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When the evaluation of newly elevated liver enzymes is unrevealing, a common diagnosis of exclusion is drug-induced liver injury. A 39-year-old active duty service member who presented with jaundice after returning from a mission in Thailand was found to have an acute hepatitis and developing acute liver failure. He was ultimately diagnosed with acute hepatitis E, but his diagnosis was initially confounded by multiple exposures to supplements known to cause drug-induced liver injury. This case illustrates the importance of broadened serologic testing in patients with acute liver injury returning from countries endemic with hepatitis E and also highlights the challenges in diagnosis of acute hepatitis E with currently available testing. [ABSTRACT FROM AUTHOR]

Jaundice is a clinical manifestation of disorders of underlying bilirubin metabolism, hepatocellular dysfunction, or biliary obstruction. As clinical presentations of yellowing of eyes or skin can be somewhat nonspecific for the underlying etiology of disease, a stepwise approach to evaluation is necessary for accurate diagnosis and effective treatment plan. In this review, we discuss underlying mechanisms of cholestasis and jaundice as well as laboratory and imaging modalities needed to evaluate a patient presenting with hyperbilirubinemia. Jaundice occurs in settings of cholestasis or inability to effectively secrete bile as well as disorders of bilirubin metabolism and hepatocellular dysfunction. Clinical signs of jaundice occur when the serum bilirubin level exceeds 2.5 to 3 mg/dL. In all cases, evaluation begins with liver chemistry tests which include bilirubin (conjugated and unconjugated), alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and total protein. In patients with hepatobiliary causes of jaundice, the alkaline phosphatase is usually elevated. In these cases, evaluation of hepatic synthetic function is crucial to the formulation of a treatment plant. When serologic evaluation is combined with hepatobiliary imaging, underlying mechanism of disease can often be elucidated. A stepwise approach to evaluation can be cost and time saving as well as a framework to improve patient outcomes. In this review, we will outline a diagnostic approach to jaundice, beginning with pathophysiology of cholestasis followed by hyperbilirubinemia and markers of synthetic dysfunction. [ABSTRACT FROM AUTHOR]

Jaundice is an important sign of acute and chronic liver diseases in children and adolescents. The spectrum of aetiologies is broad and differs from those presenting in neonates. Chronic liver disease may not present with jaundice until late in the disease. In contrast, acute onset jaundice may be a sign of severe liver disease which may progress to fulminant liver failure. Therefore, prompt diagnosis and evaluation of liver synthetic function will identify serious conditions that require referral to specialised units for assessment and consideration of liver transplantation. This review provides a systematic approach to the evaluation of jaundice in children and adolescents and an overview of the differential diagnoses. [ABSTRACT FROM AUTHOR]

In this study, we investigated the affect and the role of growth factors on liver damage. 110 Sprague-Dawley rats were divided into 11 groups: a sham group, a control group, HGF, EGF, IGF, TGF groups of irreversible jaundiced rats and a control group and HGF, EGF, IGF, and TGF groups of reversible jaundiced rats (n = 10). In the irreversible jaundiced groups, the common bile duct was explorated, double ligated, and cut. 150 μg/kg/day HGF, 5 μg/kg/day EGF, 5 μg/kg/day IGF, and 5 μg/kg/day TGF β-1 were injected intraperitoneally after the seventh post-operative day. In the reversible jaundiced group, the common bile duct was ligated and the ligation was resolved on the seventh post-operative day. For 5 days, growth factors were injected at the same dose. Ductal proliferation scores significantly decreased after growth factor administration in the EGF-A and TGF-A groups. Furthermore, ductal proliferation was decreased in the TGF-B group. As a result of this study, HGF was effective in the irreversible jaundiced groups and ineffective in the reversible jaundice groups. EGF was effective in the reversible jaundiced groups and ineffective in the irreversible jaundiced groups. In both the irreversible jaundiced and reversible jaundiced groups, IGF was ineffective, although TGF β-1 was effective. We believe that these results arise from the positive effects of effective doses of growth factor on liver damage. [ABSTRACT FROM AUTHOR]

Background. Biliary atresia is a common cause of cholestasis. In our experience, patients with biliary atresia are referred late, with the diagnosis based on an absent gall bladder at ultrasonography. Such late referrals may render patients inoperable and not acceptable for formal intraoperative diagnosis. Objectives. To determine the usefulness of an absent gall bladder on ultrasonography, and of biochemical features, in differentiating biliary atresia from other causes of cholestasis, using liver needle biopsy as a gold standard. Methods. A retrospective file review of 150 infants presenting with cholestasis to Steve Biko Academic Hospital Paediatric Gastroenterology and Hepatology Unit from January 2008 to August 2014 was undertaken. Clinical, serum biochemical, abdominal ultrasonography and liver histology findings were analysed. Three groups were compared, based on liver histology findings, consisting of patients with biliary atresia, neonatal hepatitis, and other diagnoses, respectively. Results. A total of 66/150 patients had biliary atresia, based on liver histology findings of extrahepatic obstruction. Their mean age was 4.7 (2.9) months, higher than in the other groups. In those with biliary atresia, the age at diagnosis, splenomegaly, and gamma glutamyl transferase (GGT), aspartate transaminase (AST) and GGT/AST ratio values were significantly different from the other groups. Total and conjugated bilirubin levels were similar among the groups. Ultrasonography was 69.7% sensitive, 98.8% specific and had a positive predictive value of 97.9% for biliary atresia. Ultrasonography missed 30.3% of patients with biliary atresia. Conclusion. Ultrasonography has poor sensitivity but good specificity in screening for biliary atresia; however, other investigations are necessary to confirm the diagnosis. [ABSTRACT FROM AUTHOR]

