PK 1 조 :: 조재완 DDx of jaundice

Jaundice: Introduction Jaundice - Yellowish discoloration : deposition of bilirubin – Serum hyperbilirubinemia – Liver disease – (rare) Hemolytic disorder Epidemiology – Pancreatic or biliary Ca 20 % – Gallstones 13% – Alcoholic cirrhosis 10% – Two or more factors Sickle cell anemia, organ transplantation, total parenteral nutrition, AIDS Reflect a medical emergency – Massive hemolysis – Ascending cholangitis – Neonate unconjugated hyperbilirubinemia – Fulminant hepatic failure

Classification of jaundice

Hx & P/E Information :  Use of drugs or herbal medications  Use of alcohol  Hepatitis risk factors  Abdominal operations, including gallbladder surgery  Inherited disorders including liver diseases and hemolytic disorders  HIV status  Travel history  Exposure to toxic substances Fever with chills, RUQ pain : acute cholangitis Anorexia, malaise, and myalgias : viral hepatitis Chronic liver failure/portal hypertension : Ascites, splenomegaly, spider angiomata, and gynecomastia Specific P/E finding Hyperpigmentation : hemochromatosis Kayser-Fleischer ring : Wilson's disease Xanthomas : primary biliary cirrhosis.

Lab studies Normal liver enzymes : – Hemolysis – Inherited disorders of bilirubin metabolism Indirect - Gilbert's and Crigler-Najjar syndrome Direct - Rotor and Dubin-Johnson syndrome ALP, AST/ALT : – Biliary obstruction – Intrahepatic cholestasis – Liver disease – AST/ALT ratio Serum total and indirect bilirubin Alkaline phosphatase Aminotransferases Prothrombin time Albumin

Subsequent Studies Evaluatation another disease; confirm Liver Bx Imaging tests : – Abdominal U/S – Endoscopic U/S – Abdomen CT, MRI – ERCP, PTC Serologic tests - viral hepatitis Antimitochondrial antibodies - primary biliary cirrhosis Antinuclear anti-sm, LKM antibodies - autoimmune hepatitis Serum levels of iron, transferrin, ferritin - hemochromatosis Serum levels of ceruloplasmin - Wilson's disease a-1 antitrypsin activity - a-1 antitrypsin deficiency

Approach to the Patient

Perioperative management of Liver Disease

Hx & P/E Information :  Use of drugs or herbal medications  Use of alcohol  Hepatitis risk factors  Abdominal operations, including gallbladder surgery  Inherited disorders including liver diseases and hemolytic disorders  HIV status  Travel history  Exposure to toxic substances Fever with chills, RUQ pain : acute cholangitis Anorexia, malaise, and myalgias : viral hepatitis Chronic liver failure/portal hypertension : Ascites, splenomegaly, spider angiomata, and gynecomastia Specific P/E finding Hyperpigmentation : hemochromatosis Kayser-Fleischer ring : Wilson's disease Xanthomas : primary biliary cirrhosis.

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