Thanks go to Scott who gave us the chance to discuss a patient with painless jaundice today! Now a review of bilirubinemia is in order, obvi.
From a recent intern report blog post, here is a non-exhaustive table of possible causes of jaundice/hyperbilirubinemia:
|Causes of Conjugated Hyperbilirubinemia
||Causes of Unconjugated Hyperbilirubinemia
|Extrahepatic cholestasis (biliary obstruction)
-Intrinsic and extrinsic tumors (eg, cholangiocarcinoma, pancreatic ca) -Primary sclerosing cholangitis
– AIDS cholangiopathy
– Acute and chronic pancreatitis
– Strictures after invasive procedures
– Parasitic infections: liver flukes, Ascaris
|Increased bilirubin production
– Extravascular hemolysis
– Intravascular hemolysis
– Wilson Disease
– Alcoholic hepatitis
– Nonalcoholic hepatitis
– Primary biliary cholangitis
– Drugs and toxins: herbal meds, arsenic, halothane
– Sepsis and hypoperfusion states
– Infiltrative processes (amyloidosis, lymphoma, sarcoidosis, tuberculosis)
– Cholestasis of pregnancy
|Impaired Hepatic bilirubin uptake
– Heart Failure
– Portosystemic shunts
– Certain drugs: rifampin, probenecid
-Rotor Syndrome: defect in reuptake of conjugated bilirubin
-Dubin-Johnson Syndrome: Defect of canalicular organic anion transport
|Impaired bilirubin conjugation
– Gilbert’s (stress-induced, asymptomatic except mild bilirubin elevation)
– Crigler-Najjar syndrome – Hyperthyroidism
– Liver diseases
What’s the anatomy and where does an obstruction occur to cause intra/extra-hepatic biliary dilation:
Generally, a painless jaundice ddx includes:
- Cancer: pancreatic, cholangiocarcinoma
- Hemolytic anemia
- Viral hepatitis
Which imaging first?
- First: Ultrasonography (see weird depiction of this below) as it’s more cost-effective, noninvasive, and the most sensitive imaging technique for detection of stones
- Then consider CT w/ con for better detection of parenchymal disease of the liver
- Neither CT nor ultrasound have the best sensitivity to rule out an obstructing intra-ductal stone or mass, so consider (and talk to GI) if ERCP or MRCP is necessary
On a much less related note, after last month’s INTERN HALF DAY small group discussions, there was a call in to psychiatry for help in understanding what medications they have experience with and use on an emergent basis (if needed), how the choice of emergent medications changes with elderly/frail patients, and how the QTc factors in to that equation…
***Below is the compiled commentary from psychiatry—quite lengthy, so file away to reference when needed***
Do you have a patient who is acutely agitated? Have you tried verbal de-escalation? Called IP/security?
Prep work per psychiatry: Nursing staff and physicians/residents have little experience managing the acutely agitated/potentially dangerous patient. If you are even considering using IM meds, make sure that IP (security) is present for the administration. In addition, if there is time to briefly meet with IP about the plan (ie, will you offer the patient PO meds before IM, will physical restraints be needed) BEFORE the team approaches the patient for meds=that’s the ideal. Sometimes you can avoid giving IM meds if IP is present, as the patient may end up accepting PO with the show of force. Remember that someone who just got an injection is likely to continue to be agitated and so physical restraints are often necessary when they can’t be in a room that has been cleared of dangerous objects/people.
But for “emergent” or “chemical restraints”…
1st line) The easiest, go-to is always Haldol (unless there’s a contraindication like h/o haldol allergy, dystonic reaction, NMS, parkinsons, etc…). Psychiatry usually uses 5mg Haldol, 2mg Ativan, 50mg Benadryl with the alternative of 5mg Haldol, 1mg Ativan, 1mg of Cogentin. Benadryl is for the ppx from EPS and for the sedating effect.
- For older folks, probably hold the Benadryl and Ativan. While Cogentin is historically more expensive than IM/IV Benadryl, there is less anticholinergic effects and less sedation with Cogentin, so you could maybe consider it in people who are elderly with dementia.