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The article presents views of 65‑year‑old male presented with history of an asymptomatic progressive skin rash on his bilateral palms and soles. He was having progressive jaundice and flatulence and diagnosed with cholangiocarcinoma and histopathological examination of the lesional skin biopsy indicated hyperkeratosis and parakeratosis. He was diagnosed with gram stain, potassium hydroxide examination and liver function test indicated elevated levels of total serum bilirubin.

Nanoflowers (NFs) are flower-shaped nanoparticulate systems with a higher surface-to-volume ratio and good surface adsorption. Jaundice indicates yellow discoloration of skin, sclera, and mucus membrane and is a clinical indication of bilirubin accumulation in the blood which occurs as a consequence of the incapability of the liver to excrete bilirubin in the biliary tree or conjugate bilirubin and higher production of bilirubin in the body. Several methods have been developed so far for bilirubin estimation in jaundice like the spectrophotometric method, chemiluminescence method, etc., but biosensing methods provide advantages over traditional methods concerning the surface area, adsorption, particle size, and functional characteristics. The primary objective of the present research project was to formulate and examine the adsorbent nanoflowers-based biosensor for accurate, precise, and sensitive detection of bilirubin in jaundice. The particle size of adsorbent nanoflowers was found to be in the range of 300-600nm with the surface charge (zeta potential) in the range of -1.12 to -15.42 mV. Transmission electron microscopy and scanning electron microscopy images confirmed the flower-like morphological structure of adsorbent NFs. The adsorption efficiency of NFs for bilirubin adsorption was maximum at 94.13%. Comparative studies of bilirubin estimation in the pathological sample with adsorbent NFs and diagnostic kit displayed bilirubin concentration to be 1.0 mg/dL in adsorbent nanoflowers and 1.1 mg/dL with diagnostic kit indicating effective detection of bilirubin with adsorbent NFs. The nanoflower-based biosensor acts as a smart approach to elevate adsorption efficiency on the surface of nanoflower due to a higher surface-to-volume (SV) ratio. Graphical Abstract., (Copyright ©2023, Yale Journal of Biology and Medicine.)

Background: Liver involvement during infectious mononucleosis is common, but jaundice is considered rare. This study aimed to investigate serum bilirubin concentrations in patients with infectious mononucleosis and immune abnormalities associated with jaundice., Methods: We report on an adult patient with monoclonal B lymphocytosis and IgM-lambda gammopathy who developed a severe icteric hepatitis during infectious mononucleosis. We then reviewed the clinical records of 389 patients admitted to the hospital with infectious mononucleosis between 1995 and 2018 (51.7% male patients; median age, 19 years; range, 15-87 years) with focus on liver abnormalities and associated factors., Results: Fifty-nine patients (15.1%) had serum bilirubin concentrations between 1.5 and 3 mg/dL, and 47 patients (12.0%) had serum bilirubin >3 mg/dL. Patients with increased bilirubin concentrations had a distinct clinical presentation, with more frequent abdominal pain, nausea and vomiting, and less frequent sore throat than patients with normal bilirubin. Age and sex were not significantly different for the patients with increased and normal serum bilirubin concentrations. The patients with increased serum bilirubin concentrations showed higher levels of immune activation markers than the patients with normal bilirubin, including blood lymphocyte counts, serum IgM, and β 2 -microglobulin concentrations. Heterophile antibody-positive patients (88.6%) showed similar bilirubin concentrations but higher aspartate aminotransferase and alkaline phosphatase levels than their heterophile-negative counterparts. Serum bilirubin elevations normalized quickly during follow-up., Conclusions: Transient hyperbilirubinemia is common during severe (in-hospital) infectious mononucleosis in adult patients. Patients with hyperbilirubinemia have less frequent pharyngitis symptoms and more frequent abdominal symptoms. Hyperbilirubinemia during infectious mononucleosis is associated with immune activation markers., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest to declare., (Copyright © 2022 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

For every medical trainee, the Membership of the Royal College of Physicians' Practical Assessment of Clinical Examination Skills (PACES) exam is one of the most difficult exams they must face in their career. It is designed to assess the clinical knowledge and skills of the trainee doctors who are entering higher specialist training. It sets rigorous standards to ensure the competence of the candidates across a range of skills. This article discusses a systematic approach to a patient with jaundice, which is a commonly encountered station in the exam, so that candidates will become more familiar with common causes and how to differentiate between these, as well as important bedside examination skills.

