How to reach a diagnosis in a case of jaundice ?

 This is an organized approach to diagnosis of Jaundice ,and to define exactly the underlying cause and the appropriate method of managemen...

 This is an organized approach to diagnosis of Jaundice ,and to define exactly the underlying cause and the appropriate method of management . This is very important for most physicians .
those are the steps :


I. Personal History


1. Age:

- Children: haemolysis or hepatitis.
- Adult:      hepatitis or calcular obstruction.
- Old:         malignant obstruction.

2. Sex :

- Females: calcular obstruction.

- Males: malignant obstruction.

3. Special habits:

- Alcohol: Causes liver cirrhosis.

II. Present History 
1. Onset:
- Acute: acute hepatitis & calcular obstruction.
- Gradual: malignant obstruction & cirrhosis.


2 .Course:
- Regressive: viral hepatitis.
- Progressive: malignant obstruction & cirrhosis.
- Intermittent:
• Calcular obstruction.
• Haemolytic jaundice.
• Chronic hepatitis.
• Ampullary carcinoma.
• Familial non haemolytic hyper-bilirubinaemia.

3. Duration:

- Short: acute hepatitis
- More than 2 years: exclude cancer.
- Long:. cirrhosis.

4. Urine:

- Dark: in cholestatic & hepatocellular.
- Pale: in haemolytic.

5. Stools:

- Pale with steatorrhoea: in cholestatic.
- Deeply coloured: in haemolytic.
- Slightly pale: in hepatocellular.

6. Anorexia, nausea & vomiting:

Occur at the onset ofV.H.

7. Fever:

- In pre-icteric phase of acute hepatitis.
- Charcot's fever in calcular obstruction:
Fever, rigors, jaundice & colicky pain in right hypochondrium. - During haemolytic crises, with other features of crisis.

8. Pain:

- Dull pain in Rt. hypochondrium & epigastrium : V.H., &haemolysis.
- Biliary colic: calcular obstruction.
- Epigastric pain radiating to the back: cancer head.
- Bony pains: haemolytic crises.

9. Pruritus: in obstructive jaundice.

10. Marked loss of weight: in malignant obstructive jaundice.

III. Past History

1. Biliary colic: calcular obstruction.

2. Drug intake: hemolysis, hepatitis or cholestasis.

3. Contact with patients having viral hepatitis.

4. History of blood transfusion & injections.

5. History of acute viral hepatitis & Schistosomiasis.

IV. Family History

- Haemolytic anemia.

- Non-haemolytic hyperbilirubinaemia.

 V. General Examination

1. Cachexia: in cancer head of pancreas.

2. Colour of jaundice :

- Lemon-yellow: in haemolytic anaemia.
- Olive-green: in cholestatic jaundice.
- Orange-yellow: in hepatocellular jaundice.

3. Itching marks, exanthemata & bradycardia: in obstructive jaundice.

4. Manifestations of liver failure: in hepatocellular jaundice.

5. Skin pigmentation & clubbing: in primary biliary cirrhosis.

6. Skin pigmentation & ulcers: in chronic haemolytic jaundice.

7. Haemorrhages or ecchymosis: in hepatocellular or obstructive jaundic

8. Oedema ofLL:

- Liver cirrhosis.
- Cancer head of pancreas affecting rvc.

VI : Abdominal Examination
1. Liver:

- Enlarged, soft & tender in acute hepatitis. r
- Markedly enlarged in obstructive jaundice.
- Shrunken with sharp edge in cirrhosis.
- May be hard & nodular in malignancy.

2. Gall bladder: "Courviosier's law"

- Enlarged in malignant obstructive jaundice.
- Small & tender in calcular obstruction.

3. Splenomegaly:

- In hemolytic anaemias.
- In liver cirrhosis & chronic hepatitis.
- Sometimes in viral hepatitis.

4. Ascites:

- Liver cirrhosis.
- Malignancy.

5. May be:

- Evidence of portal hypertension: in cirrhosis.
- Abdominal masses: in malignancy.

Investigations

I. Liver function tests:

A- In cholestasis:
- Total serum bilirubin: increased, mainly the direct.
- Alkaline phosphatase: >3 folds the normal.
- Prothrombin time: prolonged, but improved after IV vitamin K.
- Blood cholesterol: increased.
- Urobilin & stercobilin: diminished..

B. In hepatocellular jaundice:

- Total serum bilirubin: increased.
- Direct & indirect bilirubin: both increased.
- Alkaline phosphatase: increased <3 folds the normal.
- AL T & ·AST: increased in hepatitis.
- Albumin: diminished in cirrhosis.
- Prothrombin time: prolonged, even after IV vitamin K.

C. In haemolytic & familial non-haemolytic jaundice:

 - Total serum bilirubin: increased, mainly-the indirect.
- Urobilinogen & stercobilinogen: increased in haemolysis.
- CBC: anaemia with reticulocytosis in haemolysis.

II. Abdominal ultrasonography: may show

-Dilated intrahepatic biliary radicals: in extrahepatic obstruction.
- Hepatomegaly, splenomegaly, cirrhosis & ascites.
- Biliary & gall bladder stones and gall bladder dilatation.
- Cancer head of pancreas.
- Porta hepatis lymph nodes.

III. CT:

- May be done in cholestases if ultrasonography is not conclusive.
- It is better than sonography in showing the pancreas & porta-hepatis.

IV. Visualization of the biliary system:

- This is done mainly in extrahepatic obstruction.
- Three methods are currently available:

1. Endoscopic Retrograde cholangio pancreatography (ERCP):

• Injection of radio opaque material in the biliary system by a cathet introduced through a duodenoscope.

• Therapeutic intervention is the advantage of the procedure:
 a. Stone removal by sphincterotomy, basket or lithotripsy.
b- Biliary drainage in cancer, stricture & impacted stones by stent application.

2. Magnetic resonance cholangio pancreatography (MRCP):

• It visualizes the biliary system nicely.
• Therapeutic intervention is not possible.
• It is done if ERCP is risky for the patient.

3. Percutaneous Transhepatic cholangiography (PTC):

• Percutaneous injection of radio-opaque material into the bile ducts within the liver, using chiba needle.
• It is usually done after failure of performing ERCP.
• Biliary drainage can be achieved, by putting a stent, this IS called percutaneous transhepatic drainage (PTD).

V. Laparoscopy or laparotomy:

rarely needed now for diagnosis.

VI. Other investigations:

1. Blood picture & Retics: for haemolytic anaemia.

2. Upper endoscopy: to detect varices with cirrhosis.

3. Plain x-ray: to show Gall bladder stones.

4. Barium meal: will show the duodenum as:

a. wide C: in cancer head of pancreas.
b. Reversed 3: in cancer ampulla. 5. Liver biopsy: risky & usually not done.
a. Diagnoses the cause of hepatocellular jaundice.
b. Differentiate intra from extrahepatic obstruction.

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