Approach to the Jaundiced Patient

Approach to the Jaundiced Patient
Internal Medicine Survivor Series
By:Joel Bruggen, MD

New Onset Jaundice
* Viral hepatitis
* Alcoholic liver disease
* Autoimmune hepatitis
* Medication-induced liver disease
* Common bile duct stones
* Pancreatic cancer
* Primary Biliary Cirrhosis (PBC)
* Primary Sclerosing Cholangitis (PSC)

Jaundiced Emergencies
* Acetaminophen Toxicity
* Fulminant Hepatic Failure
* Ascending Cholangitis

Jaundice Unrelated to Intrinsic Liver Disease
* Hemolysis (usually T. bili < 4)
* Massive Transfusion
* Resorption of Hematoma
* Ineffective Erythropoesis
* Disorders of Conjugation
o Gilbert’s syndrome
* Intrahepatic Cholestasis
o Sepsis, TPN, Post-operation

New Onset Jaundice
* Viral hepatitis
* Alcoholic liver disease
* Autoimmune hepatitis
* Medication-induced liver disease
* Common bile duct stones
* Pancreatic cancer
* Primary Biliary Cirrhosis (PBC)
* Primary Sclerosing Cholangitis (PSC)

HBV Serology
Resolved HBV
HBV vaccinated
Chronic HBV
Acute HBV
HBSAb
HBcAb
IgG
HBcAb
IgM
Acute Hepatitis C
HCV RNA
Anti-HCV
Infection Day 0
HCV RNA Day 12
HCV Antibody Day 70
Plateau phase = 57 days

Alcoholic Liver Disease
* The history is the key – 60 grams/day
* Gynecomastia, parotids, Dupuytren’s
* Lab clues: AST/ALT > 2, MCV > 94

AST < 300
* Alcoholic hepatitis:
o Anorexia, fever, jaundice, hepatomegaly
o Treatment:
+ Abstinence
+ Nutrition
+ Consider prednisolone or pentoxifylline

Alcoholic Liver Disease
Discriminant Function Formula:
DF = [4.6 x (PT – control)] + bilirubin
Consider treatment for DF > 32
* Prednisolone 40 mg/day x 28 days
o contraindications: infection, renal failure, GIB
* Pentoxifylline 400 mg PO tid x 28 days

Autoimmune Hepatitis
* Widely variable clinical presentations
o Asymptomatic LFT abnormality (ALT and AST)
o Severe hepatitis with jaundice
o Cirrhosis and complications of portal HTN
* Often associated with other autoimmune dz
* Diagnosis:
o Compatible clinical presentation
o ANA or ASMA with titer 1:80 or greater
o IgG > 1.5 upper limits of normal
o Liver biopsy: portal lymphocytes + plasma cells

Drug-induced Liver Disease
* Hepatocellular
o acetaminophen, INH, methyldopa, MTX
* Cholestatic
o chlorpromazine, estradiol, antibiotics
* Chronic Hepatitis
o methyldopa, phenytoin, macrodantin, PTU
* Hypersensitivity Reaction
o Phenytoin, Augmentin, allopurinol
* Microvesicular Steatosis
o amiodarone, IV tetracycline, AZT, ddI, stavudine

Acetaminophen Toxicity
* Danger dosages (70 kg patient)
o Toxicity possible > 10 gm
o Severe toxicity certain > 25 gm
o Lower doses potentially hepatotoxic in:
+ Chronic alcoholics
+ Malnutrition or fasting
+ Dilantin, Tegretol, phenobarbital, INH, rifampin
+ NOT in acute EtOH ingestion
+ NOT in non-alcoholic chronic liver disease

Acetaminophen Toxicity
* Day 1:
o Nausea, vomiting, malaise, or asymptomatic
* Day 2 – 3:
o Initial symptoms resolve
o AST and ALT begin to rise by 36 hours
o RUQ pain, tender enlarged liver on exam
* Day 4
o AST and ALT peak > 3000
o Liver dysfunction: PT, encephalopathy, jaundice
o Acute renal failure (ATN)

