Topic : Jaundice (yellow discolouration of eyes/skin)

Ddx Prehepatic
- autoimmune haemolytic anaemia
- congenital hyperbilirubinasemia (hereditary spherocytosis, sickle cell
anaemia)
- transfusion reaction
- drug toxicity

Hepatic
- viral hepatitis
- alcoholic liver disease
- toxic drug-induced jaundice
- metastatic disease
- Gilberts Syndrome
- Crigler-Najjar Syndrome
- Dubin-Johnson Syndrome
- Wilsons Ds, Hereditary Haemochromatosis, A1AT def

Posthepatic
- choledocholithiasis
- biliary stricture
- PSC
- PBC
- Chr hepatitis
- Carcinoma of head of pancreas
- Mirizzis syndrome
- Enlarged lymph node in porta hepatis
- Carcinoma of GB

HPC
- Onset (when did this start?)
- Who noticed it?
- Where? (eyes, upper limbs)
- Is it constantly there or comes and go?
- Did it get any worse, better or the same?
- Other symptoms :
Pale stool
Stools hard to flush/ floating in the toilet bowl
Bloody stool/diarrhea (PSC/UC)
Dark urine
Itchiness (pruritus)
Abdominal pain (SRTCOPDSARA)
Fever/rigor
Lethargy/malaise
n/v
Bruises (chr liver disease)
Abdominal swelling (ascites, chr liver disease)
 Weight loss (malignancy, haemolytic anemia)
SOB (haemolytic anemia)
Back pain

Risk Factors:
Alcohol
Medications? OTC/ Herbal/Overdose paracetamol? (others isoniazid,
sodium valproate, chlorpromazine,augmentin)
Recent travel (far east/asia ass/w hep A)
Whats your living condition? Overcrowded / poor sanitation/
contaminated water/food? (Hep A & E)
In contact with people known for hep B/C/HIV
Recent blood transfusion
Piercing/tattoos
Iv drug abuse/ needle stick injuries
Unprotected sex/ multiple partners/ MSM (sexual history)
Diet- eating a lot of fatty food
Family history of jaundice/liver disease
vaccination
history of malignancy

- PMH
- PSH
- Medications and allergy
- Family history
- Social history smoking!!
- System review

Physical exam:

Hands
Clubbing
Nail Changes
Leuconychia
Muehrcke nails
Terry nails
Palmar erythema
Dupuytren's contracture
Asterixis (bilateral asynchronous flapping motions of outstretched,
dorsiflexed hands)
Arms
Bruising
Pigmentation
Scratch marks
Needle tract marks
Tattoos
Proximal muscle wasting
Neck
Increased jugular venous pressure
Cervical Lymphadenopathy
Head
Scleral Icterus
Conjunctival pallor
Jaundice
Fetor Hepaticus
Parotid gland enlargement
Chest
Spider Naevi angiomata / spider telangiectasia (central arteriole
surrounded by many smaller vessels)
Gynecomastia
Right pleural effusion
Enlarged left supraclavicular node (Virchow's node)
Abdomen
periumbilical nodule (Sister Mary Joseph's nodule) abdominal malignancy
caput medusae
hepatomegaly
Splenomegaly (the right lateral decubitus position)
Ascites*
abdominal distension
fluid wave
flank dullness to percussion
* Decompensated Cirrhosis

