This document provides a checklist for taking a history and performing an examination for a patient presenting with jaundice. It includes potential causes of jaundice to inquire about in the family and medical history. Key points on examination include inspecting the skin and mucous membranes for jaundice and examining the abdomen. The types of jaundice are differentiated based on bilirubin levels and whether the bilirubin is conjugated or unconjugated. Liver enzymes and other tests can help determine the etiology. Complications specific to obstructive jaundice are also noted.
This document provides a checklist for taking a history and performing an examination for a patient presenting with jaundice. It includes potential causes of jaundice to inquire about in the family and medical history. Key points on examination include inspecting the skin and mucous membranes for jaundice and examining the abdomen. The types of jaundice are differentiated based on bilirubin levels and whether the bilirubin is conjugated or unconjugated. Liver enzymes and other tests can help determine the etiology. Complications specific to obstructive jaundice are also noted.
This document provides a checklist for taking a history and performing an examination for a patient presenting with jaundice. It includes potential causes of jaundice to inquire about in the family and medical history. Key points on examination include inspecting the skin and mucous membranes for jaundice and examining the abdomen. The types of jaundice are differentiated based on bilirubin levels and whether the bilirubin is conjugated or unconjugated. Liver enzymes and other tests can help determine the etiology. Complications specific to obstructive jaundice are also noted.
This document provides a checklist for taking a history and performing an examination for a patient presenting with jaundice. It includes potential causes of jaundice to inquire about in the family and medical history. Key points on examination include inspecting the skin and mucous membranes for jaundice and examining the abdomen. The types of jaundice are differentiated based on bilirubin levels and whether the bilirubin is conjugated or unconjugated. Liver enzymes and other tests can help determine the etiology. Complications specific to obstructive jaundice are also noted.
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Jaundice
Checklist for history
• Family history of jaundice: Gilbert’s familial nonhemolytic hyperbilirubinemia, Crigler-Najjar’s familial nonhemolytic jaundice, Dubin-Johnson’s familial conjugated hyperbilirubinemia • History of cigarette smoking: Carcinoma pancreas • History of alcoholism: Acute alcoholic jaundice • High dietary consumption of meat: Carcinoma pancreas • History of transfusion: Hepatitis B • History of omphalitis: Infection of umbilicus → incomplete obliteration of umbilical vein → jaundice • History of drugs: Chlorpromazine, Methyl testosterone, etc. • History of injections, drug abuse, tattoos (hepatitis B) • Past history of biliary surgery (postoperative stricture) • Family history of jaundice with anemia (hemolysis) – Hereditary spherocytosis • Back pain: 25% of patients with carcinoma pancreas (relief of pain in sitting position) • Whitish clay-colored stools: Suggestive of obstructive jaundice • Melena: Periampullary carcinoma (silver paintstool) • Waxing and waning of jaundice: Suggestive of CBD stone and periampullary carcinoma • Diabetes mellitus: Early manifestation of 25% of carcinoma pancreas • Charcot’s triad: Intermittent jaundice, pain and intermittent fever.
Checklist for examination
• Examination in daylight for yellow discoloration— sclera, skin, nails bed, posterior part of the hard palate, under surface of the tongue • Look for presence of scratch mark in the lower limbs, chest and abdomen—accumulation of bile salt • Look for migratory thrombophlebitis (Trousseau’s sign seen in carcinoma pancreas • Look for spleen (hereditary spherocytosis) • Look for stigmata of liver disease—liver palms, spider angioma, ascites, collateral veins on the abdomen and splenomegaly • Look for a distended gallbladder → Courvoisier’s law • Gallbladder is better seen than felt. Better palpated by superficial palpation than by deep palpation • Look for ascites • Look for leg ulcers—Hereditary spherocytosis, sickle cell disease • Look for left supraclavicular nodes • Rectal examination—rectal shelf of Blumer, presence of primary growth, color of stool, and blood stained finger stall. What are the types of jaundice? What are your points in favor of obstructive jaundice?
