eMedicine Specialties > Gastroenterology > Liver
Hyperbilirubinemia, Conjugated: Differential Diagnoses & Workup
Updated: Feb 16, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
- CMV hepatitis
- Drug toxicity, especially the following: acetaminophen, allopurinol, anabolic steroids, chlorpromazine, estrogens, halothane, isoniazid, methyldopa, phenytoin, protease inhibitors, quinidine, rifampicin, statins, and sulfa drugs
- Exposure to environmental hepatotoxins (eg, beryllium, "nutraceuticals" [eg, herbal tea], organic solvents)
- Acute fatty liver of pregnancy
- Inherited disorders of bilirubin conjugation (eg, Rotor syndrome)
- Liver congestion
- Liver ischemia (shock liver)
- Rejection of transplanted liver
- Reye syndrome
- Total parenteral nutrition (TPN) toxicity
- Veno-occlusive disease associated with chemotherapy
Workup
Laboratory Studies
- Appropriate initial laboratory testing in cases of conjugated hyperbilirubinemia depends on the clinical history and physical examination findings.2,3,5
- All patients should be tested for the following:
- Complete blood cell (CBC) count to screen for hemolysis
- Serum aminotransferases (aspartate aminotransferase [AST], alanine aminotransferase [ALT])
- Serologic screen for hepatitis, including hepatitis C virus (HCV) antibody and hepatitis B surface antigen (HBsAg) or antihepatitis B core antibody (anti-HBcAb)
- Alkaline phosphatase (ALP): If elevated or if an obstruction is suspected, images of the bile ducts should be obtained. Gamma-glutamyl transpeptidase (GGTP) results may help differentiate a hepatic source from bone or other causes.
- Fractionated bilirubin
- Blood alcohol or acetaminophen levels upon admission (may be useful in certain cases).
- Antimitochondrial antibody when considering primary biliary cirrhosis
- Antinuclear antibodies (ANAs), smooth-muscle antibodies, and other serologic studies when considering autoimmune hepatitis
- Iron and genetic studies when considering hemochromatosis
- Copper studies when considering Wilson disease
- Alpha-1 antitrypsin fractionation and other studies when considering hereditary liver diseases
Imaging Studies
- Abdominal ultrasonography should be performed to exclude biliary obstruction and to evaluate the liver parenchyma for possible cirrhosis, tumor, steatosis, or congestion.
- Advantages
- Safe
- Noninvasive
- Portable
- Provides good visualization of the gallbladder, bile ducts, and cystic lesions
- Can detect parenchymal liver disease, such as cirrhosis or infiltration, and signs of portal hypertension
- Disadvantages
- Limited resolution
- May not detect common bile duct stones because of bowel gas
- Advantages
- Abdominal computed tomography (CT) scans provide additional information about patients with abnormal ultrasonography scans, and CT scanning may be the initial imaging modality in some cases.
- Advantages
- Better resolution than ultrasonography
- Provides good evaluation of the entire bile duct
- Can define the anatomy better than ultrasonography, especially if contrast agents are used
- Better for evaluating suspected malignancies, especially with evaluation of the arterial phase
- Permits guided needle biopsies
- Disadvantages
- More expensive and less portable than ultrasonography
- Requires radiation exposure
- Requires IV contrast medium for best results
- Less sensitive than ultrasonography for gallbladder stones
- Advantages
- Abdominal magnetic resonance imaging (MRI) produces images comparable in quality to CT scans without patient exposure to ionizing radiation. Following administration of suitable contrast agents, detailed imaging of the biliary tract is possible. Magnetic resonance cholangiopancreatography (MRCP) may be particularly useful when evaluating cholestasis of pregnancy or patients who are too debilitated to tolerate traditional cholangiography.
- Advantages
- Requires no exposure to ionizing radiation (ie, safe in pregnancy)
- Permits multiple contrast agents and multiple scanning techniques, which enhance potential information content
- Permits guided needle biopsies (open MRI systems only)
- With special contrast agents, can evaluate bile and pancreatic ducts
- Disadvantages
- Not universally available
- Cannot be used in most patients with metallic implants
- Requires IV contrast medium for best results
- Clinical experience is still somewhat limited
- Advantages
- Endoscopic retrograde cholangiopancreatography (ERCP) is useful in cases where biliary obstruction is strongly suspected. It is the investigation of choice to detect and treat common bile duct stones and is also useful for making a diagnosis of pancreatic cancer. Other conditions in which ERCP may be useful include primary sclerosing cholangitis and the presence of choledochal cysts.
- Advantages
- Allows treatment of obstruction using sphincterotomy, stone extraction, stent placement, or balloon-dilation of strictures
- Permits biopsies under direct visualization
- Provides excellent visualization of bile ducts
- Disadvantages
- Requires conscious sedation and radiation exposure
- May cause pancreatitis and other complications
- Not always successful, especially after gastroduodenal surgery
- Advantages
- Percutaneous transhepatic cholangiography (PTC or PTHC) offers most of the diagnostic and therapeutic possibilities of ERCP and may be more readily available in some settings. It can be useful in cases in which ERCP has been unsuccessful or is not available.
- Advantages
- Successful in most cases of biliary obstruction
- Allows treatment of obstruction by stone extraction, balloon-dilation of strictures, or stent placement
- Permits biopsies or brush cytology
- Provides excellent visualization of the bile ducts
- Disadvantages
- Typically more invasive than ERCP
- May not be successful unless the bile ducts are dilated
- Requires radiation exposure and use of contrast medium
- Advantages
More on Hyperbilirubinemia, Conjugated |
| Overview: Hyperbilirubinemia, Conjugated |
 Differential Diagnoses & Workup: Hyperbilirubinemia, Conjugated |
| Treatment & Medication: Hyperbilirubinemia, Conjugated |
| Follow-up: Hyperbilirubinemia, Conjugated |
| References |
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References
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Further Reading
Keywords
conjugated hyperbilirubinemia, hyperbilirubinemia, icterus, jaundice, kernicterus, bilirubin accumulation, bilirubin formation, tetrapyrrole, hemoglobin, unconjugated bilirubin, conjugated bilirubin, liver disease, biliary disease
