Summary of Clinical approach to patient with jaundice

Summary of "Clinical approach to patient with jaundice"

This video provides a comprehensive clinical framework for evaluating a patient presenting with jaundice. It emphasizes a systematic approach involving history taking, physical examination, laboratory investigations, and radiological imaging to reach a differential diagnosis and ultimately identify the underlying cause of jaundice.

Main Ideas and Concepts

1. Definition and Types of Jaundice
   • Jaundice is yellow discoloration of skin and mucous membranes caused by serum bilirubin > 3 mg/dL.
   • Must be differentiated from pseudo-jaundice (e.g., excessive carrot intake causing orange skin).
2. Stepwise Clinical Approach
   • History Taking
     • Collect personal data and detailed present illness.
     • Important risk factors and etiologies to explore:
       • Alcohol abuse (use the GAG score to quantify alcohol dependence).
       • Intravenous drug use.
       • Occupational exposures (e.g., carbon tetrachloride).
       • Travel to endemic areas (risk of viral hepatitis A, E).
       • Sexual history (hepatitis B, C, HIV).
       • Previous pregnancies (for recurrent jaundice related to pregnancy).
       • History of inflammatory bowel disease (linked to primary sclerosing cholangitis).
       • Blood transfusions (risk of viral hepatitis).
       • Inherited blood disorders (e.g., sickle cell anemia).
       • Surgical history (e.g., recent cholecystectomy may cause bile duct injury).
       • Drug and supplement history (some cause cholestasis).
     • Symptoms to note: fatigue, pruritus, dark urine, pale stools, pain (suggesting biliary colic or ascending cholangitis).
   • Physical Examination
     • Assess liver size, texture, and signs of chronic liver disease (cirrhosis signs such as spider nevi, palmar erythema, parotid enlargement, Dupuytren’s contracture).
     • Examine for splenomegaly (portal hypertension).
     • Assess neurological status for hepatic encephalopathy (confusion, altered consciousness).
     • Look for pleural effusion (hepato-pulmonary syndrome).
     • Crucial: Palpate gallbladder.
       • Courvoisier’s sign: Enlarged, palpable gallbladder with jaundice suggests pancreatic head cancer.
       • Jaundice without palpable gallbladder suggests gallstones with secondary cholangitis.
   • Laboratory Investigations
     • Liver function tests (LFTs) to differentiate patterns:
       • Hepatocellular pattern: Elevated ALT, AST, bilirubin.
       • Cholestatic pattern: Elevated alkaline phosphatase, gamma-glutamyl transferase (GGT), bilirubin.
       • Patterns may overlap.
     • Screen for specific etiologies:
       • Autoimmune hepatitis (ANA, anti-smooth muscle antibody, liver-kidney microsomal antibody).
       • Primary biliary cirrhosis (anti-mitochondrial antibody).
       • Primary sclerosing cholangitis (ANCA).
       • Viral hepatitis (A, B, C, D, E).
       • Hemolysis (LDH, reticulocyte count).
       • Hemochromatosis (serum iron, transferrin saturation, genetic testing).
       • Wilson’s disease (serum copper, ceruloplasmin).
       • Alpha-1 antitrypsin deficiency.
       • Parasitic infections (e.g., liver fluke antibodies).
       • HIV testing.
   • Radiological Investigations
     • Ultrasound (US)
       • First-line imaging to evaluate liver morphology (acute vs chronic liver disease).
       • Assess bile ducts for dilation:
         • Dilated intrahepatic bile ducts indicate extrahepatic obstruction.
         • No dilation suggests intrahepatic cholestasis.
     • If extrahepatic obstruction is suspected:
       • Painless jaundice + dilated bile ducts + palpable gallbladder → Suspect pancreatic head cancer.
         • Next step: Triphasic CT scan, dynamic MRI, or endoscopic ultrasound.
       • Painful jaundice + biliary colic → Suspect common bile duct stone.
         • Next step: Magnetic resonance cholangiopancreatography (MRCP) preferred as non-invasive.
         • Endoscopic retrograde cholangiopancreatography (ERCP) reserved for therapeutic intervention.
   • Summary of Diagnostic Algorithm
     • History → Clinical exam → Labs → Ultrasound.
     • Differentiate hepatocellular vs cholestatic pattern.
     • Identify etiology by targeted lab tests.
     • Use imaging to confirm obstruction and differentiate benign vs malignant causes.
     • Use specific imaging modalities based on clinical presentation (painful vs painless jaundice).

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Educational

Video