• It is a painless progressive jaundice
• Presence of itching and scratch marks • Presence of palpable gallbladder • Loss of weight.
Can you differentiate the types clinically by the
color of jaundice? Lemon yellow – Hemolytic jaundice Orange – Hepatocellular jaundice Deep and greenish – Obstructive jaundice
What are the causes for each type of jaundice
*Crigler-Najjar and Gilbert’s disease are due to defective uptake and conjugation of bilirubin and therefore the hyperbilirubinemia is of the unconjugated type. They are differential diagnoses for hemolytic jaundice. **Dubin Johnson’s familial conjugated hyperbilirubinemia is a condition where the hepatic excretion of conjugated bilirubin into the biliary system is impaired and therefore a differential diagnosis for obstructive jaundice
How to differentiate the types of jaundice
biochemically? There are two types of bilirubin _conjugated (direct) and _unconjugated (indirect). The direct bilirubin is increased in obstructive jaundice whereas the indirect bilirubin is increased in hemolytic jaundice. In obstructive jaundice conjugated bilirubin from the hepatocytes and biliary radicles overflow into the bloodstream, whereas in hemolytic jaundice, unconjugated bilirubin overloads the liver and is detected as elevated in blood. • The serum bilirubin level rarely exceeds 4–5 mg/ dL in hemolytic jaundice. • The bilirubin exceed to 10–20 mg/dL in obstruction due to neoplasm. • In obstruction due to stones usually it ranges up to 5 mg, rarely does it exceed 15 mg.
. What is the role of liver enzymes in the diagnosis of
jaundice? The two most important enzymes are ALT, AST and alkaline phosphatase (ALP). • ALT above 1000 is suggestive of viral hepatitis • In alcoholic liver disease AST is raised (AST : ALT is >2) • Alkaline phosphatase is raised in obstructive jaundice and infiltrative liver diseases like tumor or granuloma. Note: Normal values: ALT: 5 – 35 U/L AST: 5 – 40 U/L
. What are the sources of alkaline phosphatase and what are the conditions in which the enzyme is increased? There are three sources for alkaline phosphatase
1. Liver Equal contribution 2. Bone 3. Intestine—Small contribution Clinical conditions in which alkaline phosphatase is increased • Intrahepatic cholestasis • Cholangitis • Extrahepatic obstruction • Focal hepatic lesions without jaundice • Solitary metastases • Pyogenic abscess • Granulomas • Bone tumors (primary and secondary).
How to rule out alkaline phosphatase rise because of
bone pathology?
• Serum calcium and phosphorus (which will be
abnormal in bony pathology) • 5’ nucleotidase and γ-glutamyl transpeptidase which are specific for obstructive jaundice. What is acholuric jaundice?
What are the investigations for hemolytic
jaundice? 1. Peripheral smearfor spherocytosis 2. Osmotic fragility test for red cells (which will be increased). 3. Reticulocytecount whichwill be increased (compensatory hemopoesis) 4. Positive Coombs’ test.
Exceptions to Courvoisier’s law
1. Stones, simultaneously occluding the cystic duct and the distal CBD (Double impaction) 2. Pancreatic calculus obstructing the ampulla 3. Oriental cholangiohepatitis because of Clonorchis sinensis (Ductal stones formed secondary to the liver fluke infestation) 4. Mucocele/empyema of gallbladder 5. Carcinoma of the gallbladder with or without jaundice—it’s although rare it can also cause a palpable gallbladder (In 1 to 4 the gallbladder is palpable in a jaundiced patient with stones) 6. Nodes in porta hepatis 7. Carcinoma gallbladder with multiple metastases in liver. Sandblom’s triad?Hemobilia consists of – Biliary colic – Obstructive jaundice – --Occult/gross intestinal bleeding
The diagnosis is by Technicum 99m labeled RBC scan and
arteriogram.
What are the 3 important special risks in obstructive
jaundice? Appendicular Mass/
Checklist with special reference (in female pt.)
