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jaundice - Coggle Diagram
jaundice
Direct hyperbilirubinemia
AST ALT ALP異常
ALP:AST(or ALT) ratio > 1
autoimmune hepatitis
mechanism
type1 for smooth muscle or antinuclear antibody
type2 for liver mocrosomal type 1 antibody
genetic predisposition autoimmunity
diagosis
liver biopsy
blood test
ANA
Anti-SMA
AMA
risk factor
a history of certain infections (EBV, herpes simplex, HAV, HBV, HCV)
heredity
female
having an autoimmune disease
treatment
lifestyle change
liver transplant
medicine( corticosteroids)
symptom
enlarged spleen
diarrhea
bowel movements
gallstone
jaundice
Viral hepatitis
treatment
ribavirin
interferon
diagnosis
Liver Biopsy
Cause
HAV、HBV、HCV
HDV、HEV、EBV、CMV
symptom
dark urine
abdominal pain
fever
loss of appetite
high level ALP
severe gallstone
risk factor
female
obese
older than 40 years
Crohn's disease or irritable bowel syndrome
family history
take an antibiotic called ceftriaxone
Cause
high levels of cholesterol/ bilirubin inside the gallbladder
imbalance in the chemical make-up of bile inside the gallbladder
symptom
abdominal pain( the centre )
diarrhea
jaundice
itchy skin
a loss of appetite
diagnosis
murphy sign
ultrasound scan(high frequency )
MRI
cholangiography(ERCP)
treatment
surgery
take ursodeoxycholic acid tablets
keep healthy diet
Cholangiocarcinoma
total bilirubin (>10 mg/dL), prolonged prothrombin time, elevated INR
Mechanism
Intrahepatic (10%)
Perihilar (Klatskin tumor, 60-80%)
Extrahepatic (10-30%)
Diagnosis
Abdominal CT
ERCP
Abdominal ultrasound
Case 3（超音波發現肝內膽管擴張）
MRI
Endoscopic ultrasound
Cholangiography
CEA and CA 19-9 tumor marker test
Risk factors
Clornochis sinesis infection
Cholelithiasis
Primary sclerosing cholangitis
Ulcerative colitis
Gallbladder polyps
Carcinogen exposure
Abnormal pancreaticobiliary duct junction
Hepatitis B
Case 3
Hepatitis C
Treatment
Partial hepatectomy
Whipple procedure
PD-1 and PD-L1 inhibitor therapy
Biliary bypass
Endoscopic stent placement
Percutaneous transhepatic biliary drainage
Chemotherapy
Targeted therapy
Liver transplant
Symptom
Right upper quadrant abdominal dull pain
Case 3
Fever
Pruritus
Case 3
Tea color urine
Weight loss
Case 3（食慾不佳造成？）
Biliary atresia
Diagnosis
Liver biopsy
Ultrasound
Symptoms
Pale white stool
Dark urine
Cirrhosis with portal hypertension（liver failure if left untreated）
No kernicterus since conjugated bilirubin is unable to cross BBB
Causes
Viral infection
Toxin-mediated inflammatory response
Immune dysregulation
Genetic factor
Treatment
Operation（Kasai procedure、hepatoportoenterostomy）
Liver transplantation
AST>ALT
AST:ALT=2:1、AST<300、high γ-GT
Alcoholic hepatitis
diagnosis
CBC
Blood clotting test
Increased prothrombin time
Case 1
liver function test
uitrasound
Hepatosplenomegaly
Case 1
liver biopsy
treatment
liver transplant
stop drinking
mechanism
oxidative stress
lipid peroxidation
increase activity of TNF-alpha
risk factor
obesity
genetic factors
female
race
binge drinking
symptom
jaundice
changes in appetite
fever
Hepatic encephalopathy
Case 1
Ascites
Case 1
Edema
Case 1
ALT>AST
ALT:AST>1.5:1
nonalcoholic steatohepatitis
Diagnosis
Low thyroid-stimulating hormone
MRI can diagnose steatosis
Blood tests
Risk factor
Insulin resistance and type 2 diabetes
High cholesterol and high triglycerides
car
Metabolic syndrome
Treatment
Diet
Physical activity
Lifestyle
Transplantation
symptom
Weight loss for no clear reason
Fatigue
no symptoms in the early stages
An ache in the upper right part of your belly
Primary biliary cirrhosis
Mechanism
PBC是一種自體免疫疾病，肝臟內的小膽管會逐漸被破壞，導致膽汁和其他有毒物質在肝臟中堆積，形成膽汁淤積，可能會造成肝臟結痂、纖維化，最終導致肝硬化