Acetaminophen Toxicity Treatment
Indications for NAC therapy:
Fulminant Hepatic Failure
* Definition:
o Rapid development of hepatic dysfunction
o Hepatic encephalopathy
o No prior history of liver disease
* Most common causes:
o Acetaminophen
o Unknown
o Idiosyncratic drug reaction
o Acute HAV or HBV (or HDV or HEV)

Fulminant Hepatic Failure
* Close glucose monitoring IV glucose
* Avoid sedatives - give PO lactulose
* Avoid nephrotoxins and hypovolemia
* Vitamin K SQ
o Do not give FFP unless active bleeding, since INR is an important prognostic factor
* GI bleed prophylaxis with PPI
* Transfer all patients with FHF who are candidates to a liver transplant center

Indications:
* Hepatitis C 29%
* Alcoholic Liver Disease 15%
* Cirrhosis of unknown etiology 8%
* Hepatocellular Carcinoma 7%
* Fulminant Hepatic Failure 6%
* Primary Sclerosing Cholangitis 5%
* Primary Biliary Cirrhosis 4%
* Metabolic Liver Disease 4%
* Autoimmune Hepatitis 3%
* Hepatitis B 3%

Liver Transplantation:
Contraindications
* ABSOLUTE
o active alcohol or drug abuse
o HIV positivity
o extrahepatic malignancy
o uncontrolled extrahepatic infection
o advanced cardiopulmonary disease
* RELATIVE
o Age over 65
o poor social support
o poorly controlled mental illness

Obstructive Jaundice
CBD stones (choledocholithiasis) vs. tumor
* Clinical features favoring CBD stones:
o Age < 45
o Biliary colic
o Fever
o Transient spike in AST or amylase
* Clinical features favoring cancer:
o Painless jaundice
o Weight loss
o Palpable gallbladder
o Bilirubin > 10

Ascending Cholangitis
* Pus under pressure
* Charcot’s triad: fever, jaundice, RUQ pain
o All 3 present in 70% of patients, but fever > 95%
o May also present as confusion or hypotension
* Most frequent causative organisms:
o E. Coli, Klebsiella, Enterobacter, Enterococcus
o anaerobes are rare and usually post-surgical
* Treatment:
o Antibiotics: Levaquin, Zosyn, meropenem
o ERCP with biliary drainage

Ascending Cholangitis
Indications for Urgent ERCP
* Persistent abdominal pain
* Hypotension despite adequate IVF
* Fever > 102
* Mental confusion
* Failure to improve after 12 hours of antibiotics and supportive care

Obstructive Jaundice Malignant Causes
* Cancer of the Pancreas
* Cancer of the Bile Ducts (Cholangiocarcinoma)
* Ampullary Tumors
* Portal Lymphadenopathy

Primary Biliary Cirrhosis
* Cholestatic liver disease (ALP)
o Most common symptoms: pruritus and fatigue
o Many patients asx, and dx by abnormal LFT
* Female:male ratio 9:1
* Diagnosis:
o Compatible clinical presentation
o AMA titer 1:80 or greater (95% sens/spec)
o IgM > 1.5 upper limits of normal
o Liver biopsy: bile duct destruction
* Treatment: Ursodeoxycholic acid 15 mg/kg

Primary Sclerosing Cholangitis
* Cholestatic liver disease (ALP)
* Inflammation of large bile ducts
* 90% associated with IBD
o but only 5% of IBD patients get PSC
* Diagnosis: ERCP (now MRCP)
o No autoantibodies, no elevated globulins
o Biopsy: concentric fibrosis around bile ducts
* Cholangiocarcinoma: 10-15% lifetime risk
* Treatment: Liver Transplantation

