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BEDSIDE APPROACH TO

A CASE OF JAUNDICEDr Manish Chandra Prabhakar

MGIMS Sewagram

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Focus on

Classifying jaundice as hemolytic , hepatocellular or obstructive

Determine the etiology

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Jaundice – yellow tissue

Sclera yellow – bilirubin > 3g/dl Urine is tea or cola coloured – conjugated

bilirubin Colour – lemon yellow – hemolytic jaundice orange yellow – hepatocellular jaundice green yellow – obstructive jaundice Stool

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Yellow but no jaundice

Carotenoderma – healthy with sclera spared

Quinacrine – 4- 37% of the cases Muddy sclera

Florescent light

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Onset

Developing in matter of hours and deepening rapidly – viral or drug induced hepatitis

Long standing – Mild – hemolytic – family history Deep – obstructive Chronic liver disease – alcoholics

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Patient has fever

Malaria Leptospirosis – occupational history Viral hepatitis Cholangitis Dengue hemorrhagic fever

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Pain in abdomen

Sudden onset right upper quadrant colicy pain with chills – choledocholithiasis and ascending cholangitis

Epigastic and back ache – pancreatic cancer

Biliary obstruction but no pain with deterioration in health and decreasing weight – malignant obstruction

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Pruritus

Persistent – obstructive jaundice Transient – Viral hepatitis

Unilateral jaundice

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Emphasize on

Drug history – Predictable – dose related -

acetaminophen Unpredictable – isoniazide

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Clues to etiology

Travel / exposure to contaminant food – Hep A / hepatotoxin

Blood transfusion – HCV, HIV, HBV High risk behaviour – sharing needles ,

drug abuse , unsafe sex Alcohol Family history – Hemolytic anemias,

Wilson’s disease

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Associated features

Chronic liver cell failure – distension of abdomen , anasarca , hemorrhoids, hemetemesis ,

Arthralgia , myalgia , rash – viral hepatitis History of hepatobiliary surgery

Breathlessness – heart failure Vit D and Vit A deficiency

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General physical examination in a patient who has Icterus

Pulse – Tachycardia – fever , heart failure Bradycardia – obstructive jaundice Tachypnea – heart failure , fever Pallor – hemolysis , malignancy , cirrhosis Pallor with knuckle pigmentation –

megaloblastic anemia Lymphadenopathy – Virchow’s and Sister

Mary Joseph’s nodes. Clubbing may be seen in chronic cholestasis.

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Mental status – hepatic encephalopathy -

hepatocellular jaundice Flapping tremors Fetor hepaticus Skin – Brusing – clotting factor defects Petechiae / purpura –Thrombocytopenia

of cirrhosis

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Other integumentary manifestation of cirrhosis – spider nevi, palmar erythema, leuconychia, alopecia

Scratch marks, hyper pigmentation, xanthomas on eyelids, extensor surface and palmar creases - Chronic cholestasis

Pigmentation of shin and ulcers – sickle cell disease

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Multiple venous thrombosis – carcinoma of body of pancreas

Ankle edema – cirrhosis or IVC obstruction due to hepatic malignancy

Stigmata of chronic liver disease Raised JVP – heart failure KF ring – Wilson’s disease

spider nevi palmar erythema gynecomastia caput medusae dupuytren's contractures, parotid gland enlargement, testicular atrophy

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Abdomen in jaundice

Caput medusae Ascitis – cirrhosis / malignancy Palpation of Liver –o non palpable - not always a good signo Palpable – Large nodular liver – malignancy Smooth – extra hepatic cholestasis Uniformly enlarged – fatty liver Tender – right heart failure, viral or

alcoholic hepatitis , amyloidosis

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Murphy’s sign – cholecystitis Palpation of gall bladder – Courvoisier’s

law Spleenomegaly – hemolytic jaundice ,

portal hypertension

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To summarise

Hemolytic jaundice – Positive family history Acholuric urine Stool normal coloured Lemon yellow icteruc Anemia Hemolytic faces Spleenomegaly

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Hepatocellular jaundice

Prodromal symptoms – myalgia, fever, rash

Urine and stool colour may not be normal Pruritus may be present Orange yellow icterus Bleeding manifestation may be present Tender hepatomegaly

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Obstructive jaundice

Urine is dark Clay coloured greasy stools Pruritus Green yellow icterus Sinus bradycardia may be present Xanthelesma Murphy’s sign Vit A and D deficiency