Jaundice Flashcards
Differential diagnosis for jaundice.
Prehepatic - Hemolysis
Hepatic - Hepatitis, Cirrhosis, HC disease, abscess, cancer
Posthepatic - Gallstones, biliary stricture, pancreatic cancer, periampullary duodenal diverticulm, cholangitis, cholestasis, hemobila
Points in history that should be elicited for a history of jaundice?
Pain (stones, hepatitis) Previous attacks previous operations (specifically hepatobiliary) recent operation fever drugs toxins ETOH use blood transfusion travel itching dark urine light stools
What physical exam findings are associated with jaundice?
fever mental status vital signs, scleral icterus jaundice abdominal mass hepatomegaly Courvoisier's sign Murphy's sign, abdominal tenderness, lymphadenopathy, petechia, palmer erythema, asterixis, Charcot's triad (pain, jaundice, fever), Reynold's pentad (Charcot's triad plus mental status change and hypotension)
Courvoisier’s sign
Palpable, nontender, enlarged, dilated gallbladder + mild jaundice found in 50% patients with pancreatic adenocarcinoma or gallbladder.
Asterixis
a tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings.
sign of hepatic encephalopathy, damage to brain cells presumably due to the inability of the liver to metabolize ammonia to urea.
What lab tests should be ordered when evaluating jaundice?
AST/ALT bilirubin - direct and indirect alkaline phosphatase albumin prothrombin time Hemolysis screen
Low albumin and elevated PT suggest underlying liver dysfunction.
What components make up the hemolysis screen?
CBC, peripheral blood smear, lactate dehydrogenase, haptoglobin. Hemolysis alone is unlikely to elevate the total bilirubin over Smg/dL in the absence of liver disease.
Pregnancy test
Direct Coombs test: to detect autoimmune hemolytic anemia
Imaging for jaundice
CXR - detect mets
AXR - detect calcified stones or mass
A U/S - most cost effective and highest yield study. Differentiate intrahepatic (nonobstructive) vs. extrahepatic (obstructive. Evaluate gallstones, liver or pancreatic masses
ACT - high sensitivity for ductal dilatation
ERCP - evaluate ductal anatomy, biliary strictures/stones, extract stones, place stents, sphincterotomy
MRCP
PTC
Endoscopic U/S - evaluate pancreatic mass
Findings from labs/imaging if prehepatic or hepatic etiology?
Nondilated ducts on US
Elevated transaminases, indirect or mixed direct and indirect bilirubinernia
Send off viral serologies” IgM anti-HAV, HB Ag, Anti-HCV, Anti-HBc, Anti-HB
If negative, consider drugltoxin, hemolysis, non-A or non-B virus, or hepatocellular disease.
Consider liver biopsy for diagnosis
Findings from labs/imaging if obstructive jaundice (posthepatic etiology)?
Dilated ducts on US
Elevated direct or mixed direct and indirect bilirubinemia, elevated alkaline phosphatase.
Charcot’s triad
RUQ pain, Jaundice, Fever
Reynold’s pentad
Charcot’s + AMS and shock/hypotension
Dx and Tx for charcot’s triad
fluid resuscitation and IV antibiotics (broad spectrum) should be initiated promptly.
5-10% of patients progress to septic shock
Tx acute cholangitis?
require hemodynamic monitoring, aggressive fluid resuscitatin, and drainage of the infected bile (by PTC or ERCP) in addition to
antibiotics, followed by definitive therapy of the problem that caused the initial obstruction.
If gallstones are present: obtain ERCP, remove CBD stones and proceed with cholecystectomy.
Workup for pancreatic cancer if pancreatic mass
Workup for non-pancreatic mass
Workup for pancreatic mass?
(history of painless jaundice, pancreatic mass seen on US…): can obtain CT scan, ERCP, MRCP, CA 19-9, endoscopic US, consider FNA only if it may be useful in patients who are not surgical candidates
Workup for acute cholangitis with no pancreatic mass?
obtain ERCP (if dilated intra and extrahepatic ducts) or PTC (just dilated intrahepatic ducts) and obtain brushings to determine if benign or malignant stricture. A "double duct sign" may indicate pancreatic cancer. Malignant processes must be resected. This could involve a pancreaticoduodenectomy (Whipple procedure) for distal malignant strictures (ampullary ca), or proximal bile duct resection with hepaticojejunostomy for proximal malignant strictures (cholangiocarcinomas). Benign strictures (such as from lap chole injury) can be diverted by a hepaticojejunostomy.
Surgical jaundice
obstructive jaundice caused by stones
Signs, labs/imaging suggesting obstructive jaundice caused by stones?
obese, fecund woman in her 40s Recurrent episodes of abdominal pain High alkaline phosphatase Dilated ducts on sonogram Nondilated gallbladder full of stones
How do you diagnose obstructive jaundice caused by stones?
- Order SONOGRAM
2. confirm with ERCP
Management of obstructive jaundice caused by stones?
- Sphincterotomy and remove the common duct stone
2. Cholecystectomy
DDx for obstructive jaundice + weight loss.
Adenocarcinoma at head of pancreas
Adenocarcinoma of the ampulla of Vater
Cholangiocarcinoma arising in the common duct
Workup for obstructive jaundice + weight loss.
Management?
Sonogram
CT - for lesions seen order PERCUTANEOUS BIOPSY
if no lesion order ERCP - to show ampullary or CBD tumors not seen on CT.
Management: surgical resection
Biliary Colic
temporary occlusion of cystic duct causing COLICKY PAIN IN THE RUQ, RADIATING TO RIGHT SHOULDER AND BACK, often triggered by FATTY FOOD.
Episodes are BRIEF (20 minutes) with NO signs of peritoneal irritation or systemic signs.
Acute cholecystitis
INFLAMMATION OF THE GALLBLADDER WALL usually due to obstruction of the cystic duct by gallstones: persistent occlusion of the cystic duct from a stone causes CONSTANT PAIN, FEVER, LEUKOCYTOSIS, PERITONEAL IRRITATION in RUQ.
