Jaundice

History taking:
- onset / duration
- who noticed it
- progression
- establish type of jaundice: (prehepatic / intrahepatic / posthepatic)
colour of urine (obs J: tea coloured urine)
colour of stool (obs J: pale coloured stool)
pruritus (obs J bile salt deposition to skin pruritus)
pale, floating, foul-smelling faeces - steatorrhea
(obs J absence of bile flow into the gut)
*fx of bile acids emulsify fat into micelles, aiding lipase to digest lipids
- establish aetiology of jaundice (associated symptoms and risk factors for every aetiology)
- possible complications of disease
malabsorption of fat-soluble vits (A,D,E,K)
coagulopathy
hypoalbuminaemia



Differential diagnosis:

Causes of jaundice Aetiology Clinical features

Pre-hepatic Infections Fever (pattern), chills + rigors, jaundice, headache,
(d/t increased - malaria nausea, abdominal pain/distension, hx of foreign travel
haemolysis / jungle trekking
unconjugated
hyperbilirubinaemia) Haematological SOB, palpitations, dizziness, lethargy, abdominal pain,
- Sickle cell disease, G6PD, family history of hereditary haematological dx
jaundice hereditary spherocytosis, Splenomegaly
tea coloured urine thalassemia, autoimmune
pale stool haemolytic anaemia
itchness
steatorrhes
Blood group mismatch History of blood transfusion
Intrahepatic jaundice
-Hepatocyte prob Congenital conjugation - Gilbert (lack of enzyme)
-bile canaliculi prob abnormalities - Criggler najar (absence of enzyme)
(intrahepatic - Dubin Jonson (absence of pump)
cholestasis) - Rotor (idiopathic)

*can be conjugated or
unconjugated

Decreased conjugation due to

reduced hepatocyte uptake Coagulopathy, haematemesis, abdominal distension,

(cirrhosis - portosystemic shunt

to bypass a cirrhotic liver)



Hepatitis Fever, malaise, anorexia, nausea, vomiting, arthralgia,
- Viral (hep B, C) jaundice, RUQ discomfort, jaundice, pruritus, diarrhea
- bacterial (Weils dx lepto) RF: hx of blood transfusion, IVDU, sexual promiscuity
- Alcohol (steatohepatitis) (unprotected sex/multiple partners), hx of foreign
- Autoimmune travel, tattoos, direct contact, healthcare workers,
haemodialysis, close family members of a carrier/case,
hx of waterfall visit, alcoholic abuse (quantify how many
units/week)
Drugs toxicity Inability of hepatocytes to excrete bilirubin
- PCM overdose, valproate, rifampicin
Paralysis of biliary system (cholestasis)
- co-amoxiclav, nitrofurantoin, OCP
Primary biliary cirrhosis AMA positive
Primary sclerosing cholangitis Pruritus, fatigue. If advanced: ascending cholangitis,
cirrhosis, hx of UC
AMA ve
ANA, SMA, ANCA may be +ve
Lymphoma Fever, night sweats, weight loss, anorexia
Wilsons dx, Haemochromatosis Bronzed skin, signs of DM, family history
Metastatic liver disease Hx of cancer
HCC Hx of cirrhosis, weight loss, anorexia, fever, night sweats

Post-hepatic jaundice Choledocholithiasis - Hx of intermitten RUQ pain, hx of gallstones
Aka obstructive or (gallstones in CBD)
surgical jaundice
*always conjugated Ascending cholangitis Charcots triad : fever with C+R, jaundice, RUQ pain
Malignancy Weight loss, anorexia, fever, night sweats, abdominal
Jaundice - Head of pancreas discomfort, early satiety, painless jaundice
tea coloured urine - Bile duct (cholangioca.)
pale stool - Ampullary ca
itchness Pancreatitis Epigastric pain radiating to the back, nausea, vomiting,
steatorrhes fever
Mirizzis syndrome (GS impacted at the cystic duct causing compression to the
CBD)
RUQ pain, recurrent ascending cholangitis
Budd Chiari syndrome Severe upper abdominal pain, jaundice, abdominal
(thrombosis in hepatic vein) distension
Hepatosplenomegaly, ascites
Trauma post ERCP

Physical examination:
- Signs of dehydration (tachycardia, narrow pulse pressure, hypotension), Fever
- Inspection:
Cachectic (malignancy)
Bronzed tan skin
Scratch marks
Needle marks
scleral icterus
Keyser-fleischer rings in the iritis (wilsons dx)
Stigmata of chronic liver dx clubbing, palmar erythema, duputyren contracture, bruising,
spider naevi, gynaecomastia)
- Palpation
RUQ tenderness acute hepatitis, cholangitis, choledocholithiasis
Epigastric mass? Hepatomegaly? Splenomegaly?
Ascites chronic liver disease
Palpable lymphadenopathy


Investigations

Bloods Full blood count Low RBC with high reticulocyte increased RBC
st
(1 line to Reticulocyte level turnover (haemolysis / recent bleed)
establish Low hb, low MCV, low MCHC thalassemia
jaundice and its Serum bilirubin levels To confirm jaundice is due to hyperbilirubinaemia.
type) Direct, indirect bilirubin Gives clue on the possible aetiology
Direct > indirect hepatic / obstructive J
Indirect > direct Pre hepatic
Liver enzymes Raised ALT/AST hepatocyte damage (hepatitis)
AST > ALT excessive alcohol intake
ALT > AST viral hepatitis
ALP Released from damaged biliary epithelial cells, bones
with high turnover, placenta
GGT Expressed almost exclusively by biliary epithelial cells
[obstructive jaundice]
Serum amylase / lipase Pancreatitis
Urine Urinalysis Bilirubin is always pathological! (post hepatic J)
*urobilinogen is normal
nd
Blood (2 line Peripheral blood film Thalassemia hypochromic microcytic, target cells
ix to identify Sickle cells
cause) Spherocytes
Malaria
Viral screen / serology Hep A, B, C serology
HIV status
Autoimmune screen ANA
ASMA autoimmune hepatitis
AMA - PBC
ANCA - PSC
Coombs test Direct coombs test - AIHA
Congenital screen Haemochromatosis high ferritin, high transferrin
Wilsons high Cu, low ceruloplasmin
Coagulation profile Deranged compromised liver function
Serum albumin Liver malfunction
Imaging Ultrasound of abdomen Dilated CBD obstructive jaundice?
and HBS Head of pancreas ca, CBD stones
PBC, PSC
Liver cirrhosis, liver ca
CT scan Malignancy
Others Liver biopsy Diagnostic
ERCP Diagnostic & therapeutic - sphincterotomy