Approach to a patient with jaundice

Jaundice (icterus) is the accumulation of, and colouring of the skin and mucous membranes by, bilirubin, if it appears in excessive amounts or is not conjugated or excreted.
Jaundice is usually first noted in the eyes, but the traditional term for this finding (scleral icterus) is actually a misnomer because pathologic studies reveal most of the pigment to be deposited in the conjunctiva, not the avascular sclera. As jaundice progresses and the serum bilirubin increases, the face, mucous membranes, and eventually the entire skin acquire a yellow or orange hue.

Prominent yellowish subconjunctival fat may be mistaken for conjunctival jaundice, but fat is usually limited to the conjunctival folds and, unlike jaundice, spares the area near the cornea. Patients with carotenemia (from excess carrot or multivitamin ingestion) also develop a yellowish discoloration of the skin, especially the palms, soles, and nasolabial fold, but in contrast to jaundice, the conjunctiva are spared.

Causes of Jaundice

Prehepatic

  • Congenital defects
    • Gilbert’s disease
    • Crigler-Najjar syndrome
    • Hemolysis 
    • Congenital red cell
    • Hereditary spherocytosis defects 
    • Hereditary elliptocytosis
    • G6PD
  • Other enzymes deficiency
    • Sickle cell disease
    • Thalassemia
  • Acquired
    • Malaria
    • Incompatible blood transfusion
    • Autoimmune
    • Hemolytic disease of the newborn
    • Absorbing large hematoma
    • Hypersplenism

Hepatic

  • Intrahepatic
    • Viral hepatitis
      • Hepatitis A, B, C
      • Epstein- Barr virus
      • CMV
      • Other infections- Leptospirosis
      • Drugs- paracetamol, halothane
      • Toxins- carbon tetrachloride
      • Chronic hepato-cellular disease
        • Chronic viral hepatitis
        • Chronic autoimmune hepatitis
      • End-stage liver diseases
        • Cirrhosis
        • Hemochromatosis
        • Wilson’s disease
      • Drugs (chlorpromazine)
    • Primary biliary cirrhosis
    • Sepsis
  • Extrahepatic
    • in lumen
      • Stones (choledocholithiasis)
      • Infestation
        • schistosomiasis
        • clonorchiasis
    • in the wall
      • Congenital biliary atresia
      • Strictures e.g. post op
      • Cholangitis/ cyst
    • Outside the wall
      • Tumors
      • Lymph nodes

History

  • Age at the onset-
    • within 24 hours-
      • erythroblastosis foetalis,
      • sepsis, congenital infection
    • 2-3 days-
      • physiological jaundice( mostly),
      • crigler Najjar syndrome
    • 3rd -7th days- bacterial sepsis,
  • Duration of symptom- the persistence of physiological jaundice or prolong jaundice started from 2-3 weeks of life – biliary atresia
  • Associated symptoms
    • Stool color-
      • high colored stool- hemolytic/ hepatocellular jaundice
      • clay-colored stool- obstructive
    • Urine color
      • dark yellow- obstructive
      • yellowish -hepatocellular
    • Generalized pruritus – obstructive jaundice
    • Fever – sepsis, viral hepatitis, cholangitis, malaria
    • Weight loss
  • Anemia and associated features
    • hemolytic jaundice
    • Abdominal mass/es -choledochal cyst
    • Altered sensorium
    • Petechiae, purpura or ecchymosis
    • GI bleeding – hematemesis, melena
    • Abdominal distension
eyes of a patient with jaundice

Other History

  • Antenatal and birth history
    • Mother’s blood group- Rh/ABO incompatibility
    • Mother’s illnesses fever, rashes, Lymphadenopathy –congenital infections
    • Drugs took during pregnancy –drug-induced hepatitis, cholestasis
  • Past history of blood transfusion
  • h/o taking any hepatotoxic drug
  • The family history of jaundice and anemia-viral hepatitis, hemolytic jaundice e.g. G6PD deficiency, thalassemia. A family history of early neonatal death due to jaundice- galactosemia, Criggler-Najjar syndrome.
  • History of consanguinity

Examination

  • Confirm jaundice differentiate it from carotenemia.
  • Examine the patient under natural light
  • look for
    • -upper bulbar conjunctiva
    • -the undersurface of the tongue
    • -Soft palate
    • -Palm and soles
    • -General body surface
In newborn jaundice is detected by blanching the skin with digital pressure; bilirubin level can be estimated clinically
Dermal zone Bilirubin mg%
1 5
2 10
3 12
4 15
5 >15

Look for other general signs

  • Anemia can be seen in hemolytic jaundice, and if there is blood loss because of bleeding disorder
  • Lymphadenopathy may be associated with infections/ sepsis
  • Edema, clubbing is associated with severe liver disease
  • Purpuric rashes, petechiae or ecchymosis Eyes should be examined for KF ring

Vital signs

  • Fever is associated with the infections
  • Abnormal blood pressure, respiration, and pulse rate indicate the severity of the diseases

Systemic Examination

  • Heart and lung examination revealing S3 gallop or rales is suggestive of congestive heart failure, which leads to passive liver congestion
  • On abdominal examination, tender hepatomegaly may suggest viral hepatitis.
  • Splenomegaly found in malaria, thalassemia and other causes of hemolytic jaundice.
  • A non-tender, palpable mass is found on upper abdominal examination may indicate tumor or cyst.
  • Excoriations, spider nevi, caput medusa, Dupuytren's contracture, gynecomastia, and palmar erythema, ascites are the features of liver cirrhosis.
  • Delirium, drowsiness, asterixis, and tremor occur with liver failure.

Investigations

  • General
    • CBC, ESR, peripheral blood smear
      • Hb- hemolysis, malignancy
      • WBC- infection e.g. hepatitis, cholangitis
      • ESR- Infection
      • Peripheral smear- spherocytosis,
    • Reticulocytosis- hemolysis
  • Liver Function Tests
Bilirubin Pre-hepatic Hepatic Cholestatic
Conjugated Increases Normal or Increases Normal
Unconjugated Normal Normal or Increases Increases
ALP Normal Normal or Increases Increases
Transaminases Normal Increases Normal or Increases
  • Urine
    • Bilirubin
    • Urobilinogen
  • Clotting screen PT
  • Viral antibodies
    • Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis E, CMV, Epstein Barr virus
  • Liver biopsy to r/o hepatocellular disease
  • USG abdomen- may show gallstones, cysts or tumor masses.
  • Direct Coombs test
  • Red cell G6PD activity and T4 and TSH levels
  • ERCP, MRCP, CT
  • Specific investigations
  • Serum copper and ceruloplasmin - r/o Wilson's disease
  • Serum iron and TIBC – r/o hemochromatosis
  • Blood culture and lumbar puncture to r/o sepsis


Contributor.



Vivek Verma. College of Medical Sciences, KU.
Email: [email protected]

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