TABLE 824 Differential Diagnosis of Hyperbilirubinemias

Generalizations may benefit the emergency practitioner. A degree of unconjugated hyperbilirubinemia accompanies all hepatocellular diseases, but primary elevations in unconjugated bilirubin are rare and mostly limited to the infant pediatric population, as in neonatal jaundice and Crigler-Najjar syndrome. In the absence of severe underlying or concomitant liver disease, hemolysis does not result in jaundice. Jaundice presenting in the acutely ill and febrile patient will reflect either viral hepatitis or bacterial cholangitis; a distinction may be made by noting that cholangitis is usually accompanied by much greater elevations in alkaline phosphatase. The subacute presentation of jaundice in the patient without a history of chronic liver disease is most likely the result of infiltrative disease or slowly obstructing extrahepatic tumor, as in the head of the pancreas.15!6

A patient with fulminant liver failure (acute hepatic necrosis) presents as acutely ill with jaundice and often complications related to impaired hepatic function, including encephalopathy, coagulopathy, and water, electrolyte, and acid-base metabolic disorders ( TabJ.e,.8.2.:.5). Progression of disease to complete liver failure often occurs in 8 weeks or less. The appropriate emergency response to such patients involves recognizing the severity of the illness, instituting appropriate resuscitation, assembling an appropriate database including liver serologies and toxicology screens, and arranging for appropriate inpatient care as indicated by the acuity of the presentation. Appropriate guidelines for inpatient management should be based on age, underlying medical conditions, hemodynamic stability on presentation, and response to initial resuscitation measures. General hospital admission is indicated for management of refractory nausea, vomiting, and dehydration; intensive care unit admission is reserved for patients with encephalopathy, hemorrhage, or hemodynamic instability, especially when a question of sepsis is entertained; and transfer of the patient with fulminant liver failure to a tertiary facility with transplant capabilities would be appropriate. «I8

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