Symptoms
Xanthelasma or xanthoma
Itching
Fatigue
Dry skin and dry eyes
Impaired bone density
Symptoms of liver cirrhosis
Diagnosis
Increased blood fat, including total cholesterol level
Anti-mitochondrial antibodies
Ultrasound
MRE、MRCP、ERCP
Risk factor
Sex：Most people with PBC are women
Age：More likely to occur in people 30~60 years old
Genetic factors
Geography：More common in Northern Europe and North America
Infections
Smoking
Toxic chemicals
Treatment
Medications to slow the progression of the disease
Liver transplantation
Primary sclerosis cholangitis
Mechanism
因為膽管發炎，導致膽管狹窄及硬化，造
成膽汁淤積，最終造成膽管硬化及肝衰竭
Symptoms
Fatigue
Itching
Abdominal pain
Fever
Enlarged liver and spleen
Weight loss
Risk factor
Age：Most often diagnosed between the ages of 30 and 40
Sex：Occurs more often in men
Inflammatory bowel disease
Geographical location：People with Northern European heritage have a higher risk of primary sclerosis cholangitis
Diagnosis
ALP > 1.5x the upper limit of normal for longer than 6 months
Cholangiography
Liver biopsy
MRCP
Lab findings
Anti-neutrophil cytoplasmic antibodies
Antinuclear antibodies
Anti-smooth muscle antibody
Fecal fat
Treatment
Supportive treatment for PSC symptoms
Liver transplantation
AST ALT ALP無法鑑別診斷
Rotor syndrome
Symptoms
Non-itching juandice
Dark urine
Scleral icterus
Abdominal pain
Fever
Mechanism
在12號染色體上的SLCO1B1和SLCO1B3基因異常，導致OATP1B1和OATP1B3蛋白異常短，這兩個蛋白參與肝臟再吸收血液中的bilirubin，進而造成血中bilirubin過高產生黃疸、從尿液中排出的bilirubin增加造成dark urine
Diagnosis
Elevation of urine coproporphyrin
Imaging studies to rule out other diseases
Normal histology in liver biopsy
Treatment
Require no treatment（benign disease）
Dubin-Johnson syndrome
Diagnosis
Darkly pigmented liver
Coproporphyrin I to coproporphyrin III ratio 3~4:1（Reversed in normal people）
Treatment
No treatment required
Symptoms
Hyperbilirubinemia
Icterus
Upper abdominal pain
Mechanism
在10號染色體上的ABCC2基因異常，造成MRP2蛋白異常，MRP2蛋白的功能為將bilirubin從肝細胞中送至膽道系統後排出，其異常會導致conjugated bilirubin在肝細胞堆積、血液中conjugated bilirubin上升
Gallstone
Cholestasis
GGT, ALP elevate, and AST, ALT, and unconjugated bilirubin may elevate due to hepatocyte damage as a secondary effect of cholestasis
Risk factors
Drug
pregnancy
PSC, PBC
gallstone, mass
hepatitis
Symptoms
itchiness
Jaundice, dark urine
pale stool
Mechanism
Acute calculous cholecystitis occurs when gallstones occlude the cystic duct, leading to gallbladder distension and inflammation
Obstructive type
a gallstone or malignancy,
metabolic type
disturbances in bile formation that can occur because of genetic defects or acquired as a side effect of many medications
Diagnosis
blood test
Abdominal ultrasound, endoscopic ultrasound, or a computerized tomography (CT) scan
Treatment
treat underlying cause
surgery
drug
Pancreatitis
AST>ALT, Increased amylase and lipase level, serum triglyceride levels >1000 mg/dL, hypercalcemia
Diagnosis
Cullen sign
Grey-Turner sign
Blood test
Radiology
CT發現胰臟頭部有嚴重壞死
Case 2
Treatment
Proton pump inhibitor (PPI)
Atropine
Fluid balance
H2 antagonist
Growth hormone release inhibiting hormone (GHRIH)
Aprotinin
Risk factors
Infection
Heavy meal
Autoimmune disease
Alcohol consumption
Post-ERCP
Choledocholithiasis
Case 2
Symptom
Pain radiate to back
Case 2
Pain eased by leaning forward
Sudden severe upper abdominal pain
Case 2
indirect hyperbillrubinemia
AST ALT ALP異常
Cholecystitis
AST, ALT may be mildly elevate, dependent of the degree of inflammation
Mechanism
Blockage of the cystic duct by a gallstone causes a buildup of bile in the gallbladder and increased pressure within the gallbladder.
