HOW TO DIAGNOSE THE CAUSE OF JAUNDICE?

MIM.ILHAM4th Batch

FHCS,EUSL

Contents

• Bilirubin metabolism.• Causes of Jaundice• History• Examination• Special test.

Bilirubin metabolism.

Causes of Jaundice

Causes of Jaundice

• Increased bilirubin load (Haemolytic Jaundice)1. Hereditary spherocytosis2. Hereditary non spherocytic anaemia3. Sickle cell disease4. Thalassemia5. Acquired haemolytic anaemia6. Incompatible blood transfusion7. Severe sepsis8. Drugs

Causes of Jaundice

• Disturbed bilirubin uptake and conjugation of bilirubin

1. Viral hepatitis2. Hepatotoxins3. Cirrhosis4. Gilbert’s familial hyperbilirubinaemai (AD)5. Familial neonatal hyperbilirubinaemia6. Crigler-Najjar’s familial jaundice (Type1- AR, Type2-

AD)

Causes of Jaundice

• Disturbed bilirubin excretionExcess of conjugated serum bilirubin known as cholestasis

Intra hepatic (without mechanical obstruction)1. Cirrhosis2. Viral (chronic active) hepatitis.3. Drugs- chorpromazine, methyl testosterone4. Dubin-Johnson’s familial hyperbilirubinaemia(AR)5. Primary biliary cirrhosis6. Parenteral or enteral feeding with synthetic

nutrition

Causes of Jaundice

Extra hepatic cholestasis• Inside the duct1. Gallstones2. Foreign body eg- Broken T-tube, parasites

(Hydatid,liver fluke, round worms)• In duct wall1. Congenital atresia2. Traumatic stricture3. Sclerosing cholangitis4. Tumor of the bile duct

Causes of Jaundice

• Outside duct1. Carcinoma of head of the pancreas2. Carcinoma of the ampulla3. Pancreatitis4. Lymph node metastases

History

Age:• Young age- Hepatitis is common• Old age- Malignancy (CA) is common

History

PC:• Jaundice (Yellowish discoloration of

sclera+mucus membrane+Skin) • Exclude other causes for yellow discolouration*Carotenaemia (Only skin, mainly palm and sole are orange color) in eating carrot,mango,papaya and hypothyroidism*Antimalarial drugs*Vit-B12 deficiency

History

HPC & Systemic Rvw• Jaundice1. Sudden onset- Gall stones OR Viral hepatitis2. Gradual onset- Cirrhosis, Pancreatic CA OR

Porta hepatis metastases3. Progressive- Malignant obstruction4. Fluctuaing- Stones in the CBD, CA of the

duodenal papilla OR repeated hemolytic episodes.

History

• Pain:1. Painless- Viral hepatitis (Dragging subcostal ache due

to hepatic enlargement)2. Pailess+Fluctuating- intermittent obstruction by

gallstone OR necrosing ampullary CA3. Painless+Progressive- Malignant obstruction of CBD4. Painful- Gallstones OR Pancreatic CA Biliary colic- right subcosatl pain radiating beneath the costal margin to shoulder bladeModerate boring pain passing through to back- Chronic pancreatitis OR pancreatic tumor

History

• Fever:1. Fever with chills- Extra hepatic cholestasis with

cholangitis due to bile duct stone,Liver abscess and leptospirosis

2. Fever without chills- Viral hepatitis, Drug induced hepatitis

• Pruritus:Results from the irritation of cutaneous nerves by retained bile saltCholestatic jaundice

History

• Weight loss-Progressive weight loss- MalignancyAlso in chronic hepatocellular damage.• Anorexia and fatigueEarly signs of hepatitis(This is due to production of cachexin and TNF)

History

• Colour of the urine and stool

Pre hepatic Hepatic Post hepatic

Urine colour Normal Dark Dark

Stool colour Normal Normal Pale

History

Contact history:1. Contact with jaundice patients from work

mates, family- hygienic habits such as toilets, drinking water, taking meals from out side (HepA & HepB)

