Pre-hepatic: decreased conjugation (↑ indirect bilirubin)
- Differential diagnosis: Hemolysis, Gilbert’s (defect in uptake of indirect bilirubin), Crigler Najjar (gluconosyl transferase)
Hepatic: impaired excretion (↑ alk phos, ↑↑ AST/ALT)
- Differential diagnosis: Viral, alcohol abuse, medications (tylenol, erythromycin, isoniazid, phenytoin, valproate, OCP), cirrhosis, Dubin-Johnson syndrome (impaired excretion by liver)
Post-hepatic: biliary obstruction (↑↑ alk phos, ↑ AST/ALT, ↑ direct) – dark urine, pale stools
- Blocked common bile duct(stone, cancer of head of pancreas, lymphoma, stricture) – Courvoisier’s law (palpable nontender gall bladder – ?malignant obstruction)
- Ascending cholangitis (E coli, klebsiella, pseudomonas, enterobacter, proteus, serratia, enterococci – amp, cipro/gent, flagyl)
History
- Jaundice: onset, who noticed, associated features, pain?
- Change in bowel habits: diarrhoea, malabsorption, colour of stools,
- Nausea, vomitting, pain after eating, anorexia, GI upset
- Skin – bruising, pruritis, rash, colour change
- Bleeding: CRC and liver mets; Liver disease and hemorrhoids
- B symptoms (weight loss, fevers, night sweats)
- Family history
- Past medical history– hepatitis, gallbladder, blood transfusion, bleeding disorder, depression
- Social – smoking, alcohol use, intravenous drug use
- Contact – sexual, travel, others with jaundice
- Medications
- Allergies
Physical examination
- Vitals
- Skin colour, general appearance
- HEENT: scleral icterus, enlarged parotids, jaundice under tongue, clavicular node, encephalopathy
- Skin: spider nevi, jaundice, bruising
- Hands: palmar erythema, dupuytren’s contracture, clubbing, asterixis
- Abdominal: gynecomastia, caput medusa, hepatosplenomegaly, Murphy’s sign, palpable gall bladder, masses, ascites
Investigations
- Alk Phos – Common bile duct blockage
- Lipase – pancreas irritation
- Total bilirubin
- AST/ALT
- BUN – will increase in hemolysis
- Creatinine
- LFTs (protein, albumin, PT/PTT)
- CBC – infection, hemolysis
- U/A (bilirubin and urobilirubin)
- Viral assays (EBV, CMV, hep A, hep B, Hep C)
Radiology
- Abdominal x-ray — flat plate (gas in biliary tree, stones)
- Ultrasound – stones, dilatation, thickening of gall bladder, pericholecystic fluid
- HIDA – acute cholecystitis; radioisotope concentration in liver, secreted into bile, no opacification of GB due to cystic duct obstruction
- Liver scan
- CT abdomen
- ERCP – common bile duct stone
Charcot’s triad, Reynold’s pentad
- Fever
- RUQ pain
- Jaundice
- Mental status changes
- Shock
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