Jaundice (icterus)

Icterus is detectable when the serum Bilirubin > 30-60mmol/L. It is helpful to separate jaundice into:

Pre-hepatic (haemolytic jaundice)

Congenital hyperbilirubinaemias

Cholestatic

Differential dx of jaundice:

Questions should be appropriate to the particular situation, and the following aspects of the history should be covered:

Country of origin/recent travel:

The incidence of hepatitis B virus (HBV( infection is increased in many parts of the world (Africa, Middle and Far East)

Duration of illness:

A history of jaundice with prolonged weight loss in an older pt suggests malignancy

A short history, particularly with a prodromal history of malaise, suggests hepatitis

Recent outbreak of jaundice:

An outbreak in the community suggests hepatitis A virus (HAV) infection

Recent consumption of shellfish:

This suggests HAV infection

IV drug abuse, recent tattoos:

These both increase the risk of HBV and hepatitis C virus (HCV) infection

Male homosexuality:

Increases the chance of HBV infection

Female prostitution:

Increases the chance of HBV infection

Blood transfusion:

Increased risk of HBV and HCV. In developed countries, all blood products are screened for HBV and HCV

Alcohol consumption

Drugs taken:

Particularly in the last 2-3 months

Many drugs cause jaundice

Family history:

Enquire about congenital hyperbilirubinaemias (e.g. Gilbert’s disease)

Fevers or rigors:

These are suggestive of:

Cholangitis

Liver abscess

Clinical features:

The signs of acute and chronic liver disease should be looked for.

Certain additional signs may be helpful:

Hepatomegaly:

A smooth tender liver is seen in hepatitis and with extra-hepatic obstruction

Jaundice (icterus)

A knobbly liver irregular liver suggests metastases

Splenomegaly:

This indicates portal hypertension in pts when signs of chronic liver disease are present

Ascites:

This is found in cirrhosis, but can also be due to carcinoma (particularly ovarian) and many other causes

Palpable gallbladder:

Can suggest a carcinoma of the pancreas obstructing the bile duct

Investigations:

Viral markers

Ultrasound examination can demonstrate:

The size of the bile ducts (which are dilated in extra-hepatic obstruction)

The level of the obstruction

The cause of the obstruction in virtually all pts with tumours and 75% of pts with gallstones

LFTs:

Hepatitis:

Serum AST or ALT tends to be high early in the disease

Only a small rise in the serum ALP

Extra-hepatic obstruction:

ALP is high

Small rise in the aminotransferases

Long-standing liver disease:

The Prothrombin time (PT) is often prolonged

Serum albumin is low

Haematological tests:

A leucocytosis may indicate infection (e.g. cholangitis)

A leucopenia often occurs in viral hepatitis

Abnormal mononuclear cells suggests infective mononucleosis

Alpha fetoprotein:

Raised in hepatocellular carcinoma