CASE STUDY ON JAUNDICE

CHIEF COMPLAINT:  Mrs. S – Her eyes are yellow for two days.

HISTORY OF PRESENT ILLNESS: Mrs. S is a 36 year old unemployed who presents

with yellow discoloration of her eyes which she noticed two days ago while washing her face.
At first she thought the colour was due to the lighting in her bathroom, but this morning,
when going outside of her house to retrieve the mail, she thought her hands "looked yellow."

Mrs. S further admits to feeling "sick and tired" for the past 2 -3 weeks. She has lost her
appetite and feels weak. During this time, she has been frequently nauseated and ate very
little food. Last night she developed a fever and "shook all over with a chill." This morning
she awoke after a restless night with pain and a sensation of fullness in the right upper
abdomen. She also vomited twice. The emesis was non -bloody. She has not had diarrhoea.
She has no back or shoulder pain. She thinks she lost 20 lbs during the last 3 months. She
denies having joint pain or skin rash.

Mrs. S is a chronic alcoholic who has been hospitalized on several occasions for alcohol
related problems, including a psychiatric admission. Since graduation from law school she
has had many alcohol related work problems and lost her position at a prestigious firm three
weeks ago. Since that time she has consumed approximately one fifth of vodka every day or
so.

She takes Tylenol for frequent headaches but takes no other medications. She smokes one
pack of cigarettes per day.

PHYSICAL EXAMINATION: The patient is alert but haggard looking. She is skinny and
shows prominent cheek bones. She appears much older than her stated age. Vital signs: Blood
pressure in right arm 104/60 mmHg, Heart Rate 110/minute and regular, Respiratory Rate
18/minute, Temperature 38.90 C.

HEENT: Bilateral, deep conjunctival icterus.

CHEST: Prominent ribs. Lungs are clear to percussion and auscultation.

CARDIOVASCULAR: Soft S1 and S2. No murmurs or extra cardiac sounds.

ABDOMEN: The abdomen is round and slightly tympanitic. The liver is palpable beneath the
costal margin (9 cm.) and tender. The liver span is 20 cm. There is no rebound tenderness,
shifting dullness or splenomegaly. Normal bowel sounds.

SKIN: Icteric; spider nevi noted on shoulders.

EXTREMITIES: Bilateral tremors of hands; bilateral palmar erythema.

LABORATORY DATA:

1. Complete blood cell count

o White blood cell count: 17,000 cells/mm3 with modest shift to left
o Hemoglobin 10.6 g/dL; Hematocrit 33%
o Platelets 120,000/mm3
o MCV 110/micro m3
2. Chemistries
o Aspartate arninotransferase (AST) 150 U/L
o Alanine aminotrasferase (ALT) 60 U/L
o Total Bilirubin 22 mg/dL
o Alkaline phosphatase 400 U/L
3. Prothrombin time 13.2 seconds
4. During, hospitalization WBC rose to 42,000/mm3; total bilirubin rose to 32 mg/dL

Questions

1. Identify salient historical information that may have a bearing to this patient's chief
complaint and indicate its significance.
 Patient feels tired, nauseated, had fever with shaking chills
 Pain in upper abdomen
 Psychiatric admission
 Chronic alcoholism
 Sudden loss of weight in last 3 months
 Tylenol use

2. What is your working diagnosis for her Jaundice based on the history and physical?

 Alcoholic hepatitis
 Viral hepatitis
 Drug induced hepatitis
 Cholelithiasis
 Acute pancreatitis

3. Identify salient Laboratory findings that may have a bearing to this patient's chief
complaint and indicate its significance.

 Yellow discolouration of eyes

 Liver span 20 cm
 Tender Liver
 Skin icteric
  Dishelved
 Spider nevi
 Fine tremors of hands
 Palmar erythema

4. Cite the main clinical problem (not the diagnosis).

 Jaundice
 Other problems - Nausea, vomiting, fever, chills, abdominal pain

5. What patho-physiologic process does the laboratory data suggest.

 The liver transferases are slightly elevated along with conjugated bilirubin.

 This indicated mild hepatocellular injury with marked cholestasis.

 The alkaline phosphatase level also gives evidence of the severe cholestasis
(with increase in conjugated bilirubin).  

 The AST level is greater than the ALT level which is classic for the disease
process that is present in this patient.

6. What is the diagnosis in this patient.

Alcoholic hepatitis.

7. Cite data from the history, physical exam and laboratory to support this diagnosis.

 Recent and past history of alcoholism.

 Nausea, vomiting.

 Hepatomegaly

 Spider nevi

 AST greater than ALT. AST/ALT ratio > 1

 Leukocytosis.

 Worsening clinical status after hospitalization.

 Palmar erythema

8. What drugs can be used to treat this patient.

  A good diet can significantly improve the outcome of Alcoholic Liver
Disease.
 Obesity seems to increases the risk of advanced liver disease in heavy
drinkers. Many people with this problem are severely malnourished, due to
loss of appetite and nausea.
 In advanced liver disease (alcoholic hepatitis and cirrhosis) nutritional
supplements have been shown to significantly improve the liver function
tests.
 A diet high in antioxidants such as vitamin E and selenium may help prevent
and treat ALD. These can be taken as supplements or by increasing dietary
fresh fruit and vegetables.
 Abstinence: Even in advanced liver disease, it is still important and beneficial
to stop drinking.
 Supervision may be required to safely reduce alcohol consumption. Rapid
reduction of alcohol consumption could lead to physical withdrawal
symptoms in up to 40% of people. Symptomatic treatment can include:
 Corticosteroids for severe cases.
 Anticytokines (infliximab and pentoxifylline).
 Propylthiouracil to modify metabolism
 Colchicine to inhibit hepatic fibrosis.
 Antioxidants.
 When all else fails and the liver is severely damaged, the only alternative is a
liver transplant.

9. What advice would you give the patient regarding the use of Tylenol.
 Tylenol is Acetaminophen, which in therapeutic doses can be toxic in patients
with liver disease due to increased P-450 enzyme activity.

 Tylenol should be used cautiously in these kind of patients and they should be
properly instructed about the potential toxicity of therapeutic doses of
Tylenol.