**2. Approach to jaundice**

Jaundice (i.e., icterus) is the buildup of bilirubin; a waste product stemmed from the metabolism of aging/destruction of red blood cells (RBCs), causing a yellowish

discoloration in tissues that are filled with elastic collagen, such as skin, sclera, and mucus membranes, etc. [1].

Let us take some cases here to further understand how jaundice can present.

## **2.1 Case-1**

A 14-year-old (y/o) African-American male presented to the emergency department (ED) with severe abdominal pain, swelling of both hands and jaundice. Family history includes two uncles that suffer from "blood problems." Blood tests showed normal alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin was 3.2 mg/dL (2.8 indirect). On peripheral blood smear, sickling was found. Hemoglobin electrophoresis confirmed SS hemoglobin and patient was diagnosed with sickle cell anemia (SCA).

#### **2.2 Case-2**

A 42-year-old Caucasian male presented to the office with 2 months of jaundice and abdominal pain. The patient had a blood transfusion in 1988 at the age of 15.


#### **Table 1.**

*Types of Jaundice [2, 3].*


**173**

**Figure 1.**

*Approach to Jaundice.*

Physical exam showed typical signs of cirrhosis. Labs showed an ALP of 200, ALT 2810, AST 2670 U/L, normal gamma-glutamyl transferase (GGT), bilirubin of 3.3 mg/dL (2 direct, 1.3 indirect), and normal iron and copper levels. Patient was positive for hepatitis C, attributed to his previous blood transfusion. Alpha fetoprotein (AFP) levels were elevated and patient was scheduled for a liver ultrasound

(US) and biopsy to rule out hepatocellular carcinoma (HCC).

*Eosinophilic Cholangitis*

**Table 3.**

*DOI: http://dx.doi.org/10.5772/intechopen.86004*

*Clinical findings depending on type of jaundice [4].*

**Clinical findings Urine color Stool color Large** 

Pre-hepatic (hemolytic) Normal Brown Positive

Post-hepatic (obstructive) Dark (CB) Pale Negative

Hepatic (hepatocellular) Dark (combination of CB + urobilinogen) Slightly

**spleen**

Positive

pale

#### **Table 2.**

*Lab findings depending on type of jaundice [4].*


**Table 3.**

*Cells of the Immune System*

**2.1 Case-1**

**2.2 Case-2**

Pre-hepatic (hemolytic)

Hepatic (hepatocellular)

Post-hepatic (obstructive)

*Types of Jaundice [2, 3].*

Pre-hepatic (hemolytic)

Post-hepatic (obstructive)

*Lab findings depending on type of jaundice [4].*

Hepatic (hepatocellular)

**Table 1.**

mucus membranes, etc. [1].

discoloration in tissues that are filled with elastic collagen, such as skin, sclera, and

Let us take some cases here to further understand how jaundice can present.

A 14-year-old (y/o) African-American male presented to the emergency depart-

A 42-year-old Caucasian male presented to the office with 2 months of jaundice and abdominal pain. The patient had a blood transfusion in 1988 at the age of 15.

• Decreased conjugation (e.g., Gilbert's syndrome)

• Excess aged/destroyed RBCs (e.g., hemolysis, blood transfusion) • Decreased hepatic uptake (e.g., portosystemic shunt, drugs)

• Excretion defect (Dubin-Johnson syndrome, Rotor syndrome)

• Biliary tract disease (primary sclerosing cholangitis, primary biliary cirrhosis,

• Biliary tract obstruction (gallstones, cholangiocarcinoma, pancreatic or liver

**Unconjugated bilirubin (UCB)**

**Total bilirubin** **Conjugated bilirubin in urine**

ment (ED) with severe abdominal pain, swelling of both hands and jaundice. Family history includes two uncles that suffer from "blood problems." Blood tests showed normal alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin was 3.2 mg/dL (2.8 indirect). On peripheral blood smear, sickling was found. Hemoglobin electrophoresis confirmed SS

hemoglobin and patient was diagnosed with sickle cell anemia (SCA).

**Type of jaundice Differential diagnosis**

• Viral hepatitis • Hepatic steatosis • Alcoholic hepatitis

**Lab findings AST + ALT ALP Conjugated** 

• Non-alcoholic steatohepatitis • Autoimmune hepatitis • Ischemic hepatitis • Drug-induced hepatitis • Hemochromatosis • Wilson's disease

eosinophilic cholangitis, etc.)

cancer, pancreatic pseudocyst, etc.)

**bilirubin (CB)**

Normal Normal Normal Normal/ Normal/ Negative

Positive

Normal Positive

**172**

**Table 2.**

*Clinical findings depending on type of jaundice [4].*
