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Jaundice: yellow pigmentation of the skin, sclera, mucous membranes from…
Jaundice: yellow pigmentation of the skin, sclera, mucous membranes from raised plasma bilirubin levels. Normal plasma bilirubin levels 5-19 micromol/L.
CAUSES
PRE HEPATIC: Haemolytic anaemias, Drugs, Malaria, Gilbert's Syndrome, Crigler-Njajjar syndrome.
INTRA HEPATIC: Viral infection, Alcohol, Non-alcoholic fatty liver disease, autoimmune liver disorders, metabolic causes, Drugs, Malignancy of biliary system
POST HEPATIC/OBSTRUCTIVE: Gallstones, Surgical strictures, Extra hepatic malignancy, Pancreatitis, Parasitic Infection.
RISK FACTORS: Alcohol misuse, IV drug use, Travel to high risk areas, Hx of blood transfusions, Occupation with potential exposure, High BMI, Pregnancy, Family history, herbal remedies.
ASSESSMENT
Note duration and previous history of jaundice.Pain, site, severity and radiation.
Note colour of urine and stools, evidence of malena.
Itch, Alcohol intake, Exposure risk, family history.
Systemic features including anorexia, weight loss, fevers, rigors, athralgia, myalgia, rash, nausea or vomiting.
RED FLAGS: Confusion or altered mental state. Altered neuromuscular function. Hematemasis, malena, fever, hypotension, tachycardia, vomiting and marked abdominal tenderness.
Pregnancy, PMH.
Arrange urgent admission for those clinically unwell. Refer to sepcialist clinic/follow suspected cancer referral guidelines if indicated.
Investigations: LFT tests.
Isolated raised bilirubin, likley in Gilbert's disease. Repeat LFTs and FBC to check no indication of aneamia or haemolysis.
Raised ALP in intra hepatic cholestasis, cholangitis or obstruction. Repeat LFTs plus gamma GT to confirm liver cause.
Low bilirubin may indicate chronic liver disease.
A predominant rise in ALT is the most marked abnormality.
MANAGEMENT
If admission not required refer onwards to appropriate secondary care specialist, gastroenterologist or use the suspected cancer referral pathway.
Primary care management - will usually require admission or onward specialist referral for further investigation and treatment.
ADMISSION
Arrange if person presents clinically unwell, sign of encephalopathy, dehydration, abdominal tenderness, abdnormal blood results or hisotry of co morbidities.
Obstruction - GALL STONES
Diagnosis: in symptomatic cases can present with biliary colic - can be severe at times lasting from 30mins to few hours to epigastrum or RUQ. Nausea and vomiting. Not likely fever of abdominal tenderness.
Some can present with mild symptoms, indigestion, intolerant of fatty foods, epigastric pain. Some can be asymptomatic.
Management: Arrange admission for the acutley unwell patient with suspected complication of gall stones. Refer to speciaist in secondary care for further investigation or treatment if indicated as per NICE Guidelines.
Offer pharmacoligical firs tline analgesia and NSAID for symptom management while awaiting appointment with secondary care. Advise safety netting should symptoms worsen to contact practice or NHS24.
Investigations: arrange Abdominal ultrasound and blood tests to check LFT levels - will be abnormal in this case.
Differentails in line with those associated with jaundice.