jaundice / hepatitis
jaundice
Jaundice is a yellowish colouration of
the tissue resulting from the deposition of bilirubin
This only happens in the presence of
serum hyperbilirubinemia, and is a sign of either
·
Liver disease
·
Hemolytic disorder (less
commonly)
The degree of bilirubin elevation can be
estimated by PE.
Sclera icterus = at least 51micromol/L (3mg/dL)
May be even green in colour if
long-standing (oxidation of bilirubin to biliverdin)
Differential of yellow skin
·
Caretenoderma
·
Quinacrine
·
Phenol exposure
Increased bilirubin occurs when there is
an imbalance between the production and clearance of bilirubin.
It may result from
·
Over-production of bilirubin
·
Impaired…
o Uptake
o Conjugation
o Excretion
·
Regurgitation of unconjugated /
conjugated bilirubin from damaged hepatocytes / bile ducts.
Initial steps in jaundice patient evaluation
History taking
Some presentation of jaundice are quite
characteristic, and such history presentation should warrant a confirmatory investigations.
·
Fever + nausea + Anorexia (even
cigarettes also does not want)
o Suggestive of viral hepatitis
§
Comfirmation by HepA IgM, Hep B
surface antigen, Hep C IgM etc.
·
Pruritis + dark urine + pale
stools
o Suggestive of cholestasis
§
Check by bilirubin study
(urobilinogen,
§
Alkaline phosphatase
§
Ultrasound of bile ducts
·
Fatty food triggers colicy pain
o Suggestive of bile stone causes
§
Ultrasound
§
ERCP
·
Progressive jaundice + fever +
chills + rigors (Charcot’s triad)
o Stone obstructive cholangitis
§
ERCP
§
Ultrasound
·
Jaundice + fever +
Conjuctivitis + muscle aches + passage of small and dark urine
o Leptospirosis
§
Darkfield microscopy
·
Recurrant mild jaundice which
worsen with fasting / fever
o Gilbert syndrome
·
Hematemesis + easy brising,
mental confusion, inverted sleep pattern after severe illness like CHF, Shock
etc
o Liver insufficiency causing hepatic encelopathy
§
Liver function tests
Physical examination
Physical examination is often useful,
after a sufficient history has been taken from the patient.
History and physical exam should come
hand in hand, to provide a solid Differential Diagnosis for us to proceed onto
the investigations.
Investigations
·
Full blood count
o To rule out hemolytic causes
o Leucocyte – bac. infection
·
Liver biochemistry
o To rule out hepatocellular causes
·
Bilirubin study
o Conjugated hyper bilirubinemia
§
Hepatocellular origin
o Unconjugated
hyper bilirubinemia
hyper bilirubinemia
§
Over production,
§
Impared hepatic intake
§
Impared conjugation
·
Viral Markers
o hepatitis viruses
o EBV
o CMV
·
Serum alpha-fetoprotein
o Hepatocellular carcinoma,
o Germ cell tumors
o metastatic cancers of the liver.
·
Serum Albumin:
o
low
level indicative of chronic liver disease.
·
Prothrombin Time:
o
sensitive
indicator of chronic liver disease. Will be prolonged. Vitamin K deficiency
must be excluded.
·
Aspartate Aminotransferase:
o
increased
in hepatic necrosis, MI, muscle injury, CCF
·
Alkaline Phosphatase:
o
increased
in cholestasis(intra/extrahepatic), metastasis of liver, cirrhosis.
·
Ȣ-Glutamyl Transpeptidase:
o
increases
with alcohol consumption and drugs i.e. phenytoin
imaging
·
Ultrasound Imaging
o Bile duct imaging
o Gallstones?
o Hepatic mets?
o Pancreatic mass?
·
CT Scan
o Abdominal malignancy?
o Masses in abdomen?
·
Endoscopy (ERCP)
o Bile duct opening
o Bile duct obstruction
algorhythm of jaundiced patient (from Harrison 16th ed)
