Introduction
Production and metabolism of bilirubin
Measurement of serum bilirubin
Measurement of urine bilirubin
Approach to the patient
Jaundice
Evaluation of the patient with jaundice. ALT, alanine aminotransferase; AMA, antimitochondrial antibody; ANA, antinuclear antibody; AST, aspartate aminotransferase; CMV, cytomegalovirus; EBV, Epstein-Barr virus; LKM, liver-kidney microsomal antibody; MRCP, magnetic resonance cholangiopancreatography; SMA, smooth-muscle antibody; SPEP, serum protein electrophoresis.
Isolated elevation of serum bilirubin
Unconjugated hyperbilirubinemia
Conjugated hyperbilirubinemia
Elevation of serum bilirubin with other liver test abnormalities
History
Physical exam
Laboratory tests
Hepatocellular conditions
- Viral hepatitis
- Hepatitis A, B, C, D, and E
- Epstein-Barr virus
- Cytomegalovirus
- Herpes simplex virus
- Alcoholic hepatitis
- Chronic liver disease and cirrhosis
- Drug toxicity
- Predictable, dose-dependent (e.g., acetaminophen)
- Unpredictable, idiosyncratic (e.g., isoniazid)
- Environmental toxins
- Vinyl chloride
- Jamaica bush tea—pyrrolizidine alkaloids
- Kava Kava
- Wild mushrooms—Amanita phalloides, A. verna
- Wilson’s disease
- Autoimmune hepatitis
Cholestatic conditions
- Ultrasound
- If dilated: CT/MRCP/ERCP if needed.
- If not dilated: AMA & hepatitis serologies with CMV and EBV
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