Jaundice
Jaundice: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Icterus
A yellow discoloration of the skin, mucous membranes, or sclera of the eyes, jaundice indicates excessive levels of conjugated or unconjugated bilirubin in the blood. In fair-skinned patients, it’s most noticeable on the face, trunk, and sclera; in dark-skinned patients, on the hard palate, sclera, and conjunctiva.
Jaundice is most apparent in natural sunlight. In fact, it may be undetectable in artificial or poor light. It’s commonly accompanied by pruritus (because bile pigment damages sensory nerves), dark urine, and clay-colored stools.
Jaundice may result from any of three pathophysiologic processes. (See Jaundice: Impaired bilirubin metabolism.) It may be the only warning sign of certain disorders such as pancreatic cancer.
History and physical examination
Documenting a history of the patient’s jaundice is critical in determining its cause. Begin by asking the patient when he first noticed the jaundice. Does he also have pruritus, clay-colored stools, or dark urine? Ask about past episodes or a family history of jaundice. Does he have nonspecific signs or symptoms, such as fatigue, a fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, weight loss, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations? Ask about alcohol use and a history of cancer or liver or gallbladder disease. Has the patient lost weight recently? Also, obtain a drug history. Ask about a history of hepatitis, gallstones, or liver or pancreatic disease.
Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn’t affect the sclera. Inspect the patient’s skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops as well as crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient’s mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
Medical causes
Carcinoma
Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, a recurrent fever, and chills
Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.
Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right upper quadrant discomfort and tenderness, nausea, weight loss, and a slight fever. Examination may reveal irregular, nodular, firm hepatomegaly; ascites; peripheral edema; a bruit heard over the liver; and a right upper quadrant mass.
Withpancreatic cancer,progressive jaundice — possibly with pruritus — may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, a fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).
Cholangitis
Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right upper quadrant pain, and a high fever with chills.
Cholecystitis
Cholecystitis produces nonobstructive jaundice in about 25% of patients
Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), a fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign and, possibly, abdominal distention and rigidity.
Cholelithiasis
Cholelithiasis commonly causes jaundice and biliary colic
It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes a fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.
Cirrhosis
With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency
Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right upper quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.
With primary biliary cirrhosis,fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.
Dubin-Johnson syndrome
With Dubin-Johnson syndrome, which is a rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40
Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.
Heart failure
Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure
Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites are a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.
Hepatic abscess
Multiple abscesses may cause jaundice, but the primary effects are a persistent fever with chills and sweating
Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; an elevated right hemidiaphragm; and ascites.
Hepatitis
Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis
Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgia, myalgia, a headache, anorexia, photophobia, pharyngitis, a cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right upper quadrant pain and tenderness.
Pancreatitis (acute)
Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, the primary symptom of acute pancreatitis is usually severe epigastric pain that commonly radiates to the back
Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include a fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.
Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany — the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.
Sickle cell anemia
Hemolysis produces jaundice in the patient with sickle cell anemia
Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, swollen (painful) joints, a fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; a low-grade fever; and increased weakness, jaundice, and dyspnea.
Other causes
Drugs
Many drugs may cause hepatic injury and resultant jaundice
Examples include acetaminophen, phenylbutazone, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, 3-hydroxy-3-methylglutaryl reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and dilantin.
Treatments
Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.
A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.
Special considerations
To help decrease pruritus, frequently bathe the patient; apply an antipruritic lotion, such as calamine; and administer diphenhydramine or hydroxyzine
Prepare the patient for diagnostic tests to evaluate biliary and hepatic function. Laboratory studies include urine and fecal urobilinogen, serum bilirubin, liver enzyme, and cholesterol levels; prothrombin time; and a complete blood count. Other tests include ultrasonography, cholangiography, liver biopsy, and exploratory laparotomy.
Pediatric pointers
Physiologic jaundice is common in neonates, developing 3 to 5 days after birth. In infants, obstructive jaundice usually results from congenital biliary atresia. A choledochal cyst — a congenital cystic dilation of the common bile duct — may also cause jaundice in children, particularly those of Japanese descent.
The list of other causes of jaundice is extensive and includes, but isn’t limited to, Crigler-Najjar syndrome, Gilbert’s disease, Rotor’s syndrome, thalassemia major, hereditary spherocytosis, erythroblastosis fetalis, Hodgkin’s disease, infectious mononucleosis, Wilson’s disease, amyloidosis, and Reye’s syndrome.
Geriatric pointers
In patients older than age 60, jaundice is usually caused by cholestasis resulting from extrahepatic obstruction.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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