Jaundice

Question 1

Differential Diagnoses of Jaundice

Answer 1

1. Drug induced Hepatitis*
2. Liver Metastasis*
3. Pancreatic Cancer*

Probability diagnosis
Hepatitis A, B, C (mainly B, C)
Gallstones
Alcoholic hepatitis/cirrhosis

Serious disorders not to be missed
Malignancy:
•pancreas
•biliary tract
•hepatocellular (hepatoma)
•metastases

Infection:
•septicaemia
•ascending cholangitis
•fulminant hepatitis
•HIV/AIDS
•leptospirosis
Paracetamol overdose

Rarities:
•Wilson syndrome
•Reye syndrome
•acute fatty liver of pregnancy

Pitfalls (often missed) 
Gallstones in common bile duct
Genetic disorders: 
Gilbert syndrome, Wilson syndrome, galactosaemia, others
Cardiac failure
Primary biliary cirrhosis
Autoimmune chronic active hepatitis
Primary sclerosing cholangitis
Chronic viral hepatitis
Amyloidosis
Haemochromatosis
Viral infections (e.g. CMV, EBV)

Masquerades checklist
Drugs (several, see list)
Anaemia (haemolytic)

Is the patient trying to tell me something?
Not usually applicable

Question 2

Jaundice - Key History

Answer 2

Key history

Associated symptoms (e.g. rash, pruritus, fever, arthralgia, weight loss). Medical history. Contact with people with hepatitis or jaundice. Overseas travel, family history, drug history, IV drug use, sexual history, occupational history.

Question 3

Jaundice - Key PE

Answer 3

Key examination

• General inspection including skin for signs of excoriation
• The abdominal examination is important with a focus on the liver and spleen
• Look for signs of chronic liver disease
• Test for hepatitis flap (asterixis) and fetor, which indicate liver failure
• Include dipstick urine testing for bilirubin and urobilinogen

Question 4

Jaundice - Key Investigations

Answer 4

Key investigations

• The main ones are the standard LFTs and viral serology for infective causes (hepatitis A, B, C and possibly EBV)
• Consider hepatobiliary imaging, autoantibodies for autoimmune chronic active hepatitis and primary biliary cirrhosis, tumour markers and iron studies

Question 5

Jaundice - Diagnostic Tips

Answer 5

Diagnostic tips

•All drugs should be suspected as potential hepatotoxins.
•All patients with jaundice should be tested for hepatitis B surface antigen (HBsAg).
•Clinical jaundice manifests only when the bilirubin level exceeds 50 → mol/L.
•The most common causes of jaundice recorded in a general practice population are (in order):
viral hepatitis, gallstones, pancreatic cancer, cirrhosis, pancreatitis and drugs.
•Haemolytic anaemia leading to jaundice has multiple causes (e.g. autoimmune, malaria, drugs, hereditary disorders, metabolic defects).