Objectives: Hemolysis, icterus, and lipemia (HIL) are common sources of endogenous interference in clinical laboratory testing. Defining the threshold of interference for immunoassays enables appropriate reporting of their results when they are affected by HIL., Methods: Pools of residual patient serum samples were spiked with a known amount of interferent to create samples with varying concentrations of hemolysate, bilirubin, and Intralipid that mimicked the effects of endogenous HIL. Samples were analysed on the Alinity i analyser (Abbott Diagnostics) for more than 25 immunoassays. The average recovery relative to the non-spiked sample was calculated for each interference level and was compared to a predefined allowable bias., Results: C-peptide, estradiol, serum folate, free T4, homocysteine, insulin, and vitamin B12 were found to be affected by hemolysis, at hemoglobin concentrations between 0.3 to 20 g/L. Immunoassays for BNP, estradiol, free T3, and homocysteine were affected by icterus at conjugated bilirubin concentrations between 50 to 1,044 μmol/L. BNP, serum folate, and homocysteine were affected by Intralipid with measured triglyceride concentrations between 0.8 to 10 mmol/L. Lastly, serological immunoassays for HIV and hepatitis A, B and C were also affected by interferences., Conclusions: Immunoassays are impacted by varying degrees of HIL interference. Some measurands, in the presence of interference, are affected in a manner not previously indicated. The data presented herein provide an independent evaluation of HIL thresholds and will be of aid to resource-limited clinical laboratories that are unable to internally verify endogenous interferences when implementing the Alinity i analyser., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

Background: The hemolytic nature of hemolytic disease of the newborn (HDN) is described as the abnormal destruction and decomposition of red blood cells, causing heterogeneous manifestations such as abnormal red blood cell volume and morphology. Mean corpuscular volume (MCV) and red blood cell volume distribution width (RDW) are commonly used parameters related to red blood cell volume. Total serum bilirubin (TSB) is routinely monitored among newborns. This study aims to explore the value of MCV and RDW, combined with TSB, to improve the efficiency of HDN diagnosis., Methods: Three hundred eighty-eight children with HDN and 371 children with non-HDN pathological jaundice who were diagnosed and treated in the neonatal department of our hospital from January 2019 to December 2020 were included in the study. Clinical data collected include examination results of laboratory indicators, such as MCV, coefficient of variation of red blood cell volume distribution width (RDW-CV), standard deviation of red blood cell volume distribution width (RDW-SD), and TSB. The differences in the indicators between the two groups of children were retrospectively analyzed., Results: 1) The detection rate of HDN in children in the early group was higher than that in the late group (P < 0.001). 2) The early-stage group had lower TSB levels and higher values of MCV, RDW-CV and RDW-SD (P < 0.001). Compared with the children in the non-HDN group, the indices in the HDN group were higher in the early stage (P < 0.001). 3) In the early stage, the TSB, MCV, RDW-CV, and RDW-SD were positively correlated with the diagnosis of HDN (P < 0.001). Early monitoring of TSB, MCV, RDW-CV and RDW-SD was valuable for HDN detection, the area under the curve (AUC) was 0.729, 0.637, 0.715, and 0.685, respectively (P < 0.001). 4) After a binary logistic analysis at TSB > 163.3 μmol/L, MCV > 96.35fL, and RDW-CV > 16.05%, the diagnosis rate of HDN increased (P < 0.001). The AUC of the HDN detected using the combined indicators was 0.841., Conclusion: At MCV > 96.35fL or RDW-CV > 16.05%, children with jaundice in three days of birth (especially children with TSB > 163.3 μmol/L) should be screened for HDN. A combination of TSB, MCV, and RDW-CV can improve the early detection rate of HDN, contribute to reduce the readmission rate and risk of hyperbilirubinemia., (© 2023. The Author(s).)

Acute liver failure is characterised by the presence of jaundice and encephalopathy with or without coagulopathy in a patient with a previously normal liver. 1 A variety of tropical infections can lead to this clinical presentation. Hepatosplenomegaly and bleeding manifestations are common in such patients. Deranged liver biochemistry and poor outcomes are hallmarks of viral hepatitis inducing liver failure.

Objective: The aim: To analyze the incidence of Hepatitis A in Ukraine and Poltava region and to study the clinical and epidemiological features of the course of Hepatitis A in adult patients., Patients and Methods: Materials and methods: The course of HA in 96 hospitalized patients was analyzed. The diagnosis of HA was established on the basis of clinical and epide¬miological data and confirmed by the results of laboratory studies (serological and molecular biological)., Results: Results: In 2019, in the Poltava region, there was an increase in the incidence of Hepatitis A with a predominance among sick people of working age, among the urban population. This part of people aged from 60 to 75 years old constitutes 9.4%. This study showed that the waterway was the dominant way of HA transmission. The course of the disease in most hospitalized patients was typical and cyclic, with a predominance of a mixed variant of the pre-jaundice period and jaundice. One third of patients survey that they had fever, which persisted with jaundice., Conclusion: Conclusions: The findings of this study indicates that the patients older than 40 years were more likely to have concomitant chronic pathology than younger patients, and Hepatitis A was more severe with the development of prolonged cholestasis, wave-like course and recurrence. In most patients under the age of 40, the course of Hepatitis A was mild, but splenomegaly and severe cytolytic syndrome were more common.