Investigations:
1. Blood test:
FBC
Liver Function Tests
Indirect (Unconjugated) Bilirubin
Direct (Conjugated) Bilirublin
Elevated Aminotransferases
(ALT) > (AST)
(AST) > (ALT) Alcoholic hepatitis
Alkaline Phosphatase
Gamma-glutamyl transpeptidase (GGT)
Hepatic synthetic function
Albumin
Prothrombin
Serum amylase outrule chr pancreatitis
Viral Screen:
- Hepatitis A
IgM anti-HAV Antibodies (Acute)
IgG anti-HAV Antibodies (Convalsecent)
Hepatitis B
Hepatitis B surface antigen (HBsAg)
hepatitis B surface antibody
Hepatitis B e antigen (HBeAg)
anti-HBe
IgM hepatitis B core antigen antibodies (IgM anti-HBc)
HBV DNA
- Hepatitis C, HIV, EBV, CMV, Varicella Zoster Virus
Immune Screen:
- Immunoglobulins IgM / IgG / IgA
- antimitochondrial antibodies (PBC)
- Anti nuclear anti-smooth muscle (AH)
- Anti liver-kidney microsomal antibodies (AH)
Metabolic Screen:
- Alpha Fetoprotein
- TTG
- Iron
- Transferrin
- ferritin (Hemochromatosis)
- ceruloplasmin (Wilson disease)
- alpha-1 antitrypsin (alpha-1 antitrypsin deficiency)
Hemolysis:
- Anaemia (FBC)
- Increased reticulocyte count
- Increased indirect bilirubin (unconjugated)
- Increased serum lactate dehydrogenase
- Reduced serum haptoglobin
- Direct Coombs / Direct Antiglobulin test
- Peripheral Blood Smear
o Red Cell Fragmentation
- Intravascular Hemolysis:
o Plasma hemoglobin (hemoglobinemia)
o Urine free hemoglobin (Hemoglobinuria)
o Urine hemosiderin
2. Liver Ultrasound
a. Gallstones
b. abnormal bile ducts
3. magnetic resonance cholangiopancreatography (MRCP) (1st line)
4. endoscopic retrograde cholangiopancreatography (ERCP) (2nd line)
5. percutaneous transhepatic cholangiography (PTC) (3rd line)
6. contrast-enhanced CT (suspect neoplastic obstruction)
7. liver bx (extrahepatic cause of jaundice is unknown)

**Notes:
- ALT>AST (usually). If AST>ALT it is alcoholic hepatitis
- Albumin and PT (hepatic synthetic function in chr. Liver disease)
- +ve AMA (PBC)
- +ve ASMA and +ve anti-liver kidney microsomal ab (AH)
- Maddrey Discriminant Function:
Disease severity and mortality risk in alcoholic hepatitis
 DF = (4.6 x [prothrombin time (sec) - control prothrombin time (sec)]) +
(serum bilirubin)

DF value 32
high short-term mortality
may benefit from glucocorticoids
DF value <32
low short-term mortality
No benefit from glucocorticoids

Management:
1. correct dehydration
2. monitor urinary output
3. check clotting times vit k 10mg iv stat if prolonged PT
4. ensure adequate nutrition NG tube if vomiting, dietitian review
5. Acute presentation ERCP/PTC/surgical drainage
6. Elective:
- Steroids and azathioprine, liver transplant in 10% for AH
- splenectomy
- ERCP/PTC/cholecystojejunostomy (obs jaundice)
- No treatment necessary for Gilberts
- iv normal saline, iv pabrinex 1+2 tds 3/7, alcohol abstinence,
dietitian review with high calorie diet, chlordiazepoxide 40mg
QDS, +/- glucocorticoids (alcoholic hepatitis)
- liver tansplant (plasmapheresis/exchange
transfusion/haemofiltration/dialysis as bridging strategies in
pending transplant) (acute Wilsons ds)
- Trientine with Zinc , low copper diet (low liver and shellfish) (in
moderate hepatic dysfunction in Wilsons)
- Penicillamine with dietary modification (in asymptomatic
Wilsons)
- Phlebotomy/venesection aim for transferrin<50ng/mL (acute
haemochromatosis, symptomatic, elevated transferrin sat, ferritin)
- Longterm phlebotomy/venesection, desferrioxine, vaccination
against hep A and hep B, lifestyle modification ( avoid iron sup,
alcohol, vit C), refer to dietitian if DM, dyslipidaemia, HTN, alcohol
excess (longterm tx for haemochromatosis)
- Supportive treatment for hep A and E
- Supportive treatment and Tenofovir (1st line tx for chr Hep B),
Lamivudine (coinfection with HIV), Entacavir (renal impairment),
Peginterferon alpha 2a +/- Ribavirin (180mcg once weekly sc for
48weeks in HBeAg positive or negative chro HBV) (Chr Hep B)