Diagnosis of Immune-Mediated Liver Disease
Periductal concentric fibrosis
Unusual Causes of Jaundice
* Ischemic hepatitis
* Congestive hepatopathy
* Wilson’s disease
* AIDS cholangiopathy
* Amanita phalloides (mushrooms)
* Jamaican bush tea
* Infiltrative diseases of the liver
o Amyloidosis
o Sarcoidosis
o Malignancy: lymphoma, metastatic dz

Wilson’s Disease
* Autosomal recessive – copper metabolism
* Chronic hepatitis or fulminant hepatitis
* Associated clinical features:
o Neuropsychiatric disease
o Hemolytic anemia
* Physical exam: Kayser-Fleischer rings
* Diagnosis: ceruloplasmin, urinary Cu
* Treatment: d-penicillamine

Critical Questions in the Evaluation of the Jaundiced Patient
* Acute vs. Chronic Liver Disease
* Hepatocellular vs. Cholestatic
o Biliary Obstruction vs. Intrahepatic Cholestasis
* Fever
o Could the patient have ascending cholangitis?
* Encephalopathy
o Could the patient have fulminant hepatic failure?

Evaluation of the Jaundiced Patient HISTORY

* Pain
* Fever
* Confusion
* Weight loss
* Sex, drugs, R&R
* Alcohol
* Medications
* pruritus
* malaise, myalgias
* dark urine
* abdominal girth
* edema
* other autoimmune dz
* HIV status
* prior biliary surgery
* family history liver dz

Evaluation of the Jaundiced Patient PHYSICAL EXAM
* BP/HR/Temp
* Mental status
* Asterixis
* Abd tenderness
* Liver size
* Splenomegaly
* Ascites
* Edema
* Spider angiomata
* Hyperpigmentation
* Kayser-Fleischer rings
* Xanthomas
* Gynecomastia
* Left supraclavicular adenopathy (Virchow’s node)

Evaluation of the Jaundiced Patient LAB EVALUATION
* AST-ALT-ALP
* Bilirubin – total/indirect
* Albumin
* INR
* Glucose
* Na-K-PO4, acid-base
* Acetaminophen level
* CBC/plt
* Ammonia
* Viral serologies
* ANA-ASMA-AMA
* Quantitative Ig
* Ceruloplasmin
* Iron profile
* Blood cultures

Evaluation of the Jaundiced Patient
* Ultrasound:
o More sensitive than CT for gallbladder stones
o Equally sensitive for dilated ducts
o Portable, cheap, no radiation, no IV contrast
* CT:
o Better imaging of the pancreas and abdomen
* MRCP:
o Imaging of biliary tree comparable to ERCP
* ERCP:
o Therapeutic intervention for stones
o Brushing and biopsy for malignancy

Case studies

Approach to the Jaundiced Patient.ppt

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Managing Low Birth Weight and Sick Newborns

Managing Low Birth Weight and Sick Newborns

Advances in Maternal and Neonatal Health

Session Objectives
* To define essential elements of the care of sick newborns, including neonatal resuscitation
* To discuss best practices and technologies

Management of Newborn Illness

* Education of mothers to recognize danger signals
* Working with families to develop complication plan for newborns
* Early recognition and appropriate management of newborn illness

Minimum Preparation for ANY Birth
The following should be available and in working order:
* Heat source
* Mucus extractor
* Self-inflating bag of newborn size
* 2 masks (for normal and small newborns)
* 1 clock
* At least one person skilled in newborn resuscitation present at birth

Essential Care for All Newborns
Most newborns breathe as soon as they are born and only need:
* A clean and warm welcome
* Vigilant observation
* Warmth
* To be observed for breathing
* To be given to the mother for warmth and breastfeeding

Immediate Care of the Newborn: Warmth
* Lay newborn on mother’s abdomen or other warm surface
* Immediately dry newborn with clean (warm) cloth or towel
* Remove wet towel and wrap/cover newborn, except for face and upper chest, with a second towel/cloth

* Blood on newborn is not a risk to newborn, but is a risk to caregiver
* Bathe after 24 hours
* In areas with high HIV prevalence, consider bathing earlier to reduce risk of maternal-fetal transmission, and to reduce risk to caregiver and to other newborns

Immediate Care of the Newborn
* Assess breathing
* Keep head in a neutral position
* IMMEDIATELY assess respirations and need for resuscitation

Signs of Good Health at Birth
Objective measures
* Breathing
* Heart rate above 100 beats/minute
Subjective measures
* Vigorous cry
* Pink skin
* Good muscular tone
* Good reactions to stimulus
* Most important measure is whether newborn is breathing
* Assessing all of above delays resuscitation, if it is necessary.