BACKGROUND: Paraneoplastic syndromes are disorders caused by cancer that are not a direct result of the cancer mass itself or metastases to the affected organ. Paraneoplastic cholestasis is described with lymphoma and renal cell carcinoma. Unlike ovarian carcinoma, paraneoplastic syndromes are rarely seen in dysgerminoma. CASE: A 22-year-old woman presented with 3 days of jaundice and lower abdominal pain. Liver tests revealed marked cholestasis and high alkaline phosphatase and bilirubin levels. Imaging showed a normal-appearing liver, a large multiseptated ovarian cystic mass, ascites, and paraaortic lymphadenopathy. Debulking surgery found a dysgerminoma with metastasis to aortic lymph nodes. Hepatic dysfunction completely resolved within 4 weeks of surgery. CONCLUSION: Paraneoplastic syndrome should be considered in the differential diagnosis for patients with ovarian malignancies who present with cholestasis. [ABSTRACT FROM AUTHOR]

Pancreatic cancer (PC), the fourth leading cause of cancer-related deaths, is characterized by high aggressiveness and resistance to chemotherapy. Pancreatic carcinogenesis is kept going by derangement of essential cell processes, such as proliferation, apoptosis, metabolism and autophagy, characterized by rhythmic variations with 24-h periodicity driven by the biological clock. We assessed the expression of the circadian genes ARNLT, ARNLT2, CLOCK, PER1, PER2, PER3, CRY1, CRY2 and the starvation-activated histone/protein deacetylase SIRT1 in 34 matched tumor and non-tumor tissue specimens of PC patients, and evaluated in PC derived cell lines if the modulation of SIRT1 expression through starvation could influence the temporal pattern of expression of the circadian genes. We found a significant down-regulation of ARNLT ( p = 0.015), CRY1 ( p = 0.013), CRY2 ( p = 0.001), PER1 ( p < 0.0001), PER2 ( p < 0.001), PER3 ( p = 0.001) and SIRT1 ( p = 0.017) in PC specimens. PER3 and CRY2 expression levels were lower in patients with jaundice at diagnosis ( < 0.05). Having adjusted for age, adjuvant therapy and tumor stage, we evidenced that patients with higher PER2 and lower SIRT1 expression levels showed lower mortality ( p = 0.028). Levels and temporal patterns of expression of many circadian genes and SIRT1 significantly changed upon serum starvation in vitro, with differences among four different PC cell lines examined (BXPC3, CFPAC, MIA-PaCa-2 and PANC-1). Serum deprivation induced changes of the overall mean level of the wave and amplitude, lengthened or shortened the cycle time and phase-advanced or phase-delayed the rhythmic oscillation depending on the gene and the PC cell line examined. In conclusion, a severe deregulation of expression of SIRT1 and circadian genes was evidenced in the cancer specimens of PC patients, and starvation influenced gene expression in PC cell lines, suggesting that the altered interplay between SIRT1 and the core circadian proteins could represent a crucial player in the process of pancreatic carcinogenesis. [ABSTRACT FROM AUTHOR]

Aims Fluorescence in situ hybridisation (FISH) increases the sensitivity for detecting pancreatobiliary tract cancer over routine cytology. In this study, diagnostic accuracy and costs of cytology and FISH in detecting cancer in patients with jaundice with biliary strictures were assessed. Methods Brushing specimens from 109 patients with jaundice were obtained during endoscopic retrograde cholangiopancreatography and examined by cytology and FISH. The specimens were considered FISH-positive for malignancy if at least five polysomic cells or 10 cells with homozygous or heterozygous 9p21/p16 deletion were detected. Definitive diagnosis of the stricture as benign or malignant relied on surgical pathology (45 cases) or clinical-radiological follow-up >18 months (64 cases). We calculated costs of cytology and FISH based on the reimbursement from the Piedmont region, Italy (respectively, €33 and €750). Results Ninety of 109 patients had evidence of malignancy (44 pancreatic carcinomas, 36 cholangiocarcinomas, 5 gallbladder carcinomas, 5 other cancers), while 19 had benign strictures. Routine cytology showed 42% sensitivity, but 100% specificity for the diagnosis of malignancy, while FISH-polysomy showed 70% sensitivity with 100% specificity and FISH-polysomy plus homozygous or heterozygous 9p21/p16 deletion showed 76% sensitivity with 100% specificity. The cost per additional correct diagnosis of cancer obtained by FISH, in comparison with cytology, was €1775 using a sequential cytological approach (ie, performing FISH only in patients with negative or indeterminate cytology). Conclusions FISH should be recommended as the second step in detecting cancer in patients with jaundice with pancreatobiliary tract strictures and cytology negative or indeterminate for malignancy. [ABSTRACT FROM AUTHOR]

A Continuing Education Unit (CEU) from the American Academy of Family Physicians (AAFP) various topics such as approach to evaluation and management of dizziness, evaluation of jaundice in adults, and diagnostic evaluation of acute coronary syndrome.

Objective: Rare co-existance of disease or pathology Background: Hepatitis B virus (HBV) has been reported as a coinfection with hepatitis C virus (HCV), hepatitis D virus (HDV), cytomegalovirus (CMV), and human immunodeficiency virus (HIV). Case Report: A 34-year-old female presented to our clinic with epigastric pain and severe acute hepatitis manifested as jaundice associated with hyperbilirubinemia, elevated transaminases, and coagulopathy. The patient was diagnosed with acute HBV with Epstein-Barr virus (EBV) coinfection leading to subsequent chronic hepatitis B. Conclusions: To our knowledge, this patient case is the first reported case of HBV and EBV coinfection reported in the literature. HBV and EBV coinfection may cause severe acute hepatitis with HBV chronicity. [ABSTRACT FROM AUTHOR]

The article presents information on various genetic disorders, congenital anomalies and metabolic issues in newborn infants. These include caput succedaneum, cephalhematoma, subgaleal hematoma, hydrocephalus, herpetic conjunctivitis, seizures, apnea, pneumonia, pyloric stenosis, constipation and conjugated hyperbilirubinemia. The signs and symptoms, diagnosis and treatment for the diseases are discussed.

