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JAUNDICE

  • 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

Red flags for jaundice: unexplained weight loss, progressive jaundice (incl. painless jaundice), cerebral dysfunction, e.g. confusion, somnolence.

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Table J1 Jaundice (adults): diagnostic strategy model

Probability diagnosis

Hepatitis A, B, C

Gallstones in common bile duct

Alcoholic hepatitis/cirrhosis

Drugs (e.g. flucloxacillin, sodium valproate)

Serious disorders not to be missed

Malignancy

  • pancreas

  • biliary tract

  • hepatocellular (hepatoma)

  • metastases

Severe infections

  • septicaemia

  • ascending cholangitis

  • fulminant hepatitis

  • HIV/AIDS

Rarities

  • Wilson syndrome

  • Reye syndrome

  • acute fatty liver of pregnancy

Pitfalls (often missed)

Gallstones

Gilbert syndrome

Cardiac failure

Primary biliary cirrhosis

Autoimmune chronic active hepatitis

Haemochromatosis

Viral infections (e.g. CMV, EBV)

Chronic viral hepatitis

Leptospirosis

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.

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Table J2 Characteristic liver function tests

Liver function tests (serological)

Hepatocellular (viral) hepatitis

Haemolytic jaundice

Obstruction

Alcoholic liver disease

Bilirubin

↑ to ↑↑↑

↑ unconjugated

↑ to ↑↑↑

↑ to N

Alkaline phosphatase

↑ to <2 N

N

↑↑↑ >2 N

Alanine transferase

↑↑↑ >5 N

N

N or ↑

Gamma gultamyl transferase

N or ↑

N

↑↑

↑↑↑

Albumin

N or ↓

N

N

N to ↓↓

Globulin

N or ↑

N

N

N to ↑

N = is within normal limits

Note: The normal ALP is 30–120 μ/L: it is elevated with cholestasis, osteoblastic activity (e.g. Paget disease), hepatitis and bony metastases.

Infective viral hepatitis

Hepatitis image 298–302

  • 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 ...

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