Birth Asphyxia
* Definition: Failure to initiate and sustain breathing at birth
* Magnitude:
o 3% of 120 million newborns each year in developing countries develop birth asphyxia and require resuscitation
o An estimated 900,000 of these newborns die as a result of asphyxia

Steps in Resuscitation
* Anticipate need for resuscitation at every birth, be prepared with equipment in good condition
* Prevent of heat loss (dry newborn and remove wet clothes)
* Assess breathing
* Resuscitate:
o Open airway
+ Position newborn
+ Clear airway
o Ventilate
o Evaluate

Assess Breathing
Newborn crying?
Provide routine care
* Chest is rising symmetrically
* Frequency >30 breaths/min.
* Not breathing/ gasping
* Breathing < 30 or > 60 breaths/ min.

Immediately start resuscitation
Provide routine care
Open Airway
* Position newborn on its back
* Place head in slightly extend position
* Suction mouth then nostrils

Ventilate
* Select appropriate mask size to cover chin, mouth and nose with a good seal
* Squeeze bag with two fingers or whole hand, look for chest to rise
* If chest not rising:
o Reposition head and mask
o Increase ventilation
o Repeat suctioning

Evaluate
After ventilating for about 1 minute, stop and look for spontaneous breathing
If no breathing, breathing is slow (< 30 breaths/ min.) or is weak with severe indrawing
If newborn starts crying/breathing spontaneously
Continue ventilating until spontaneous cry/ breathing begins

* Stop ventilating
* Do not leave newborn
* Observe breathing
* Put newborn skin-to-skin with mother and cover them both

Harmful and Ineffective Resuscitation Practices
Practices to be avoided include:
* Routine aspiration of the newborn’s mouth and nose as soon as the head is born
* Routine aspiration of the newborn’s stomach at birth
* Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation
* Postural drainage and slapping the back: dangerous
* Squeezing the chest to remove secretions from the airway
* Routine giving of sodium bicarbonate to newborns who are not breathing
* Intubation by an unskilled person
* Some traditional practices:
o Putting alcohol in newborn’s nose
o Sprinkling or soaking newborn with cold water
o Stimulating anus
o Slapping newborn

Infection Prevention for Resuscitation
* Handwashing
* Use of gloves
* Careful suctioning if using a mucus extractor operated by mouth
* Careful cleaning and disinfection of equipment and supplies
o Do not reuse bulb—difficult to clean, poses risk of cross infection
* Correct disposal of secretions

Documentation
Details of the re
Post-Resuscitation Tasks: Successful Resuscitation
Post-Resuscitation Tasks: Unsuccessful Resuscitation
Policy Decisions for Resuscitation
Principles of Success
Care of the Low Birth Weight Newborn
Care of the Preterm Newborn
Principles of Management for Low Birth Weight and Preterm Newborns
* Warmth
* Feeding
* Detection and management of complications (e.g., resuscitation, assisted respiration)

As for all newborns:
* Lay newborn on mother’s abdomen or other warm surface
* Dry newborn with clean (warm) cloth or towel
* Remove wet towel and wrap/cover with a second dry towel
* Bathe after temperature is stable

Warmth: Problem with Incubators
* Potential source of infection
* Often temperature controls malfunction
* Often share incubator for more than one newborn

Need alternative method: kangaroo care
Feeding
Early and exclusive breastfeeding
* Breastmilk = best nourishment
* Already warm temperature
* Facilitated by kangaroo care