Hilar cholangiocarcinoma, Klatskin tumor or proximal bile duct cancer, is a tumor growing in the right hepatic duct, left hepatic duct or at their confluence. It is a relatively rare but devastating disease. The tight stricture of the biliary ducts and the development of obstructive jaundice are the main characteristics of the disease. In the early phase, symptoms are nonspecific and jaundice is not present, leading to delayed diagnosis and denying the possibility of curative treatment. We present the case of a 74 years old woman who was referred to us with ambiguous symptomatology and without jaundice. The ultrasound and CT scan showed dilation of the left biliary tree, without increase of the cholestatic enzymes. Magnetic resonance cholangiography depicted a tumor in the left hepatic duct (3X3 cm.) with enlargement of the bile ducts above. The surgical treatment consisted of left hepatectomy and hilar lymph nodes dissection. The pathology findings showed a cholangiocarcinoma with a few hilar nodes involvement. Our approach was potentially curative. Unfortunately these situations are seldom because in the majority of cases the patients have obstructive jaundice at presentation and the tumors are unresectable. We consider that a magnetic resonance cholangiography made when we suspect a bile duct tumor, leads us to an early diagnosis and gives us the possibility of a potential curative surgical treatment. [ABSTRACT FROM AUTHOR]

Geographically, β-thalassemia can be found in many countries including in Indonesia. Thalassemia intermedia referred to patients as being too haematologically severe to be called minor, but too mild to be called major. Patients with thalassemia intermedia usually present themselves to medical attention in later childhood or even adulthood and are sustainable without the need for regular transfusion therapy. Three main factors are responsible for the clinical sequele of thalassemia intermedia: chronic anemia, ineffective erythropoiesis, and iron overload. There are many complications related to β-thalassemia intermedia such as gastroentero-hepatology diseases (splenomegaly, gallstones, choledocolithiasis, predispose patients to liver fibrosis and cirrhosis), vascular, endocrine and bone diseases. About 55-63% thalassemia intermedia patients suffer from gallstone with 68-85% of these patients undergo cholecystectomy, and 67-90% patients undergo splenectomy. Therefore, ultrasound examination is required to be performed regularly during illness and before patient underwent surgery or splenectomy to detect the presence of gall stones. In this case report a patient with gallstones and choledocholithiasis was reported. Severe cholestatic jaundice in β-thalassemia intermedia was diagnosed six months before hospitalization. The patient underwent open cholecystectomy and exploration common bile duct stones. [ABSTRACT FROM AUTHOR]

Background: Choledocholithiasis is one of the causes of jaundice and may require urgent treatment. Endoscopic retrograde cholangiopancreatography (ERCP) has been the primary management strategy for choledocholithiasis. However, small stones can be overlooked during ERCP. Aim: The aim of this study was to evaluate the accuracy of intraductal ultrasonography (IDUS) for detecting choledocholithiasis in icteric patients with highly suspected common bile duct (CBD) stones without definite stone diagnosis on ERCP. Methods: Ninety-five icteric (bilirubin ≥3 mg/dL) patients who underwent ERCP for highly suspected choledocholithiasis without definite filling defects on cholangiography were prospectively enrolled in the present study. We evaluated the bile duct using IDUS for the presence of stones or sludge. Reference standard for choledocholithiasis was endoscopic extraction of stone or sludge. Result: Bile duct stones were detected with IDUS in 31 of 95 patients (32.6 %). IDUS findings were confirmed by endoscopic stone extraction in all patients. The mean diameter of CBD stones detected by IDUS was 2.9 mm (range 1-7 mm). IDUS revealed biliary sludge in 24 patients (25.2 %) which was confirmed by sludge extraction in 21 patients (87.5 %). In dilated CBD, detection rate of bile duct stone/sludge based on IDUS was significantly higher than in non-dilated CBD ( p = 0.004). Conclusion: IDUS is useful for the detection of occult CBD stone on ERCP in icteric patients with highly suspected CBD stones. [ABSTRACT FROM AUTHOR]

We aimed to determine the role of exchange transfusion related complications, treatment, and etiology as well as subgroup incompatibility in patients subject to ET (exchange transfusion) due to newborn jaundice. 82 patients hospitalized due to newborn jaundice and exposed to exchange transfusion between August 2007 and August 2011 were retrospectively studied. Before ET mean total serum bilirubin was 29,2±9,83. The most frequent cause of ET was ABO incompatibility (31%) followed by Rh incompatibility (19%) and subgroup incompatibility (17%), respectively. In 46% of all patients and in 71% of the patients presenting with subgroup incompatibility , direct combs test was detected to be (+). 49% of the patients were administrated with intravenous immunoglobulin. 5 of the patients who were exposed to ET presented with hydrops fetalis. Of these patients 3 had Rh, 1 had ABO while the other had subgroup incompatibility. Although ABO and Rh incompatibility are substantial underlying reasons of severe jaundice requiring exchange transfusion, particularly widespread use of RhoGAM thereby enabling the prior identification and precautions, ET need was reduced compared to previous cases. On the contrary, SGU related severe hemolytic jaundice relatively enhanced, however. [ABSTRACT FROM AUTHOR]

