JAUNDICE
JAUNDICE: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the Following Questions:
- Is the jaundice associated with hepatomegaly? There is little or no hepatomegaly associated with hemolytic anemias, pernicious anemia, Gilbert's disease, and Dubin-Johnson syndrome.
- Is the hepatomegaly massive? Massive hepatomegaly is associated with Gaucher's disease.
- Is there associated fever, right upper quadrant pain, or a tender liver? These findings would suggest viral hepatitis, cholecystitis, infectious mononucleosis, leptospirosis, ascending cholangitis, hepatic vein thrombosis, and toxic hepatitis.
- Is the gallbladder enlarged? The finding of an enlarged gallbladder with the jaundice suggests obstructive jaundice, carcinoma of the pancreas, carcinoma of the bowel ducts, or ampulla of Vater.
- Is there skin pigmentation? The presence of skin pigmentation that is not bilirubin suggests hemochromatosis.
- Is there splenomegaly? The presence of significant splenomegaly suggests infectious mononucleosis, cirrhosis of the liver, hemolytic anemia, Gaucher's disease, kala azar, or agnogenic myeloid metaplasia.
- Is there edema and ascites? The presence of edema and ascites suggests alcoholic cirrhosis.
DIAGNOSTIC WORKUP
The basic workup includes a CBC, sedimentation rate, reticulocyte count, red cell fragility test, urinalysis, chemistry panel, VDRL test, EKG, a chest x-ray, and flat plate of the abdomen.
If infectious hepatitis is suspected, a hepatitis profile, febrile agglutinins, Monospot test, cytomegalic virus antibody titer, and leptospirosis antibody titer should be done. If lupoid hepatitis is suspected, a test for antinuclear antibodies and a smooth muscle antibody should be done.
If hemochromatosis is suspected, a serum iron, iron-binding capacity, and ferritin should be done.
If hemolytic anemia is suspected, serum haptoglobins, hemoglobin electrophoresis, and sickle cell preparations may be done.
If obstructive jaundice is suspected, then gallbladder ultrasound should be done to rule out gallstones, and a CT scan of the abdomen may be done to look for GI neoplasm. An upper GI series may assist in finding a primary neoplasm in the GI tract.
ERCP or percutaneous transhepatic cholangiography will assist in determining whether there is definitely obstructive jaundice and whether it is due to a surgically resectable lesion. Peritoneoscopy can also be helpful. An exploratory laparotomy will probably be necessary regardless of whether one performs the above tests. Cholangiopancreatography and endoscopic ultrasonography are two newer methods that may be used to evaluate the biliary tree and pancreatic ducts, especially when a neoplasm is suspected.
Hepatocellular jaundice will often require a needle biopsy of the liver to pin down the diagnosis. Antimitochondrial antibodies will need to be ordered to screen for biliary cirrhosis. An alpha 1-fetoprotein will help diagnose hepatocellular carcinoma. By the time you have reached this point, you have gone to considerable expense in the diagnostic workup. It would be much more prudent to ask for a gastroenterology consultation before ordering all these expensive diagnostic tests.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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