• A careful gynecological history is taken in all women • Last menstrual period—to find out whether it is a mid-menstrual pain (mittelschmerz) and to rule out pregnancy • History of vaginal discharge—pelvic inflammatory disease • History of dysmenorrhea • Pelvic examination to rule out adnexal and cervical tenderness • High vaginal swabto rule out Chlamydia trachomatis • Urine for pregnancy test • Ultrasound abdomen.
The important causes for mass right iliac fossa
• Appendicular mass • Ileocecal tuberculosis • Carcinomacecum • Rightovarian cyst/tumor • Pelvic inflammatory disease • Iliac lymphadenopathy • Psoas abscess • Tumor in undescended testis • Unascended kidney • Retroperitoneal tumors • Chondrosarcoma of the ilium • Crohn’s disease • Actinomycosis of the cecum • Tubo-ovarian mass.
What are the diagnostic points in favor of appendicular mass?
1. History of Murphy’s triad of symptoms migratory pain, vomiting/anorexia, and fever 2. Short duration 3. Patient—ill looking and febrile 4. Tender mass in the right iliac fossa 5. The tender mass is indistinct, dull to percussion and fixed to the right iliac fossa (unlike ovarian).
What are the characteristic features of tuberculosis?
The patient often has central abdominal pain for months with general ill health, weight loss, and change in bowel habit. The mass is firm, the surface and edges are difficult to define. Ascites may or may not be there. The typical doughy feel may be there. The patient may have evening rise of temperature.
What are the characteristic features of carcinoma
cecum? There won’t be any history of acute pain.Some patients present with anemia, diarrhea, or intestinal obstruction. The right iliac fossa mass will be firm, or hard, distinct and fixed it is not tender, does not resolve with observation. The patient’s temperature and pulse are normal.
What are the clinical point in favor of an ovarian cyst?
Clinical points in favor of ovarian cyst • Smooth, spherical with distinct edges • You cannot get below the swelling (arises from the pelvis) • It may be mobile from side to side (horizontally) No up and down mobility • It is dull to percussion • The lower part of the swelling may be palpable during pelvic examination • The movement of the cyst per abdominally will be transmitted to the examining finger in the pelvis.
What are the clinical points in favor of fibroid uterus?
• Fibroids can grow to enormous size and fill the whole abdomen • It arises out of the pelvis and so lower edge is not palpable • It is firm or hard • Bosselated or knobby • It is dull to percussion • Slight transverse mobility will be present. What is appendicular mass? What is appendicular abscess? One should suspect appendicular abscess during the course of conservative treatment of appendicular mass. The clinical criteria for the diagnosis of appendicular abscess are: 1. A rising pulse rate 2. Increasing or spreading abdominal pain 3. Increasing size of mass 4. Patient looking ill.
What are the differences between appendicular mass
and abscess? Appendicular mass Appendicular abscess 1. Mass forms around the 3rd day Abscess around 5 – 10 days 2. Fever absent Fever present 3. Local signs subside with AB Local signs aggravate with AB 4. Leukocytosis will return to normal Rising leukocyte count 5.Imaging—absence of fluid inside presence of fluid inside 6. Clinically patient is not sick Patient is very sick Ochsner-Sherren regimen
Why appendicectomy is contraindicated in
appendicular mass? 1. Immediate appendicectomy is technically more difficult 2. Fear of disturbing the natural barrier present in the mass 3. The mass will resolve without surgery (90% will resolve with conservative treatment) 4. Operation can always be resorted to, should the initial conservative trial fail.
What is the indication for stopping the conservative
of 40 years undergo a barium enema examination (double contrast) or a colonoscopy after successful conservative treatment of appendicular mass.
What is Alvarado score?
MANTRELS What is the acceptable negative appendicectomy rate? It should ideally be less than 20% (withthe introduction of CT for the diagnosis of acute appendicitis the negative appendicectomy rate should be less than 5%)
Note : A wholesale move to the
routine use of spiral CT for the diagnosis of appendicitis will emasculate the clinical skills of the next generation of the surgeons. It is important not to substitute clinical uncertainty for radiological ambivalence.