Background: Idiopathic painless jaundice with significant elevations in serum transaminases, occurring in a previously healthy patient, invokes a circumscribed set of possibilities including viral hepatitis, auto-immune hepatitis (AIH) and drug-induced liver injury (DILI). Methods: In this described case, common causes of cholestatic jaundice were considered including drug-induced liver injury, viral causes of hepatitis, and auto-immune antibodies. Biliary obstruction was excluded by appropriate imaging studies. Liver biopsy was obtained, though not definitive. Results: After detailed investigation failed to reveal a cause of the jaundice, an empiric trial of steroids was initiated on the possibility that our patient had antibody-negative AIH and not DILI, with an associated grave prognosis. Conclusions: Empiric treatment with prednisone led to rapid resolution of jaundice and to the conclusion that the correct diagnosis was antibody-negative AIH. [ABSTRACT FROM AUTHOR]

INTRODUCTION: In 2007, the Canadian Paediatric Society (CPS) published guidelines aimed at preventing severe hyperbilirubinemia. OBJECTIVES: To determine whether hospitals had implemented these guidelines; to investigate how guideline-recommended care is organized; and to understand the factors influencing guideline implementation. METHODS: The present study was an online survey conducted from December 2011 to May 2012 of all Ontario hospitals offering maternal-newborn services. RESULTS: A total of 97 of 100 eligible hospitals responded. Seventy-seven of the 97 (79%) respondents reported having implemented universal neonatal bilirubin screening. Among these hospitals, hospital-based postdischarge follow-up was reported more frequently than follow-up at community-based locations: hospital laboratory (n=40 [52%]), mother-baby care unit (n=32 [42%]), outpatient clinic (n=25 [33%]), primary care provider in community (n=19 [25%]) and community laboratory (n=8 [10%]). The CPS guidelines were the most frequently reported factor influencing implementation (n=74[96%]). DISCUSSION: The survey provides valuable insight into the impact of a complex guideline in Canada's largest province. There was heterogeneity in how hospitals organized services, but there was a notable trend toward hospital-based postdischarge care. The shift to hospital-based care runs counter to current health policy directions and highlights the lack of integration among health care sectors. CONCLUSION: The majority of Ontario hospitals implemented universal bilirubin screening following the release of the CPS guidelines. Further analysis is needed to determine the impact that the guidelines and the differences in implementation have had on clinical outcomes and the utilization of health services. [ABSTRACT FROM AUTHOR]

There are multiple causes of jaundice in the first 2 weeks of life. The aim of this article is to help explain what these causes are and why they occur. It discusses how to focus on the history, examination and investigations in such cases. Initial management will vary depending on the clinical context; as such, this article also outlines the initial management of the most common scenarios., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The association between serum erythrocyte immune function indexes and blue light treatment effect and severity in child patients with pathological jaundice was testified., Methods: One hundred and seven children with pathological jaundice and 69 children with physiological jaundice were enrolled to analyze the association between erythrocyte immune function indexes and blue light treatment or disease progression., Results: The area under the ROC curve (AUC) of red blood cell immune complex rosettes (RBC-ICR) and red blood cell C3b receptor rosette (RBC-C3bR) in diagnosing pathological jaundice and assessing the efficacy of blue light therapy overweighed 0.8. Meanwhile, the RBC-ICR values of the child patients were positively correlated with the severity of the disease, and the RBC-C3bR and red blood cell immune affinity receptor (FEER) values were negatively correlated with them (p < 0.05)., Conclusions: The erythrocyte immune function indexes of child patients with pathological jaundice were relevant to the disease severity, and was provided with diagnostic value for pathological jaundice or assessed value for the efficacy of blue light therapy.

The study investigated a non-invasive and instant method of jaundice detection using machine vision technique. Color images of sclera region of the eyes of healthy subjects and patients suffering from jaundice were acquired. Image processing algorithms were developed by using CIELab color model. The principal component analysis (PCA)-based discrimination analysis was applied over the color data obtained from patient's sclera region, which showed a variance of 89%. The results of PCA biplot indicated correlations among jaundice patients and color attributes. Based upon these results, neuro-fuzzy-based software was developed for the prediction of jaundice as well as the calculation of degree of its severity. The experimental results show satisfactory performance as compared to the conventional chemical methods. The proposed technique is totally non-invasive and low cost. [ABSTRACT FROM AUTHOR]

Part 3: The surgeon's perspective The first two of these three articles have looked at the issues of management of extrahepatic biliary tract obstruction from diagnostic and therapeutic view points. By the time the case has been transferred to the surgical team, the patient may still be in a critical condition. Extra hepatic biliary duct obstruction (EHBDO) has a number of systemic physiologic effects, other than the obvious clinical sign of jaundice ( Figure 1). Patients may be inappetant, and in a cachectic condition, they may have an anaemia of chronic disease, intestinal sloughing or haemorrhage, hepatic compromise, coagulopathy, endotoxaemia, decreased myocardial contractility, acute tubular necrosis and be at risk of biliary tract rupture. [ABSTRACT FROM AUTHOR]

