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• Jaundice is defined as a serum bilirubin level above 19 µmol/L.

• Clinical jaundice manifests only when the bilirubin exceeds 50 µmol/L.

• Jaundice is difficult to detect visually below 85 µmol/L if lighting is poor.

• The most common causes recorded in a general practice population are (in order) viral hepatitis, gallstones, carcinoma of pancreas, cirrhosis, pancreatitis and drugs.

• Always take a full travel, drug and hepatitis contact history in any patient presenting with jaundice.

Key history

• Associated symptoms (e.g. rash, pruritus, fever, arthralgia, weight loss)

• Medical history

• Contact with people with hepatitis or jaundice

• Overseas travel, family history, drug history, IV drug use, sexual history, occupational history

Key examination

• General inspection including skin for signs of excoriation.

• The abdominal examination is important with a focus on the liver and spleen.

• Look for signs of chronic liver disease.

• Test for hepatitis flap (asterixis) and fetor, which indicate liver failure.

• Include dipstick urine testing for bilirubin and urobilinogen.

Key investigations

• The main ones are the standard LFTs and viral serology for infective causes (hepatitis A, B, C and possibly EBV).

• Consider hepatobiliary imaging, autoantibodies for autoimmune chronic active hepatitis and primary biliary cirrhosis, tumour markers and iron studies.

Infective viral hepatitis

Hepatitis

• Hepatitis A, B, C, common esp. B and C

• A and E—faeco–oral transmission

• B, C, D—from IV drugs and bodily fluids

• Sexual transmission with B and C

• Diagnosed by viral markers for A, B, C, D

Management

• Patient education

• Rest, fat-free diet

• Avoid alcohol, smoking and hepatotoxic drugs

• Advice on hygiene and prevention

• Regular follow-up for B and C: LFTs, α-fetoprotein.

• Interferon alpha for chronic Hepatitis B and C (ideally for 48 wks); lamivudine or tenofir or adefovir for B; ribavirin for C

Prevention

• Hepatitis A vaccine: 0, 6–12 mths

• Hepatitis B vaccine: 0, 1, 6 mths

• Hepatitis A and B combined: 0, 1, 6 mths

• Immunoglobulin for A and B

Cholestatic jaundice (bile outflow obstruction)

• Intrahepatic cholestasis—intrahepatic biliary tree

• Extrahepatic cholestasis—obstruction by gall stones, bile sludge, carcinoma e.g. pancreas, cholangitis

Symptoms: jaundice (green tinge), dark urine, pale stools, pruritus ± pain

Investigation: ultrasound, ERCP

Jaundice in the infant

Common in the newborn—usually physiological and benign but usually pathological within first 24 hrs and if bilirubin is conjugated consider serious biliary atresia.

ABO blood group incompatibility

• Antibody-mediated haemolysis (Coomb test +ve): mother is O, child is A or B

• Perform direct Coomb test on infant

• Immediate phototherapy

Breast milk jaundice

• Occurs in 2–4% of breastfed infants—usually begins late in first week and peaks at 2–3 weeks. Diagnosis confirmed by suspending (not stopping) breastfeeding for 24–48 h. Bilirubin falls—mother expresses milk 48 h then resumes.

Symptoms: exhaustion, disorientation, poor concentration, insomnia, anxiety, anorexia, others.

How to minimise the problem (advice to patients)

Before the flight

• Allow plenty of time for planning.

• Plan a stopover if possible.

• If possible, arrange the itinerary so that you are flying into the night.

• Ensure a good sleep the night before flying.

• Ensure a relaxed trip to the airport.

• Take along earplugs if noise (75–100 dB) is bothersome.

During the flight

• Fluids: Avoid alcohol and coffee. Drink plenty of non-alcoholic drinks such as orange juice and mineral water.

• Food: Eat only when hungry and even skip a meal or two.

• Dress: Women should wear loose clothes and comfortable (not tight) shoes and take them off during flight.

• Sleep: Try to sleep on longer sections of the flight (give the movies a miss). Sedatives such as temazepam, zopiclone or antihistamines can help sleep.

• Activity: Try to take regular walks around the aircraft and exercise at airport stops.

• Special body care: Continually wet the face and eyes.

At the destination

• Take a nap for 1–2 hrs if possible.

• Wander around until you are tired and go to bed at the usual time. It is good to have a full day's convalescence and avoid big decision making soon after arrival.

(Pre-occasion jitters/performance anxiety)

Propranolol 10–40 mg (o) 30–60 mins before the event or performance.

Tinea cruris.