2. Contact Hx of muddy water in leptospirosis

History

Obstetric Hx:• Ask about LRMP and calculate POA• Benign intra hepatic cholestasis is common in

pregnancy period

History

PMHx• Viral hepatitis• History of transfusion of blood OR blood

products (HepB & HepC)• Recent parenteral injection (HepB & HepC)• Amoebic dysentery• Jaundice following febrile illness- some

congenital haemolytic anaemia may be triggered by febrile illness eg- G6PD deficiency

History

• Recurrent left hypochondrial pain due to splenomegaly eg- Hereditary spherocytosis

• Recurrent foot ulcer eg- some form of chronic haemolytic anaemia such as sickle cell disease

• Hx of breast cancer and bowelcancer• SLE and other connective tissue disorders (Hx

suggestive of joint pain, skin rash)

History

PSHx• Previous difficult biliary surgery suggest –

traumatic stricture OR a residual stones in the CBD

• Post operative jaundice1. Resorption of haematomas,haemoperitonium,

haemolysis of transfused erythrocyte2. Impaired hepatocellular function- halogenated

anaesthetics, sepsis

History

DRUG Hx:• Smilar to pre-hepatic jaundice- rifampicin,

methyldopa• Intra-hepati jaundice- ethanol (cirrhosis ),

paracetamol, halothane, methyldopa, barbiturates

• Post-hepatic jaundice- isoniazid, chlorpromazine• Antileprosy drugs and Antipsychotic drugs• OCP,Saliclate,Sulfonamide , MAOi

History

Family Hx:• FHx of jaundice+anaemia+splenectomy- Hereditary spherocytosis• FHx of jaundice+anaemia- congenital

hyperbilirubinaemias• Consanguinity of parents- Inherited congenital

haemolytic anaemia eg- G6PD deficiency• Neuropsychiatry llness+jaundice- Wilson’s

disease

History

Social Hx:• Hx of Alcohol consumption in Units for years-Chronic alcohol liver disease Hepatocellular CA jaundiceCirrhosis and pancreatic CA• Toddy consumption- Amoebic liver abscess• Sexual promiscuity and unprotected sexual behavior-

HepB transmission• Occupational Hx- Sheep farmers OR allied workers- Hydatid infestationWorking at chemical enviorment eg-CCl4

Examination

General:• Depth of jaundice:Lemmon yellow- haemolytic jaundiceOrange- hepatocellular causeDeep mahogany hue- Prolonged obstructive jaundice

Examination

• Anaemia:Suggestive of Haemolytic,malignant OR cirrhotic causes

Examination

• Liver failure

Examination

• Supraclavicular node enlargement- Metastatic CA• Skin-Scratches and xanthomas in chronic cholestasis

Examination

• Pyrexia- Cholangitis, Viraemia and hepatic involvement eg-Infectious mononucleosis, septicaemia and haemolysis and hepatic abscess

Examination

Abdominal Ex:• Scars: previous surgery of biliary tree

Examination

• Caput medusaeDilated periumblical vein indicatye portal HT and cirrhosis

Examination

• Site of tenderness:Tenderness over the gall bladder indicate biliary inflammation

Examination

• Gall bladderA palpable gall bladder in the presence of the jaundice means that janundice is unlikely to be due to a stone (Courvoisier’s sign). CA of head of the pancreas must be suspected

Examination

• Liver:1. Palpable large nodule of large proportion-

metastatic malignancy2. Small nodules- cirrhosis3. Slightly enlarged smooth live chronic

cholestasis4. Tender liver- viral hepatitis and liver abscess

Examination

• Spleen:Splenomegaly may be evident of congenital haemolytic anaemia

Examination

• Abdominal massHard and irregular abdominal mass suggestive of malignancy.• AscitesDue to abdominal malignancy or liver failure

Examination

• Rectal ExColour of the stoolPresence of a primary malignancy or metastatic deposit in the pouch of douglas