Diagnosis
Blood test
Ultrasound
Symptoms
Right upper abdominal pain, nausea, vomiting, fever
Treatment
supportive measures
Surgery
drainage
Risk factors
gallstone
female sex, increasing age, pregnancy, oral contraceptives, obesity, diabetes mellitus
Cirrhosis
Causes
Alcoholic liver disease
Non-alcoholic fatty liver disease
Chronic hepatitis C
Chronic hepatitis B
PBC、PSC
Autoimmune hepatitis
Treatment
Laxatives to decrease the risk of constipation
Antibiotics for infection
Remove the copper in organs in patients with Wilson's disease
Transplantation
Diagnosis
Liver biopsy（through the skin or internal jugular vein）
Symptoms
Spider angioma
Palmar erythema
Gynecomastia
Hypogonadism
Ascites
Enlarged spleen
Esophageal varices
Caput medusae
Cruveilhier-Baumgarten bruit
Lab findings
Thrombocytopenia
AST、ALT moderately elevated with AST > ALT
Elevated γ-GT
Decreased albumin
Increased prothrombin time
Leukopenia、neutropenia
Viral hepatitis
HAV
AST, ALT elevate, the values are usually 4-100 times
the normal levels
Risk factors
It is usually spread by eating food or drinking water contaminated with infected feces.
close contact with an infectious person
Symptoms
Nausea, vomiting, diarrhea
dark urine, jaundice
fever
abdominal pain
Diagnosis
Blood test
Treatment
No treatment and therapy is aimed at maintaining comfort and adequate nutritional balance
HBV
AST, ALT may be normal or mildly elevate
Risk factors
exposure to infectious blood or body fluids containing blood
sexual contact, blood transfusions
re-use of contaminated needles and syringes
vertical transmission from mother to child (MTCT)
Symptoms
None
tiredness
yellowish skin, dark urine
abdominal pain
Diagnosis
Blood test
Treatment
most adults clear the infection spontaneously
Early antiviral treatment, interferon
Liver transplant
HCV
AST, ALT may be normal or mildly elevate
Risk factors
sexual
percutaneous contact with contaminated blood is responsible for most infections
unknown
Symptoms
Typically none
Diagnosis
Blood test
Treatment
antiviral medication
liver transplant
environmental toxicity
Vinyl chloride
Jamaica bush tea (pyrrolizidine alkaloids)
Kava kava (a kind of pepper)
Wild mushrooms (Amanita phalloides, A. verna)
Hemolysis
AST>ALT, decreased hemoglobin, decreased hematocrit, increased reticulocyte count, increased LDH, decreased haptoglobin
Diagnosis
PE: skin color, abdomen tenderness (check for enlarged liver or spleen)
Blood test mentioned previously and examine the shape and size of blood samples under microscopy
Urine test to check for presence of RBC BREAKDOWN
Bone marrow aspiration or biopsy
Treatment
RBC transfusion
Immunosuppressant
Splenectomy
Intravenous immunoglobulin
Mechanism
RBC turnover
Intracorpuscular defect
Extracorpuscular defect
Immune hemolysis
Intravascular hemolysis
Extravascular hemolysis
Transfusion-related hemolysis
Symptom
Enlarged spleen or liver
Paleness of skin
Fatigue
Fever
Dark urine
Jaundice
Heart murmur
Dizziness
Risk factors
Infection
Tumors
Autoimmune disorders (ex: SLE)
Drug usage (ex: acetaminophen, antibiotics, ibuprofen, quinidine, rifampin)
Leukemia
Lymphoma
G6PD deficiency
Genetic disorders
AST ALT ALP無法鑑別診斷
Ineffective erythropoiesis
Treatment (preclinical)
Apo-transferrin
Minihepcidin
JAK2 inhibitors
Risk factor
Genetic factors
Mechanism
Imbalance of erythroid proliferation and differentiation characterized by an increase in erythroblast proliferation that fails to differentiate and give rise to enucleate RBCs
Increased iron absorption in response to stress and depositing in the organs
Associated diseases
Pernicious anemia
Thalassemia
Erythropoietic porphyria
Iron deficiency anemia
increased bilirubin production
Massive blood transfusion
Resorption of hematoma
crigler-najjar types 1&2
diagnosis
genetic testing
ultrasonography
CT
treatment
plasmapheresis
phototherapy
liver transplant
mechanism
lack the enzyme to change bilirubin into a form of that can be removed
symptom
fever
vomitting
seizure
difficulty swallowing
risk factor
family history
lack or deficiency of the enzyme uridine diphosphate glucuronosyl transferase
mutation in the gene UGT1A1
Gilbert syndrome
Serum bilirubin concentration usually <3 mg/dL, normal liver function test
Diagnosis
Genetic testing
Blood count and liver function test
Treatment
The bilirubin levels in the blood may fluctuate over time, and the jaundice usually resolves on its own, no treatment is required
Mechanism
Autosomal recessive
Mutation of the promotor region of UGT1A1
Symptom
Mild intermittent jaundice
Symptoms usually first appear during adolescence
Illness, dehydration, stress, insomnia, malaise, fatigue... (but usually asymptomatic between episodes)
Risk factor
Family history
More prevalent in males