Jaundice

68 yr old woman presented with jaundice. (Really jaundice, sort of like simpson kind of yellow)

It started 2 weeks ago. There is intermittent abdominal discomfort but mostly pain free. She noted that her stool is getting pale and hard to flush. The urine is getting darker and darker.

She is otherwise well. Not any medication. Denies ETOH abuse or any new medications.

This is the first time you see her.

Examination is essentially normal other than jaundice. She is haemodynamically stable, afebrile. Abdomen is soft, non tender, no ascites and no hepatomegaly.

What are your differentials at this stage ? How would you manage this patient ?

A structured approach will break down jaundice into pre, intra and post hepatic cause.

 In my mind, I thought this is going to be carcinoma of head of the pancreas. (Painless jaundice).

I was putting all my money on post hepatic jaundice.

The differentials listed in Murtagh

• Intrahepatic 
• Alcoholic hepatitis/cirrhosis 
• Drugs
• Primary biliary cirrhosis 
• Viral hepatitis 
• Extrahepatic 
• Cancer of bile ducts
• Cancer of pancreas
• Other cancer: primary or secondary spread
• Cholangitis
• Pimary sclerosing cholangitis 
• Common bile duct gallstones
• Pancreatitis
• Post-surgical biliary stricture or oedema 

I spoke to my supervisor because I thought about sending this patient to the hospital. 

The final decision was that we started the initial work up first. 

What investigations would you order? Any bedside test?

I contemplated whether to send this woman to hospital to work up in the community. Because she was well so I decided to order some blood tests and review her in a few days time. 

The blood tests I ordered at that time: FBE, LFT, Ca-125, ESR, CRP, UEC, Hepatitis B, Hepatitis A and hepatitis C serology, urinalysis

Hepatitis screen is normal.

The following is the LFT.   What does it tell you and What would you do now ?

This LFT picture is worrying. The bilirubin is 20 times over the normal limit. Combining this with the derrange ALP and GGT. This lady requires an urgent decompression. I ordered an urgent CT chest, abdo and pelvis. The following is the report. 

 It shows gross intrahepatic biliary dilatation likely secondary to cholangiocarcinoma. I contacted one of the local surgeons and he said this patient needs urgent decompression. 

She was transferred to a tertiary hospital for urgent decompression. An ERCP was performed and a stent was inserted. The surgery was complicated by post-op haematoma and re-obstruction. The obstruction subsequently resolve by itself and patient was discharged with out patient upper GI follow up for curable surgery. 

Lessons learned from this case:

- Get advice from other people when you are not sure

- Needs a structured approach to jaundice 

- Clinical appearance can be deceiving
- Urinalysis can be helpful in determining the cause of jaundice. The presence of bilirubin in urine  and the absence of urobilinogen indicates post hepatic obstruction.