Week 4 - Jaundice and no energy

Question 1

L.K is a 65-year-old male. “My eyes look yellow and I have no energy.”

Take a history of this patient.

HPC:
Yellow - think haemolytic, hepatic and obstructive jaundice
• Pale stools (obstructive) for 2 weeks and dark urine (not haemolytic) over the last 2 months.
• Nausea, not hungry, lost 3kg over last 6 weeks (typical of obstructive jaundice. Also think malignancy because of weight loss).
• Alcohol: 1-2 glass wine at night, smoking: 35 pack years.
• Diabetes - on metformin, ramipril (ACE inhibitor).
• BMI 26, abdomen - NAD.
• Alcohol, smoking, diabetes and obesity all risk factors for gallbladder/pancreatic disorders.
• US imaging - dilated biliary tree, no gall stones (5-10% of cases without gallstones).

LFT:
• AST = 80 (<45)
• ALT = 400 (<55)
• ALP = 221 (<110)
• GGT = 85 (<60)
• Bilirubin = 48 (2-24)
• Albumin = 38 (34-48)
• Amylase = increased
• Lipase = increased.

• AST and ALT suggest there is some hepatocyte damage.
• ALP and GGT - bile duct damage.
• Bilirubin high, albumin normal.
• Amylase and lipase increased

Answer 1

HPC:
• Onset - how long have you had jaundice/no energy? Initiating factor?
• Jaundice present anywhere else?
• Alleviating factors?
• Timing - experienced before? Constant or intermittent? How long does it last/worse at a particular time?
• Exacerbating factors?
• Severity?
• Associated symptoms?
• Effect on lifestyle?

• Dark urine, pale stools?
• Skin itching (pruritus)?
• Fever (cholangitis)?
• Weight loss, loss of appetite (malignancy)?
• Abdominal pain or change in bowel habit?
• Vomiting of blood or dark stools?
• Alcohol - quantity, frequency, duration (CAGE questions)?
• IV drugs?
• Tattoos?
• Blood transfusion?
• Started any new medications recently?
• Recent contact with patients with jaundice or liver problems?
• History of recent high-risk sexual behaviours?
• Recent travel (to areas where hepatitis A is endemic)?
• Immunised against hepatitis B?
• History of IBD (primary sclerosing cholangitis)?
• Surgeries (pancreatic or biliary)?
• Occupation (contact with hepatotoxins)?
• Family history of liver disease?
• RUQ pain radiating to shoulder/back?
• Depressed mood/irritable, loss of interest in hobbies, worthlessness, suicidality?
• Polyuria, polydipsia?

PMHx:
• Past history of any medical conditions? i.e. liver disease, GI problems (gallstones, pancreatitis, IBD), cancer, diabetes etc.

PSHx:
• Past surgeries? i.e. pancreatic or biliary.

Medications:
• Any regular/new medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?
• Travel vaccines.

FHx:
• Family history of any medical conditions? i.e. liver disease, GI problems (gallstones, pancreatitis, IBD), cancer, diabetes etc.

SHx:
• Background? 
• Occupation? i.e contact with hepatotoxins.
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition? i.e. junk food, high calorie, fat, meat, salt, fried and refined foods etc.
• Alcohol/recreational drugs? 
• Physical activity?

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands. Patient properly positioned lying flat, chest and abdomen exposed.
2. General inspection: distressed/in pain, colour (jaundice, pallor - liver mets), habitus - cachectic. May be confused/drowsy (liver disease/encephalopathy).

3. Vital signs:
• HR
• RR
• BP 
• Temp
• O2 sats, BGL, BMI.

4. Hands:
   • Palms - warm/cool, dry/sweaty, pallor of creases, erythema (chronic liver disease)
   • Nails - CRT, clubbing.
   • Arms - bruising/petechiae, scratch marks, acanthosis nigricans in axilla (skin marker for GI malignancy).
5. Face:
   • Eyes - conjunctival pallor, scleral jaundice.
   • Mouth - peripheral/central cyanosis, angular stomatitis, brown black lesions around the mouth and in buccal mucosa in Peutz-Jeghers syndrome (harmatomas/polyps in GIT), glossitis, hydration.
6. Neck/chest:
   • Shrug shoulders - supraclavicular lymph nodes - enlarged left supraclavicular node (Virchow’s node) secondary to gastric malignancy.
   • Gynaecomastia in males (chronic liver disease/medication), spider naevi (up to 3 can be found in normal patients).
7. Abdomen:
   • Inspection - scars, skin lesions, abdominal distension, prominent veins, visible masses/pulsations (epigastric mass), visible peristalsis.
   • Palpation - light and deep (tenderness - rebound, guarding, rigidity), hepatomegaly (liver mets), splenomegaly, paraortic lymph nodes, inguinal lymph nodes. Palpable gallbladder + jaundice (Courvoisier’s sign).
   • Percussion - ascites.
   • Auscultation - bowel sounds.

8. Legs:
• Bruising/muscle wasting.
• Oedema.
• Clubbing, CRT.
• Peripheral pulses.
• Trousseau’s sign - migratory thrombophlebitis (pancreatic cancer typically produces inflammation of the superficial veins - particularly in legs.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: Painless obstructive jaundice (due to pale stools, dark urine and digestive abnormalities, although the pain is very typical).
• DDx:
Extrahepatic - obstruction occurs outside the liver and more common.
- Gallstones* (most common - in gallbladder or CBD).
- Pancreatic cancer*
- Other malignancy (with secondary spread to liver and causing obstruction) e.g. lower GI carcinoma (duodenal), lymphoma.
- Parasites e.g. Ascaris, liver fluke (also infections and congenital disorders - rare).
- Pancreatitis, pancreatic cyst.

Intrahepatic - inflammation/obstruction occurs within the liver.

• Metastasis.
• Sclerosing cholangitis.
• Cholangiocarcinoma (Klatskin tumour at the hilum of the liver compressing the CBD).
• Acute hepatitis.

Gallstones and pancreatic cancer most likely - older patient (extrahepatic more likely).

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• LFTs
• Lipids
• Lipase, amylase (elevated in 40% of pancreatic cancers).
• USS abdomen - check of gallstones.
• CT - pancreas head.
• ERCP.
• Tumour markers - CEA & CA19-9 antigen.

Question 5

What treatment does this patient require?

Answer 5

Pancreatic cancer:
• Most ductal cancers present with metastatic disease, <20% are suitable for radical surgery.
• Consider pancreatoduodenectomy if fit and with no metastases.
• Post-op morbidity is high, non-curative resection confers no survival benefit.
• Post-op chemotherapy delays disease progression.
• Referral to palliative care.
• Disabling pain may need large doses of opiates or radiotherapy.