Definition of Kangaroo Care
* Early, prolonged and continuous skin-to-skin contact between a mother and her newborn
* Could be in hospital or after early discharge

How to Use Kangaroo Care
* Newborn’s position:
o Held upright (or diagonally) and prone against skin of mother, between her breasts
o Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways
* Newborn’s clothing:
o Usually naked except for nappy and cap
o May be dressed in light clothing
o Mother covers newborn with her own clothes and added blanket or shawl
* Newborn should be:
o Breastfed on demand
o Supervised closely and temperature monitored regularly
* Mother needs lots of support because kangaroo care:
o Is very tiring for her
o Restricts her freedom
o Requires commitment to continue

Effectiveness of Kangaroo Care
* Randomized controlled trial
* Conducted in three tertiary and teaching hospitals in Ethiopia, Indonesia and Mexico
* Study effectiveness, feasibility, acceptability and cost of kangaroo mother care when compared to conventional methods of care
Benefits of Kangaroo Care
* Is efficient way of keeping newborn warm
* Helps breathing of newborn to be more regular; reduce frequency of apneic spells
* Promotes breastfeeding, growth and extra-uterine adaptation
* Increases the mother’s confidence, ability and involvement in the care of her small newborn
* Seems to be acceptable in different cultures and environments
* Contributes to containment of cost— salaries, running costs (electricity, etc.)

Summary

* Skilled attendant
* Equipment available and working
* Begin resuscitation immediately
o Ventilate
o Reassess frequently
o Kangaroo care once successful

References

Managing Low Birth Weight and Sick Newborns.ppt

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Normal Newborn Care

Normal Newborn Care - Advances in Maternal and Neonatal Health

Normal Newborn Care
Session Objective
* Define essential elements of early newborn care
* Discuss best practices and technologies for promoting newborn health
* Use relevant data and information to develop appropriate essential newborn recommendations

Newborn Deaths
Essential Newborn Care Interventions
* Clean childbirth and cord care
o Prevent newborn infection
* Thermal protection
o Prevent and manage newborn hypo/hyperthermia
* Early and exclusive breastfeeding
o Started within 1 hour after childbirth
* Initiation of breathing and resuscitation
o Early asphyxia identification and management
* Eye care
o Prevent and manage ophthalmia neonatorum
* Immunization
o At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO)
* Identification and management of sick newborn
* Care of preterm and/or low birth weight newborn

Cleanliness to Prevent Infection
* Principles of cleanliness essential in both home and health facilities childbirths
* Principles of cleanliness at childbirth
o Clean hands
o Clean perineum
o Nothing unclean introduced vaginally
o Clean delivery surface
o Cleanliness in cord clamping and cutting
o Cleanliness for cord care
* Infection prevention/control measures at healthcare facilities

Thermal Protection
* Newborn physiology
o Normal temperature: 36.5–37.5°C
o Hypothermia: < 36.5°C
o Stabilization period: 1st 6–12 hours after birth
+ Large surface area
+ Poor thermal insulation
+ Small body mass to produce and conserve heat
+ Inability to change posture or adjust clothing to respond to thermal stress
* Increase hypothermia
o Newborn left wet while waiting for delivery of placenta
o Early bathing of newborn (within 24 hours)

Hypothermia Prevention
* Deliver in a warm room
* Dry newborn thoroughly and wrap in dry, warm cloth
* Keep out of draft and place on a warm surface
* Give to mother as soon as possible
o Skin-to-skin contact first few hours after childbirth
o Promotes bonding
o Enables early breastfeeding
* Check warmth by feeling newborn’s feet every 15 minutes
* Bathe when temperature is stable (after 24 hours)

Early and Exclusive Breastfeeding
* Early contact between mother and newborn
o Enables breastfeeding
o Rooming-in policies in health facilities prevents nosocomial infection
* Best practices
o No prelacteal feeds or other supplement
o Giving first breastfeed within one hour of birth
o Correct positioning to enable good attachment of the newborn
o Breastfeeding on demand
o Psycho-social support to breastfeeding mother

