Jaundice

• • Classified as obstructive (conjugated bilirubinemia) or nonobstructive (unconjugated bilirubinemia)

  • Adult etiologies include:

  • -Obstruction due to benign or malignant causes (stones, tumors, strictures)

    -Sludge or stasis due to infection or total parenteral nutrition (TPN)

    -Hemolysis or hepatocellular dysfunction

  • Neonatal etiologies include:

  • -Physiologic

    -Biliary atresia

    -Choledochal cyst

    -TPN

    -Hemolysis

    -Alagille syndrome

    -Intrahepatic bile duct paucity

    -Byler syndrome

Symptoms and Signs

• • Jaundice

  • Malaise

  • Anorexia

  • Fatigue

  • Pruritus

  • Encephalopathy

  • Kernicterus

Laboratory Findings

• • Hyperbilirubinemia (conjugated or unconjugated)

  • Associated elevation of liver function tests if hepatocellular dysfunction

  • Anemia if associated sepsis, bleeding, or hemolysis

Imaging Findings

• • US: Shows biliary dilatation if obstruction present

  • CT: Shows biliary obstruction present and accompanying mass

  • ERCP, magnetic resonance cholangiopancreatography (MRCP), or percutaneous transhepatic cholangiogram (PTC): Shows biliary obstruction if mass present and proximal and distal extent

• • Conjugated hyperbilirubinemia in neonate

Rule Out

• • Anatomical obstruction to bile flow

• • History and physical exam

  • Bilirubin (conjugated and unconjugated)

  • US

  • CT

  • ERCP, MRCP, or PTC

When to Admit

• • Cholangitis

  • Obstructive jaundice in neonate

  • Encephalopathy

Surgery

• • Resolution of bilary tract stone disease by cholecystectomy and decompression of common bile duct by operative, radiologic or endoscopic intervention

  • Resection with biliary reconstruction of mass causing obstruction

  • Biliary-enteric bypass if benign stricture or unresectable malignant disease

Indications

• • Biliary obstruction

Contraindications

• • Medical comorbidity precluding resection or general anesthesia

  • Extrahepatic disease if malignant cause

Medications

• • Ursodiol

  • Phototherapy (neonate)

  • Exchange transfusion (neonate)

Treatment Monitoring

• • Serum bilirubin

Complications

• • Biliary-enteric anastomotic leak or stricture

References