Pediatric emergency medicine trisk 0878 0878
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5. Are there any rashes, arthralgias, arthritic joints, or conjunctivitis? (to question
about autoimmune causes)
6. Have there been any recent behavioral changes, especially in a teenager? (to
evaluate for Wilson disease)
7. Are bleeding, bruising, swelling, excessive sleeping, or mental status changes
present? (to assess overall liver function)
8. What medications are taken, and are any of them new? (to identify potential
hepatotoxins)
9. Is there a family history of liver diseases, early-onset emphysema, or iron
overload? (to evaluate for genetic causes, such as Alagille syndrome, α1 antitrypsin disease, or hemochromatosis)
10. (For infants) Were there any infections during pregnancy? Were the newborn
screens normal?
It is also important to perform a meticulous physical examination, starting with
the growth parameters of the child, including weight and height percentiles, as
well as the growth curve. Central and distal perfusion should be assessed. While
examining the abdomen, the liver size, contour, and texture should be noted, as
well as an estimation of spleen size. The presence or absence of abdominal
tenderness and the location should be identified in children with reliable
examinations. The skin examination should include evaluation for bleeding,
bruising, spider angiomas, caput medusa, excoriations or signs of pruritus, and
palmar erythema. The neurologic examination should include mental status
evaluation, as well as observation for dysarthria, tremor, or rigidity.
Splenomegaly, stigmata of portal hypertension, and neurologic changes all point
to more chronic causes of liver disease.
EVALUATION
The most concerning etiologies for conjugated hyperbilirubinemia are the results
of hepatocyte destruction or biliary obstruction. Identification of these conditions
should be the focus of the evaluation in the emergency department. The
emergency provider must quickly assess two things: (1) Does the child have
impaired liver function, or just liver irritation/injury? and (2) Is the liver disease
acute or chronic? Initial function tests should include:
Albumin (reflects liver synthetic function, but also reflects nutritional status and
is a negative acute phase reactant)
Prothrombin time (PT) and international normalized ratio (INR) (reflects liver
synthetic function, but also may be abnormal with vitamin K deficiency)
Ammonia
