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Published on 02/06/2015 by admin

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Jaundice

PREDOMINANCE OF DIRECT (CONJUGATED) BILIRUBIN

• Extrahepatic obstruction
• Common duct abnormalities: calculi, neoplasm, stricture, cyst, sclerosing cholangitis
• Metastatic carcinoma
• Pancreatic carcinoma, pseudocyst
• Ampullary carcinoma
• Hepatocellular disease: hepatitis, cirrhosis
• Drugs: estrogens, phenothiazines, captopril, methyltestosterone, labetalol
• Cholestatic jaundice of pregnancy
• Hereditary disorders: Dubin-Johnson syndrome, Rotor’s syndrome
• Recurrent benign intrahepatic cholestasis

PREDOMINANCE OF INDIRECT (UNCONJUGATED) BILIRUBIN

• Hemolysis: hereditary and acquired hemolytic anemias
• Inefficient marrow production
• Impaired hepatic conjugation: chloramphenicol
• Neonatal jaundice
• Hereditary disorders: Gilbert’s syndrome, Crigler-Najjar syndrome

Jaundice in the Adult Patient

PREHEPATIC CAUSES

• Unconjugated hyperbilirubinemia: excessive heme metabolism from hemolysis (e.g., sickle cell disease, spherocytosis, G6PD, immune hemolysis), ineffective erythropoiesis (e.g., thalassemia, folate, severe iron deficiency), or large hematoma reabsorption

INTRAHEPATIC CAUSES

• Unconjugated hyperbilirubinemia: disorders of enzyme metabolism such as Gilbert’s disease (common, benign), Crigler-Najjar syndrome (rare, severe), or drugs such as rifampin and probenecid
• Conjugated hyperbilirubinemia: intrahepatic cholestasis
• Viruses: hepatitis A, B, and C; Epstein-Barr
• Alcohol: alcoholic hepatitis, alcoholic cirrhosis
• Autoimmune: primary biliary cirrhosis, primary sclerosing cholangitis
• Drug induced: acetaminophen, penicillins, oral contraceptives, chlorpromazine (Thorazine), steroids (estrogenic or anabolic), some herbals
• Hereditary metabolic: hemochromatosis, Wilson’s disease, Dubin-Johnson and Rotor’s syndromes, α1-antitrypsin deficiency
• Systemic disease: sarcoidosis, amyloidosis, glycogen storage diseases, celiac disease, tuberculosis, Mycobacterium avium-intracellulare
• Other: sepsis, total parenteral nutrition, pregnancy, graft-versus-host disease, environmental toxins

POSTHEPATIC CAUSES

• Conjugated hyperbilirubinemia: intrinsic or extrinsic obstruction of the biliary system
• Intrinsic blockage: gallstones, cholangitis, strictures, infection (e.g., cytomegalovirus, Cryptosporidium in AIDS patients, parasites, cholangiocarcinoma, gallbladder cancer)
• Extrinsic blockage: pancreatitis, pancreatic carcinoma, pancreatic pseudocyst
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