Reem Ahmed Alyahya212522156

CLINICAL APPROACH TO JAUNDICE IN ADULTS

Introduction• A 66 y/o patient presented to the hospital complaining of yellowish staining of his eyes over the last 3 months. • This discoloration is also associated with itching and palpable mass in the right hypochondrium.• The history is negative for abdominal pain• He also reported Wight loss of 10 kg during the last 3 months.

Jaundice• The word “jaundice” comes from the French word jaune, which means yellow.• jaundice is a yellowish discoloration of the skin, sclera, and mucous membranes by bilirubin. • The discoloration typically is detected clinically once the serum bilirubin level rises above 3 mg/dL• Bilirubin metabolism takes place in three phases—prehepatic, intrahepatic, and posthepatic. Dysfunction in any of these phases may lead to jaundice.

Jaundice

Pre-hepatic

hepatic Post-heptic

unconjugated hyperbilirubine

mia

Conjugated hyperbilirubine

mia

Unconjugated hyperbilirubinemiaMechanism Examples Suggestive findingsIncrease bilirubin production

Hemolysis, resorption of large hematomas

Few or no clinical manifestations of hepatobiliary disease

anemia, jaundice splenomegaly and gallstones

Serum bilirubin level (4-6 mg/dl)

Normal aminotransferase levels

Normal urine color Features of

hemolysisDecrease hepatic conjugation

Gilbert syndrome, cirgler najjar syndrome

Conjugated hyperbilirubinemiaMechanism examples Suggestive findingsHepatocellular dysfunction

Viral hepatitis , drugs, cirrhosis, hepatocellular carcinoma.

Aminotransferase levels > 500 U/L

Intrahepatic cholestasis

Alcoholic liver disease, drugs, toxins, hepatitis, primary biliary cirrhosis

Alkaline phosphatase and GGT > 3 times normal

Aminotransferase levels< 200 U/L

Extrahepatic cholestasis

CBD stones, pancreatic cancer, CBD strictures, acute cholangitis

Alkaline phosphatase and GGT > 3 times normal

Aminotransferase levels < 200 U/L

Hereditary disorders Dubin-Jhonson syndrome, Rotor’s syndrome

Normal liver enzymes.

Evaluation:

History of presenting

illness

Past medical history

Physical examinatio

nInvestigatio

ns

History of presenting illness:•Onset and duration of jaundice•Urine and stool color•Prodromal symptoms (e.g. fever, malaise and myalgia) before jaundice•Pruritus•Steatorrhea •Wight loss•Abdominal pain (location, severity, duration and radiation)

Past medical history:•Hepatobiliary disease: gallstones, hepatitis, cirrhosis•Disorders that could cause hemolysis: hemoglobinopathy , G6PD deficiency. • Infiltrative disorders: amyloidosis, lymphoma, sarcoidosis , AIDS.•Drug history•Vaccination against hepatitis

Past medical history:•Surgical history: previous surgeries on the biliary tract ( a potential cause of strictures.) •Social history: risk factors of hepatitis, amount and duration of alcohol use, injection drug use and sexual history.•Family history: should include questions about recurrent mild jaundice and hereditary liver disorders.

Physical examination:• Vital signs are reviewed for fever and signs of systemic toxicity (e.g. hypotension and tachycardia)•General appearance is noted, cachexia and lethargy•Head and neck examination includes inspection of the sclera for icterus and the eyes for Kayser-Fleischer rings. • The abdomen is inspected for collateral vasculatures, spider nevie, ascites and surgical scars.

Physical examination:• The abdomen is examined for shifting dullness, fluid thrill, masses and tenderness.• The liver should be palpated for hepatomegaly, masses, nodularity and tenderness• The spleen is palpated for splenomegaly.•Men are checked for testicular atrophy and gynecomastia.

Physical examination:•Upper extremities are examined for Dupuytren’s contractures, and asterixis.• The skin is examined for jaundice, palmar erythema, needle tracks, excoriations, Xanthomas, hyperpigmentation, petechiae, and purpura.•Neurologic examination including mental status assessment.

Investigations

Blood tests imaging

Liver biopsy

Initial laboratory tests:• Normal alkaline phosphatase and aminotransferases:

hemolysis or inherited disorders of bilirubin metabolism may be responsible for the hyperbilirubinemia.

• Predominant alkaline phosphatase elevation:suggests biliary obstruction or intrahepatic cholestasis

• Predominant aminotransferase elevation:suggests that jaundice is caused by intrinsic hepatocellular disease

Initial laboratory tests:• Elevated INR :- Corrects with Vitamin K administration : impaired

intestinal absorption of fat-soluble vitamins and is compatible with obstructive jaundice

- does not correct with vitamin K suggests hepatocellular disease with impaired synthetic function

Subsequent evaluation:• Suspected hepatocellular injury:• Serologic tests for viral hepatitis• Measurement of antimitochondrial antibodies (for primary biliary cirrhosis)• Measurement of antinuclear anti-smooth muscle and liver-kidney microsomal antibodies (for autoimmune hepatitis)• Serum levels of iron, transferrin, and ferritin (for hemochromatosis)• Serum and urinary copper , serum levels of ceruloplasmin (for Wilson disease)

Subsequent evaluation:• Suspected biliary obstruction or intrahepatic cholestasis:• Abdominal US: highly accurate in detecting extrahepatic obstruction (gall stones)• CT scan: more accurate in pancreatic lesions. • If the results are positive for extrahepatic cholestasis, other tests may be necessary to determine the cause: MRCP , ERCP

• Liver biopsy:• Not commonly required but can help in diagnosing autoimmune hepatitis or biliary tract disorders (e.g., primary biliary cirrhosis, primary sclerosing cholangitis)

Treatment:• The underlying cause and any complications are treated • Jaundice itself requires no treatment in adults “ unlike children “• Itching if bothersome, maybe relieved by cholestyramine 2-8 g orally twice daily•However cholestyramine is ineffective in patients with complete biliary obstruction.

Back to our case:• A 66 y/o patient presented to the hospital complaining of yellowish discoloration of his eyes over the last 3 months. • This discoloration is also associated with mild itching and palpable mass in the right hypochondrium.• The history is negative for abdominal pain• He also reported Wight loss of 10 kg during the last 3 months.Pancreatic cancer induced

biliary obstruction

Conclusion• Acute jaundice, particularly with viral prodrome

in the young and healthy suggests acute viral hepatitis

• Painless jaundice in elderly patients with weight loss , an abdominal mass and minimal pruritis suggests biliary obstruction caused by cancer.

• Prodominant increase in Aminotrnsferase suggests hepatocellular dysfunction.

• Prodominant increase in Aalkaline phosphatase suggest cholestasis

• Significant hepatic dysfunction is indicated by altered mental states and coagulopathy.

References:• The merck manual of diagnosis and therapy. 19th edition. 2011• Kumar and clark. Clinical medicine.8th edition.2012• Macleod’s clinical examination.13th edition. 2013• UpToDate: http://www.uptodate.com/contents/diagnostic-approach-to-the-adult-with-jaundice-or-asymptomatic-hyperbilirubinemia• American Familiy physician: http://www.aafp.org/afp/2004/0115/p299.html

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