Jaundice in adults

Question 1

Probability diagnosis

Answer 1

Hepatitis A, B, C (mainly B, C)

Gallstones

Alcoholic hepatitis/cirrhosis

Question 2

Serious disorders not to be missed

Answer 2

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

Question 3

Pitfalls (often missed)

Answer 3

• 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)

Question 4

Masquerades checklist

Answer 4

Drugs (several, see list)

Anaemia (haemolytic)

Question 5

Is the patient trying to tell me something?

Answer 5

Not usually applicable.

Question 6

Key history

Answer 6

Associated symptoms e.g.

• rash
• pruritus
• fever
• arthralgia
• weight loss

Medical history.

• Contact with people with hepatitis or jaundice.
• Overseas travel
• FHx
• drug history
• IV drug use
• sexual history
• occupational history.

Question 7

Key examination

Answer 7

General inspection including skin for signs of excoriation

Abd exam 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 8

Key investigations

Answer 8

The main ones are the standard

• LFTs
• viral serology (hepatitis A, B, C and possibly EBV)

Hepatobiliary imaging

Autoantibodies for;

• autoimmune chronic active hepatitis
• primary biliary cirrhosis

Tumour markers

Iron studies

Question 9

Diagnostic tips

Answer 9

All drugs should be suspected as potential hepatotoxins.

All pts should be tested for HBsAg

Clinical jaundice manifests only when the bilirubin level exceeds 50 → mol/L.

The most common causes of jaundice (in order):

1. viral hepatitis
2. gallstones
3. pancreatic cancer
4. cirrhosis
5. pancreatitis
6. drugs.

Haemolytic anaemia leading to jaundice has multiple causes e.g.

• autoimmune
• malaria
• drugs
• hereditary disorders
• metabolic defects