- Haldol is nice because can be used either IV or IM. For particularly problematic patients, psychiatry will recommend IV Haldol 2mg q30min until behaviorally under control.
- Checking EKG’s frequently to monitor QTc.
- IV Haldol is nice because, while it does carry risk of QT prolongation, it does not carry the same risk of dystonic reaction as IM/PO. Haldol dosing is not quite equivalent, PO:IM/IV = 2:1. For folks who are frail/old, you can probably just give Haldol 1-2mg IM!
2nd line) In general, SL or IM Zyprexa (Olanzapine) 10mg is a great option. DO NOT give IM BENZOS within 1 hour of IM Zyprexa given a risk of life threatening respiratory depression.
- Zyprexa is convenient because po, SL, IM dosing is all equivalent. No IV version though.
- For older/frail folks, cut the dose in half, at least, to 5mg
2nd/3rd line) IM Geodon (Ziprasidone) can be a good choice if you are worried about the whole IM benzos thing with Zyprexa or if there was previous dystonic reaction which is far less likely with Geodon.
- IM Geodon is 4X as strong as PO. You can use 10-20mg IM which is equivalent to 80mg PO dose. No SL or IV version.
- If you use IM Geodon, make sure to get an EKG afterwards once the patient has calmed down – it is one of the most QT-prolonging.
2nd/3rd/4th line) Consider the sedating power of Risperidone or Risperdal. 2mg of Risperdal is about equivalent to a 5mg Haldol emergent dose.
- You can use 1-2 mg PO or even much lower doses for someone smaller, older, or antipsychotic naive such as 0.5mg.
- No IM/IV formulation available.
-for older or frail folks, cut the doses by at least half (2mg Haldol, 5mg Zyprexa) prior to giving. Some will go as low as 0.5mg Haldol.
-SL formulations are always a good step right before the point of needing to go to emergent chemical restraint if you can speak with a patient and have them agree to take it. Common SL options include Zyprexa Zydis, Risperdal M-tabs. At UCSF, Zyprexa (zydis) is the most commonly used SL form–you can still offer benzos with it as long as it isn’t given IM. You may see more Risperdal M-tabs at ZSFG (on formulary) than Zydis (non-formulary, need pharmacy approval) but you could use either, especially if you know the patient is routinely on Risperdal or Zyprexa, then that could guide you.
-Psychiatry likes sedating antipsychotics (Olanzapine, Risperidone, Haldol) in an acute situation, and those three tend to be interchangeable
-You can often ask someone: “We can get you some medication that might help you feel less afraid.” or “Hey, is there anything that has helped you feel better and calm when you’re upset and agitated?”
-If someone is already on a standing antipsychotic, giving an extra dose of that is a safe bet (i.e. an extra 50-100 of Seroquel if they’re already getting some
-If you are in more emergent territory or aren’t sure about safety, then you will probably want to just go IV/IM route for safety to both patient and staff.
-If a patient is not at all psychotic or delirious and seem purely behavioral (meth agitation maybe) or if you are really concerned about a prolonged QT, you could always give IM benzos alone, such as 2-3mg Ativan to start.
Examples of emergent meds at the General:
Risperdal M tabs
Olanzapine Zydis (non-formulary therefore required approval by pharmacy formulary manager)
Olanzapine IM (non-formulary therefore required approval by pharmacy formulary manager)
With cases of QTc prolongation, consider using olanzapine IM or fluphenazine IM per psychiatry pharmacy. Haldol PO is actually not a big concern, the parenteral formulations (IM/IV) are more likely to prolong QT. If you’re interested, here is a quick table (reference below) of antipsychotics/QTc increase.
Examples of QTc prolongation associated with select antipsychoticsa
||Approximate QTc interval prolongation in millisecondsb
||-1 to -4
||7 to 15
||39 to 53
||2 to 6.5
||2 to 4
||6 to 15
||3.5 to 10
||33 to 41
||16 to 21
|aList is not comprehensive. Other antipsychotics may be associated with QTc prolongation bQTc prolongation interval may depend on the route of administration