Date post: | 07-May-2015 |
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BEDSIDE APPROACH TO
A CASE OF JAUNDICEDr Manish Chandra Prabhakar
MGIMS Sewagram
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Focus on
Classifying jaundice as hemolytic , hepatocellular or obstructive
Determine the etiology
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Jaundice – yellow tissue
Sclera yellow – bilirubin > 3g/dl Urine is tea or cola coloured – conjugated
bilirubin Colour – lemon yellow – hemolytic jaundice orange yellow – hepatocellular jaundice green yellow – obstructive jaundice Stool
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Yellow but no jaundice
Carotenoderma – healthy with sclera spared
Quinacrine – 4- 37% of the cases Muddy sclera
Florescent light
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Onset
Developing in matter of hours and deepening rapidly – viral or drug induced hepatitis
Long standing – Mild – hemolytic – family history Deep – obstructive Chronic liver disease – alcoholics
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Patient has fever
Malaria Leptospirosis – occupational history Viral hepatitis Cholangitis Dengue hemorrhagic fever
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Pain in abdomen
Sudden onset right upper quadrant colicy pain with chills – choledocholithiasis and ascending cholangitis
Epigastic and back ache – pancreatic cancer
Biliary obstruction but no pain with deterioration in health and decreasing weight – malignant obstruction
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Pruritus
Persistent – obstructive jaundice Transient – Viral hepatitis
Unilateral jaundice
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Emphasize on
Drug history – Predictable – dose related -
acetaminophen Unpredictable – isoniazide
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Clues to etiology
Travel / exposure to contaminant food – Hep A / hepatotoxin
Blood transfusion – HCV, HIV, HBV High risk behaviour – sharing needles ,
drug abuse , unsafe sex Alcohol Family history – Hemolytic anemias,
Wilson’s disease
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Associated features
Chronic liver cell failure – distension of abdomen , anasarca , hemorrhoids, hemetemesis ,
Arthralgia , myalgia , rash – viral hepatitis History of hepatobiliary surgery
Breathlessness – heart failure Vit D and Vit A deficiency
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General physical examination in a patient who has Icterus
Pulse – Tachycardia – fever , heart failure Bradycardia – obstructive jaundice Tachypnea – heart failure , fever Pallor – hemolysis , malignancy , cirrhosis Pallor with knuckle pigmentation –
megaloblastic anemia Lymphadenopathy – Virchow’s and Sister
Mary Joseph’s nodes. Clubbing may be seen in chronic cholestasis.
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Mental status – hepatic encephalopathy -
hepatocellular jaundice Flapping tremors Fetor hepaticus Skin – Brusing – clotting factor defects Petechiae / purpura –Thrombocytopenia
of cirrhosis
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Other integumentary manifestation of cirrhosis – spider nevi, palmar erythema, leuconychia, alopecia
Scratch marks, hyper pigmentation, xanthomas on eyelids, extensor surface and palmar creases - Chronic cholestasis
Pigmentation of shin and ulcers – sickle cell disease
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Multiple venous thrombosis – carcinoma of body of pancreas
Ankle edema – cirrhosis or IVC obstruction due to hepatic malignancy
Stigmata of chronic liver disease Raised JVP – heart failure KF ring – Wilson’s disease
spider nevi palmar erythema gynecomastia caput medusae dupuytren's contractures, parotid gland enlargement, testicular atrophy
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Abdomen in jaundice
Caput medusae Ascitis – cirrhosis / malignancy Palpation of Liver –o non palpable - not always a good signo Palpable – Large nodular liver – malignancy Smooth – extra hepatic cholestasis Uniformly enlarged – fatty liver Tender – right heart failure, viral or
alcoholic hepatitis , amyloidosis
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Murphy’s sign – cholecystitis Palpation of gall bladder – Courvoisier’s
law Spleenomegaly – hemolytic jaundice ,
portal hypertension
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To summarise
Hemolytic jaundice – Positive family history Acholuric urine Stool normal coloured Lemon yellow icteruc Anemia Hemolytic faces Spleenomegaly
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Hepatocellular jaundice
Prodromal symptoms – myalgia, fever, rash
Urine and stool colour may not be normal Pruritus may be present Orange yellow icterus Bleeding manifestation may be present Tender hepatomegaly
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Obstructive jaundice
Urine is dark Clay coloured greasy stools Pruritus Green yellow icterus Sinus bradycardia may be present Xanthelesma Murphy’s sign Vit A and D deficiency