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Causes of Elevated Billirubin Cheat Sheet (DRAFT) by [deleted]

Causes of Elevated Billirubin

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Causes of Elevated Bilirubin

Elevated unconj­ugated biliru­bin
Gilbert’s syndrome
Crigle­r-N­ajjar syndrome
Hemolysis (intra­vas­cular and extrav­asc­ular)
Ineffe­ctive erythr­opo­iesis
Resorption of large hematomas
Neonatal jaundice
Hypert­hyr­oidism
Medica­tions
Post-blood transf­usion
Elevated conjugated hyperb­ili­rub­ine­mia
Bile duct obstru­ction
     Choled­och­oli­thiasis
     Malignant obstru­ction
     Bile duct flukes
Bile duct stricture
AIDS cholan­gio­pathy
Viral hepatitis
Toxic hepatitis
Medica­tions or drug-i­nduced liver injury
Acute alcoholic hepatitis
Ischemic hepatitis
Cirrhosis
Primary biliary cirrhosis
PSC
Infilt­rative diseases of the liver
     Sarcoid
     Granul­omatous hepatitis
     Tuberc­ulosis
     Metastatic cancer
     Lymphoma
Hepato­cel­lular carcinoma
Wilson disease (espec­ially fulminant Wilson’s disease)
Autoimmune hepatitis
Ischemic hepatitis
Congestive hepato­pathy
Sepsis
TPN
Intrah­epatic choles­tasis of pregnancy
Benign post-o­per­ative jaundice
ICU or multif­act­orial jaundice
Benign recurrent choles­tasis
Vanishing bile duct syndrome
Ductopenia
 

Continued

Dubin-­Johnson syndrome
Rotor syndrome
Sickle cell liver crisis
Hemoph­ago­cytic lympho­his­tio­cytosis
PSC, primary sclerosing cholan­gitis; TPN, total parenteral nutrition.

Algorithm Elevated (predo­minant unconj­ugated)

Elevated total bilirubin (predo­minant unconj­uga­ted)
1. History and physical exam
Assess liver transa­minases and serum alkaline phosph­atase
2. Review medica­tions
Evaluate for hemolysis
Evaluate for Gilbert's syndrome
3. If persistent elevation is otherwise unexpl­ained, may consider
diagnostic testing for Gilbert's syndrome (UGT1A1 genotype)
and evaluate for uncommon etiologies in Table 6
4. If persistent elevation is otherwise unexpl­ained, is
sympto­matic, is worsening over time, and/or associated with
abnormal transa­minases
--> consider liver biopsyy

Algorithm Elevated (predo­minant conjug­ated)

Elevated total bilirubin (predo­minant conjug­ated)
1. History & physical exam
Assess liver transa­minases and serum alkaline phosph­atase
2. Review medica­tions
Evaluate for clinically overt etiolo­gies: sepsis, TPN, cirrhosis, & biliary obstru­ction
Perform right upper quadrant ultrasound
3. If ductal dilatation --> ERCP or MRCP
If no ductal dilatation --> check AMA, ANA, and SMA
4. If persistent elevation is otherwise unexpl­ained, is
sympto­matic, is worsening over time, and/or associated with
abnormal transa­minases
--> consider liver biopsy