Jaundice in the ICU

• Fractionate first: unconjugated (hemolysis, Gilbert, drugs) versus conjugated (sepsis-associated cholestasis, obstruction, TPN, hepatitis).
• Sepsis cholestasis is common and relatively benign; treat the infection rather than the bilirubin.
• Rising conjugated + LFTs: ultrasound for obstruction; review TPN and drug list.
• Isolated bilirubin elevation without LFT derangement rarely requires ICU action.

Evaluating and Managing Hyperbilirubinemia

• Hyperbilirubinemia
• CONJUGATED, alk phos/GGTP increased → biliary obstruction → image: extrinsic (pancreatitis, mass, pancreatic cancer, hepatoma) vs intrinsic (choledocholithiasis, cholangitis, stricture, cholangiocarcinoma, PSC) → consider ERCP, MRCP, bile drainage, antibiotics
• CONJUGATED, bile ducts not dilated → cholestasis: pregnancy · TPN · sepsis · infiltrative · drugs (allopurinol, quinidine, sulfonamide, chlorpromazine, erythromycin, chlorpropamide, methimazole, estrogen, anabolic steroids)
• CONJUGATED, ALT increased → hepatocellular dysfunction — chronic: Wilson's, autoimmune hepatitis, non-alcoholic steatohepatitis · acute: viral, alcoholic, drugs, hypoxia/ischemia, thrombosis → serologies, liver biopsy, drug levels · inherited: Dubin–Johnson, Rotor
• UNCONJUGATED → overproduction: reabsorbing hematoma · hemolysis — other (drugs, hemoglobinopathy, enzyme deficiencies), autoimmune (cold AIHA, warm AIHA, malignancy, infection), microangiopathy (DIC, TTP, HUS, vasculitis, malignancy)
• UNCONJUGATED → impaired uptake or conjugation: hereditary (Gilbert's, Crigler–Najjar II) · acquired (drugs)