECYSTECTOMY
OR CHOLECYSTOSTOMY
=perforation or gangrene.

33. Disposition
 HOSPITALIZATION
 New onset jaundice
 Transaminase levels
approaching1000iu/L
 Bilirubin approaching 10 mg/dl,
 Any evidence of coagulopathy.
 Extrahepatic Obstructive jaundice-For
biliary drainage.


34.  DISCHARGE
 Patients with hepatitis or cholestatic
jaundice may be managed in the
outpatient setting, particularly patients
with normal mental status, stable vital
signs, ability to take oral fluids, no
evidence of acute bleeding or
significant coagulopathy, no
complicating infectious process, and
the ability to access follow-upcare

35. discussions
 A 41-year-oldmale with a history of
cirrhosis presents with fever, abdominal
distension, and confusion. A
paracentesis is performed in the
evaluation of spontaneous bacterial
peritonitis (SBP). What are the
diagnostic criteria found in the ascitic
fluid that confirms BP?
 a. Ascitic fluid neutrophil count >100
 b. Ascitic fluid neutrophil count >250
 c. Ascitic fluid total WBC count >100
 d. Ascitic fluid total WBC >250

36.  A 56-year-oldmale presents with fever
and abdominal distention. Bedside
ultrasound reveals ascites and the
results of paracentesis indicate possible
spontaneous bacterial peritonitis (SBP).
What daily medication should be stopped
upon admission?
 a. Amlodipine
 b. Crestor
 c. Lactulose
 d. Nadolol

37. MB is an 25-year-old female veteran who became ill one month after
returning from combat. Her initial symptoms were fatigue, anorexia,
and nausea. She noticed dark urine and became jaundiced a few
days later. She denied having fever, chills, abdominal pain or changes
in bowel habits. She had been previously healthy and did not have
any abnormal labs.
which of the followings are possible diagnoses ?
(1) Acute viral Hepatitis
(2) Drug induced viral disease
(3) Primary Biliary Cirrhosis
(4) Hereditary Hemochromatosis
(5) choledocholithiasis

38. WBC 6.2 K/mm3 (4.5-11)
Normal differential
Hemoglobin 12 g/dL (14-18)
Platelet count 268 K/mm3 (130-450)
Total Bilirubin 8.3 mg/dL (0.2-1.2)
Direct Bilirubin 4.7 mg/dL (0-0.2)
AST 5700 U/L (0-35)
ALT 6200 U/L (0-35)
Alkaline
Phosphatase
110 U/L (30-114)
Initial laboratory tests:

39. Which of the following tests are indicated (choose all that are correct)?
A. Gamma-glutamyl transpeptidase
B. Hepatitis A serologies
C. Anti-mitochondrial antibodies
D. Hepatitis B and C serologies
E. Prothrombin time