Breathing Initiation and Resuscitation
* Spontaneous breathing (> 30 breaths/min.) in most newborns
o Gentle stimulation, if at all
* Effectiveness of routine oro-nasal suctioning is unknown
o Biologically plausible advantages – clear airway
o Potentially real disadvantages – cardiac arrhythmia
o Bulb suctioning preferred
* Newborn resuscitation may be needed
o Fetal distress
o Thick meconium staining
o Vaginal breech deliveries
o Preterm

Eye Care To Prevent or Manage Ophthalmia Neonatorum
* Ophthalmia neonatorum
o Conjunctivitis with discharge during first 2 weeks of life
o Appears usually 2–5 days after birth
o Corneal damage if untreated
o Systemic progression if not managed
* Etiology
o N. gonorrhea
+ More severe and rapid development of complications
+ 30–50% mother-newborn transmission rate
o C. trachomatis

Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued)
* Prophylaxis
o Clean eyes immediately
o 1% Silver nitrate solution
+ Not effective for chlamydia
o 2.5% Povidone-iodine solution
o 1% Tetracycline ointment
+ Not effective vs. some N. gonorrhea strains
* Common causes of prophylaxis failure
o Giving prophylaxis after first hour
o Flushing of eyes after silver nitrate application
o Using old prophylactic solutions

Efficacy of Prophylaxis for Conjunctivitis in China
* Objective: To assess etiology of newborn conjunctivitis and evaluate the efficacy of regimens in China
* Design: November 1989 to October 1991 rotated regimens monthly: tetracycline, erythromycin, silver nitrate
* 302 (6.7%) infants developed conjunctivitis, most S. aureus (26.2%) and chlamydia (22.5%)
* Silver nitrate, tetracycline: fewer cases than no prophylaxis (p < 0.05), erythromycin: not significant

Prophylaxis for Conjunctivitis: Objective and Design
* Objective: To compare efficacy in prevention of nongonococcal conjunctivitis
* Design: Randomized control trial to compare erythromycin, silver nitrate, no prophylaxis
o Examined with test for leukocyte esterase and chlamydia trachomatis antibody probe 30–48 hours postpartum, 13–15 days later, and telephone contact up to 60 days of life
* Main outcome measured: conjunctivitis within 60 days of life and nasolacrimal duct patency

Prophylaxis for Conjunctivitis: Results and Conclusion

* Results: 630 infants
* 109 with conjunctivitis
o Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 (0.39-0.97)
+ Chemical conjunctivitis with silver nitrate resolves within 48 hours
o Erythromycin vs. no prophylaxis: Hazard ratio 0.69 (not significant)
* Conclusion: Parental choice of prophylaxis, including no prophylaxis, is reasonable IF antenatal care and STD screening

Povidone-Iodine for Conjunctivitis: Objective and Design

* Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya
* Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine
* Results:
o Conjunctivitis:
+ Chlamydia in 50.5%
+ S. aureus in 39.7%
o More infections in silver nitrate than povidone-iodine, OR 1.76, p < 0.001
o More infections in erythromycin OR 1.38, p=0.001

Povidone-Iodine for Conjunctivitis: Conclusion
Povidone-iodine:
o Is good prophylaxis
o Has wider antibacterial spectrum
o Causes greater reduction in colony-forming units and number of bacterial species
o Is active against viruses
o Is inexpensive

Immunization
* BCG vaccinations in all population at high risk of tuberculosis infection
* Single dose of OPV at birth or in the two weeks after birth
* HBV vaccination as soon as possible where perinatal infections are common

Summary
The essential components of normal newborn care include:

* Clean delivery and cord care
* Thermal protection
* Early and exclusive breastfeeding
* Monitoring
* Eye care
* Immunization
References

Normal Newborn Care.ppt

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