A 61-year-old man with AIDS on chronic highly active antiretroviral treatment (HAART) presented with lethargy and jaundice and was found to have abnormal liver function tests (LFTs). Investigations including viral/ autoimmune markers and imaging were unrevealing, except for positive Epstein-Barr virus. HAART was held, however, transaminases and total bilirubin continued to rise. The liver biopsy revealed classical Hodgkin's lymphoma (HL). HL presenting only with liver findings without lymphadenopathy is rare. Extreme cases can lead to fulminant liver failure. The bone marrow biopsy and dramatic elevation in serum ferritin were consistent with haemophagocytic lymphohistiocytosis. Finding a chemotherapy regimen was challenging given abnormal LFTs and HAART interactions. Initial chemotherapy regimen has successfully decreased LFTs; however, it was limited by pancytopenia. The patient's regimen was changed, however second regimen was complicated by neuropathy. LFTs improved and the patient was able to receive the standard care chemotherapy for HL with significant clinical, laboratory and radiological improvement. [ABSTRACT FROM AUTHOR]

This article outlines a practical approach to the investigation of the jaundiced child and reviews the imaging modalities and findings that can establish a diagnosis or narrow the differential. A systematic approach to the work-up of the jaundiced child prevents unnecessary tests and facilitates prompt treatment. Imaging of the jaundiced neonate and infant is reviewed separately to that of the older child and adolescent owing to different aetiologies in the two age groups. There are wide and varied differential diagnoses for the cause of jaundice in a child, which are broadly classified as pre-hepatic, hepatic and post-hepatic. Imaging does not play a significant role in elucidating the cause of pre-hepatic (unconjugated hyperbilirubinaemia); the underlying causes include physiological jaundice, breast milk jaundice, haemolysis and sepsis. Imaging does, however, play an important role in the investigation of conjugated hyperbilirubinaemia, which nearly always reflects hepatic dysfunction. One of the major roles of imaging is to differentiate intrahepatic from extrahepatic causes of jaundice although the underlying diagnosis is often ultimately established by a combination of clinical presentation and findings, laboratory tests, imaging and histology. Initial laboratory tests include liver function tests (including conjugated bilirubin fraction), hepatitis screening, TORCH (Toxoplasmosis, Other (syphilis, hepatitis, zoster), Rubella, Cytomegalovirus and Herpes) titres, a sepsis screen (blood, urine and cerebrospinal fluid (CSF)), metabolic screen (e.g. alpha1-antitrypsin phenotype testing) and sweat test, and in older children a toxic screen and autoantibodies. These results help to determine the most appropriate imaging. [ABSTRACT FROM AUTHOR]

Jaundice is a clinical finding that is a frequent cause of referral for imaging. Based on the clinical history, physical examination and blood biochemistry alone, it is often impossible to accurately distinguish between an obstructive and a non-obstructive cause of jaundice, thus radiological evaluation is essential. The primary aim of radiology is to assess whether the cause is obstructive and to determine the cause of obstruction when present. This paper aims to discuss the range of imaging modalities available and highlights the strengths of each modality. We present a rational imaging strategy to evaluate the jaundiced adult. [ABSTRACT FROM AUTHOR]

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Competition is one of the most cited mechanisms to explain secondary sexual dimorphism in animals. Nonetheless, it has been proposed that sexual dimorphism in bat wings is also a result of adaptive pressures to compensate additional weight caused by fetus or pup carrying during the reproductive period of females. The main objective of this study is to verify the existence of sexual dimorphism in Sturnira lilium wings. We employed geometric morphometrics techniques using anatomical landmarks superimposition to obtain size (Centroid Size) and shape variables of wings, which were reduced by Linear Discriminant Analysis (LDA). We also employed classical morphometrics using wing length measurements to compare efficiency between these two morphometric approaches and make comparisons using wing area measurements. LDA indicated significant differences between wing shapes of males and females, with 91% (stepwise classification) and 80% (leave-one-out cross validation) of correct classification. However, the size variable obtained did not contribute to such classifications. We have observed larger areas in female wings, but we found no differences in wing length measurements and no allometric effects in wing length, shape and area measurements. Interestingly, our study has provided evidences of morphological differences where classical morphometrics have failed. LDA and area measurements analyses revealed that females have a different area distribution in distinct portions of the wing, with wider dactylopatagia and plagiopatagia, and wingtips more triangular than males. No differences in body length or relative wing length were observed between the sexes, but pregnant females have more body weight than non-pregnant females and males. Our findings suggest that sexual dimorphism in the wing shape of S. lilium is probably related to the increase in flight efficiency of females during reproductive period. It decreases wing loading in specific portions of the wing and reduces energy cost to maintain a faster and maneuverable flight. [ABSTRACT FROM AUTHOR]

