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 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.


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.


- 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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