A patient with jaundice usually presents with scierai icterus or yellow discoloration of the mucous membranes or skin. The jaundice is a clinical indication of hyperbilirubinemia. Hyperbilirubinemia can be the result of elevated levels of conjugated (measured as direct bilirubin) or unconjugated bilirubin. The initial laboratory tests obtained should include a bilirubin with measurement of the direct bilirubin fraction. If fractionating is not available, an elevated urine bilirubin level will indicate conjugated hyperbilirubinemia, as unconjugated bilirubin cannot be filtered by the kidney. If the direct fraction is low then unconjugated hyperbilirubinemia is diagnosed; causes include hemolysis, hematoma reabsorption, and Gilbert’s disease. An elevated direct fraction indicates conjugated hyperbilirubinemia. Pain, previous biliary operations, and ingestion of hepatotoxic drugs are important elements in the history of patients with conjugated hyperbilirubinemia. Conjugated hyperbilirubinemia can be caused by inability of the hepatocytes to excrete conjugated bilirubin or obstruction in the biliary system. Serum transaminases will be elevated in patients with hepatocellular dysfunction; causes include viral and alcoholic hepatitis, sepsis, parenteral nutrition, etc. Elevations in the coagulation profile can also indicate hepatic parenchymal disease. Alkaline phosphatase is elevated in a malignant segmental ductal obstruction (rather than common duct) in which case the bilirubin is usually normal. Low levels of urinary urobilogen are also indicative of obstructive jaundice.
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