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.
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.
- 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.
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.