Jaundice

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