Discovered in 1981 by Tanaka and Murao ( Agric Biol Chem 45:2383-2384, ), bilirubin oxidase (BOD) is a sub-group of multicopper oxidases (MCOs) also utilizing four Cu ions. It catalyzes the oxidation of bilirubin to biliverdin, hence the classification of bilirubin oxidase, and has been primarily used in the determination of bilirubin in serum and thereby in the diagnostic of jaundice. Unlike laccases, the most studied MCOs, BODs display a high activity and stability at neutral pH, a high tolerance towards chloride anions and other chelators, and for some species, a high thermal tolerance. Therefore, BODs could potentially be an alternative to laccase which are so far mainly restricted to applications in acid media. Because of growing interest in BODs for numerous applications under mild pH conditions, based on the number of patents and publications published in the last 5 years, here I will summarize the available data on the biochemical properties of BODs, their occurrence, and their possible biotechnological use in (1) the field of Healthcare for the elaboration of biofuel cells or bilirubin sensors or (2) the field of environmentally desirable applications such as depollution, decolorization of dyes, and pulp bleaching. [ABSTRACT FROM AUTHOR]

Aims Total bilirubin tests are individually inexpensive but can result in huge costs to healthcare systems worldwide, because they are very commonly requested. The main objective of this study was to evaluate the diagnostic accuracy of the icteric index, a test with zero reagent cost, as a preliminary biomarker to decide when total bilirubin measurement is necessary. Methods We retrospectively reviewed all the requested total bilirubin values and their corresponding icteric index results in a 2-year period (2010e11). Receiver operating characteristic (ROC) curve analysis was used to determine the optimal icteric index cut-off value to discriminate between normal and abnormal bilirubin values (>20.5 mmol/l; >1.2 mg/dl). Results The study included total bilirubin and icteric index results of 100 207 patients. The ROC curve analysis suggested 34.2 mmol/l (2 mg/dl) as the optimal icteric index threshold to identify abnormal bilirubin values. The area under the curve was 0.981. Regardless of the patient population studied (primary care, hospital and different individual hospital departments), sensitivity was greater than 94% and specificity was over 98%. Likelihood ratio values provided strong evidence that total bilirubin is less than 20.5 mmol/l (<1.2 mg/dl) when the icteric index is less than 34.2 mmol/l (<2 mg/dl). Conclusions This study supports the use of the icteric index to identify patients with abnormal total bilirubin values. Considerable economic savings can be achieved if this strategy is applied on a clinical daily basis. Its implementation and report should be discussed and planned by laboratory professionals together with requesting physicians. [ABSTRACT FROM AUTHOR]

Background. Jaundice is a rare but important symptom of malignant and benign conditions. When patients present in primary care, understanding the relative likelihood of different disease processes can help GPs to investigate and refer patients appropriately.Objective. To identify and quantify the various causes of jaundice in adults presenting in primary care.Design. Historical cohort study using electronic primary care records.Setting. UK General Practice Research Database.Methods. Participants (186 814 men and women) aged >45 years with clinical events recorded in primary care records between 1 January 2005 and 31 December 2007. Data were searched for episodes of jaundice and explanatory diagnoses identified within the subsequent 12 months. If no diagnosis was found, the patient’s preceding medical record was searched for relevant chronic diseases.Results. From the full cohort, 277 patients had at least one record of jaundice between 1 January 2005 and 31 December 2006. Ninety-two (33%) were found to have bile duct stones; 74 (27%) had an explanatory cancer [pancreatic cancer 34 (12%), cholangiocarcinoma 13 (5%) and other diagnosed primary malignancy 27 (10%)]. Liver disease attributed to excess alcohol explained 26 (9%) and other diagnoses were identified in 24 (9%). Sixty-one (22%) had no diagnosis related to jaundice recorded.Conclusion. Although the most common cause of jaundice is bile duct stones, cancers are present in over a quarter of patients with jaundice in this study, demonstrating the importance of urgent investigation into the underlying cause. [ABSTRACT FROM AUTHOR]

Jaundice is a sign that describes yellowing of skin, sclera and mucous produced by increased levels of bilirubin. It is common cause of consultation in emergency department and outpatient clinics. It is very common in the neonatal period. Jaundice is not an isolated entity but is talking us of a specific disease. Therefore, after appropriate clinical assessment and taking relevant paraclinical, may be start imagine studies with US scan of liver; according this study findings we need additional studies as contrast abdominal CT to evaluate biliary tract, MRI or other noninvasive methods according to patient condition and availability. Depending on the results is necessary to continue with ERCP as the diagnostic, therapeutic or both. [ABSTRACT FROM AUTHOR]

A high performance liquid chromatography (HPLC) method was developed for the determination of bilirubin concentration in pig liver. The sample was extracted by sequential extraction with dimethyl sulfoxide and acetonitrile, followed by HPLC analysis. The accuracy of the analytical method was estimated by spiking pig liver samples with three different concentrations of bilirubin (2.5, 5 and 10 µg/mL) and a recovery of 75.7--84.9% was obtained, with corresponding intra-day and inter-day precisions of 1.6--4.1% and 2.4--3.9%, respectively. The limit of detection of bilirubin was 0.3 µg/mL and the analytical time for one sample was 9 min. In this study, the bilirubin concentration of normal and jaundiced pig livers was determined. It was concluded that the procedure could provide scientific data for detecting increased bilirubin concentration to identify jaundiced livers. The analytical method was found to be rapid, sensitive, accurate, repeatable and reproducible, and could be applied for the measurement of bilirubin concentration in pig liver. [ABSTRACT FROM AUTHOR]