Approach to the Jaundiced Patient

By: Dr. Berhane Redae

Introduction :
not a common presenting complaint in adults . when present, it may indicate a serious problem. Patients with jaundice may present with no symptoms at all or they may present with a lifethreatening condition

variety of underlying causes. Viral hepatitis Alcoholic liver disease Autoimmune hepatitis Medication-induced liver disease Common bile duct stones Pancreatic cancer Primary Biliary Cirrhosis (PBC) Primary Sclerosing Cholangitis (PSC) A systematic approach is warranted to clarify the cause quickly so that treatment can begin as soon as possible

Jaundice
Definition: Jaundice Yellowish colouration of sclera,mucous membrane & skin. It is Symptom not a disease. Literally, means yellow. Caused by high Bilirubin. Normal range 0.3-1.2 mg /dL. Clinically obvious 2.5 mg /dl.

Bilirubin
Bilirubin is formed by a b/down product of heme rings. Approximately 80 % of the heme moiety comes from catabolism of red blood cells. Remaining 20 % resulting from ineffective erythropoiesis and breakdown of muscle myoglobin and cytochromes.

Causes of hyperbilirubinemia :
Overproduction by reticuloendothelial system.

Failure of hepatocyte uptake.

Failure to conjugate or excrete. Obstruction of biliary excretion into intestine.

Pre-hepatic (Haemolytic) :
Excessive haemolysis due to any cause: RBC disorder Hereditary spherocytosis. Sickle cell anaemia. Auto-immune Mismatched blood transfusion. Paroxysmal cold hemoglobinuria. Infective Sepsis. Malaria.

Hepatic Jaundice :
Hepatic Jaundice Due to a disease affective hepatic tissue either congenital or acquired diffuse hepatocellular injury.

Post-hepatic (Obstructive) :
Post-hepatic (Obstructive) It is due to intra or extra hepatic obstruction of bile ducts. Extra-hepatic Gallstones. Carcinoma of the head of pancreas or CBD. Intra-hepatic: Primary Biliary Cirrhosis . Sclerosiing cholangitis. Drugs.

Main features :
:Main features: Jaundice. Dark urine. Pale stool. Prurities. Absent Urobilinogen in urine. Alkaline phosphatase .

Critical Questions in the Evaluation of the Jaundiced Patient Acute vs. Chronic Liver Disease Hepatocellular vs. Cholestatic
Biliary Obstruction vs. Intrahepatic Cholestasis

Fever
Could the patient have ascending cholangitis?

Encephalopathy
Could the patient have fulminant hepatic failure?

Evaluation of the Jaundiced Patient

HISTORY The Following Aspects of the history should be covered. Duration of the illness . Recent outbreaks of jaundice . Intravenous drug abuse, recent injection,blood transfusion. Alcohol consumption .

Evaluation of the Jaundiced Patient

HISTORY ( cont ) Drug Taken . Travel. Family History. Recent Surgery of Biliary Tract or carcinoma . Fever or Rigors.

PHYSICAL EXAM
BP/HR/Temp Mental status Asterixis Abd tenderness Liver size Splenomegaly Ascites Edema
Spider angiomata Hyperpigmentation Kayser-Fleischer rings Xanthomas Gynecomastia Left supraclavicular adenopathy (Virchows node)

Physical Examination
The physical examination should focus primarily on: Stigmata of chronic liver disease Marks of itching . Charcots triad: fever + rigors + jaundice . Courvoisiers Law: obstructive jaundice + palpable gallbladder = malignant cause.

 Certain findings suggest specific diseases such as: Hyperpigmentation in hemochromatosis. A Kayser-Fleischer ring in Wilson's disease. Xanthomas in primary biliary cirrhosis.

LAB EVALUATION
AST-ALT-ALP Bilirubin total/indirect Albumin INR Glucose Na-K-PO4, acidbase Acetaminophen level

CBC/plt
Ammonia Viral serologies ANA-ASMAAMA Quantitative Ig Ceruloplasmin Iron profile Blood cultures

Evaluation of the Jaundiced Patient

Ultrasound

More sensitive than CT for gallbladder stones. Equally sensitive for dilated ducts. Portable, cheap, no radiation, no IV contrast.

Evaluation of the Jaundiced Patient :

CT Better imaging of the pancreas and abdomen. is commonly used to identify hepatic masses, particularly small metastases, with an accuracy of about 80%. MRCP is more sensitive than CT or ultrasound in diagnosing common bile duct abnormalities, particularly stones. Imaging of biliary tree comparable to ERCP. Evaluation of the Jaundiced Patient

 ERCP * Diagnostic: Calculi, tumours, strictures. Biopsy of pancreatic or distal CBD. * Therapeutic Extract stones and drain bile. Stent to relieve obstruction.

 PTC Percutaneous transhepatic cholangiography is valuable when intrahepatic ductal dilatation is present. This procedure can be used to determine the location of biliary tract obstruction.

Liver Biopsy
Conditions in which needle biopsy is useful include: cirrhosis. chronic hepatitis. granulomatous hepatitis tumors, undiagnosed hepatomegaly. cholestasis of unknown cause, infiltrative processes and miliary tuberculosis

JaundiceSummary
Patients history of great importance . Physical findings can narrow the differential diagnosis. Simple Laboratory Tests can focus evaluation. Ultrasound important if diagnosis not obvious.

 Selected Laboratory tests confirms diagnosis and leads to successful treatment.

Use treatment that is proven to be effective, is of no harm, and where cost is justified.