Jessica Nelson's SGR on the jaundiced patient

2. So, What is Jaundice
Anyway?

3. So, What is Jaundice
Anyway?

4.  Causes of Jaundice
 Liver Function Testing
 Patterns elevation
 Diagnosis
 Disposition

7.  Bilirubin
 Aspartate Aminotransferase
 Alanine Transaminase
 International Normalized Ratio
 Gamma-glutamyl Transpeptidase
 Alkaline Phosphatase
 Ammonia
 Albumin

8. LFT Panel
 AST
 ALT
 ALP
 Total Bilirubin
 Albumin
Specific Orders
 GGT
 INR
 Direct Bilirubin
 Ammonia

9.  Product of heme catabolism
 Metabolized in the liver
 Conjugated vs. Unconjugated
 Patterns of elevation

12.  What are they?
 Where are they?

13. How high can they go?
 Slight to moderate
 Moderate to high
 Very high

14. How high can they go?
 Slight to moderate
 Moderate to high
 Very high
Hemolysis
Fatty liver
Metastatic disease
Pancreatitis
Medications

15. How high can they go?
 Slight to moderate
 Moderate to high
 Very high
Chronic hepatitis
Skeletal muscle
MI
Mononucleosis
Alcoholic cirrhosis

16. How high can they go?
 Slight to moderate
 Moderate to high
 Very high
Muscle trauma
Acute viral hepatitis
Toxic hepatitis
Ischemic hepatitis

17. How can ratios help?
 AST/ALT = 1
 AST/ALT <1
 AST/ALT >2

18. How can ratios help?
 AST/ALT = 1
 AST/ALT <1
 AST/ALT >2
Ischemia

19. How can ratios help?
 AST/ALT = 1
 AST/ALT <1
 AST/ALT >2
Hepatocellular damage
Viral hepatitis
Ischemia
Toxic hepatitis

20. How can ratios help?
 AST/ALT = 1
 AST/ALT <1
 AST/ALT >2
Alcoholic hepatitis
Hepatocellular injury
Active cirrhosis
Tylenol overdose
Medication

23.  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

24. ALP
 Composite assay
 Non-specific
 Suggests:
 Obstruction
 Infiltration

25. GGT
 Amino acid transfer
 Sensitive
 Alcohol ingestion
 Suggests:
 Obstruction

26.  Nitrogen waste from protein breakdown
 Liver converts to urea
 How do we interpret elevations?

27.  Protein synthesized by the liver
 Marker of malnutrition
 Do we care about it?

28. Albumin
 Protein synthesized by the liver
 Marker of malnutrition
 Do we care about it?
Sort of….but not today

29. 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.

30. Guess what he took home after his
abscess I&D a week ago…

31. Guess what he took home after his
abscess I&D a week ago…Bactrim

32. 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

35.  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

36.  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?

37.  Imaging?
 Disposition?
Admit Discharge

38. 16 year old female presents with vomiting,
abdominal pain, and skin discoloration.

39. Mom leaves to park the car.
When interviewed alone, the patient starts
to cry and tells you she doesn’t want to live
anymore.

40. With further questioning, she talks about a
fight with her boyfriend and admits to taking
some pills later that night…

41. With further questioning, she talks about a
fight with her boyfriend and admit to taking
some pills later that night…2 days ago.

42. 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.

45.  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?

46.  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?

47.  Imaging?
 Disposition?
Admit or Discharge

48.  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.

49. 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

52.  T Bili 9.0
 AST 70
 ALT 150
 INR 1.1
 ALP 200
 GGT 100
 HgB 13
 WBC 10.4
 Platelets 268

53.  T Bili 9.0
 AST 70
 ALT 150
 INR 1.1
 ALP 250
 GGT 100
 HgB 13
 WBC 10.4
 Platelets 268

54.  Imaging?
 Treatment?
 Disposition?

55.  Neonatal Jaundice
 Jaundice in Pregnancy

57. 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's
Emergency 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