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Jaundice in Adults - Coggle Diagram
Jaundice in Adults
Diagnosis: History taking
Alcohol intake in units.
Travel abroad to areas endemic for viral hepatitis and parasites
Systemic features such as anorexia, weight loss, fever, rigors, arthralgia, myalgia, rash, fatigue, nausea and vomiting. Be alert for red flags.
Other risk factors for viral hepatitis - IV drug use, tattoos, body piercings, blood transfusion, multiple sexual partners, sex between men or with sex workers.
Itching (pruritus)
Past medical history of biliary surgery, gallstones, hepatitis, autoimmune liver disease, thyroid disease, or non-alcoholic fatty liver disease.
Pain including site, severity and radiation
Co-morbidities such as IBD, obesity, diabetes, and metabolic syndrome.
Colour of urine and stools, including any evidence of tarry/blood stools suggesting melaena
Drugs
Duration and previous episodes of jaundice
Occupation
Possibility of pregnancy
Family history of inherited anaemias or haemoglobinopathies.
Risk factors
Inflammatory bowel disease
Previous malignancy
Increased BMI and metabolic syndrome
Abdominal surgery
Travel to areas with a high risk of parasitic infection
Pregnancy
Factors which increase the risk of viral hepatitis or HIV
Use of certain prescribed and over the counter drugs, including herbal medicines and dietry supplements
Alcohol misuse
A family history of inherited anaemias, haemoglobinopathies, or liver disease.
Diagnosis: Investigations
Amylase - if pancreatitis if suspected
Full blood count
Hepatitis A, B and C if risk factors are present
Clotting screen
Urine dipstick
LFTs
Carbohydrate antigen 19-9 (CA19-9) is not recommended as a screening tool for pancreatic cancer.
U&Es
Depending on the results of the initial tests, arrange additional investigations as appropriate.
Consider arranging an abdominal ultrasound scan or CT scan (the latter is usually requested in secondary care)
Diagnosis: Examination
Masses such as hepatomegaly, splenomegaly or palpable gallbladder
Abdominal tenderness
Look for lymphadenopathy - enlargement of the left supraclavicular lymph nodes can be caused my malignancy including metastatic pancreatic and gastric cancer, more widespread lymphadenopathy with hepatosplenomegaly can indicate lymphoma
Visible veins
Look for signs of liver failure - altered neuromuscular function such as asterixis can occur with hepatic encephalopathy, altered mental state such as drowsiness, confusion, disorientation or coma, bruising, petechiae, or purpura.
Ascites indicates underlying causes of intra-abdominal malignancy, chronic liver disease, or severe heart failure
Look for signs of chronic liver disease - palmar erythema, spider naevi, fingernail clubbing, keukonychia, dupuytren's contractures, gynaecomastia,
Look for signs of sepsis - fever, tachycardia, hypotension
Red flags
Signs of severe hepatic dysfunction - bruising, purpura, petechiae.
Signs of gastrointestinal blood loos - haematemesis or melaena
Signs associated with hepatic encephalopathy eg confusion/alteration in mental state/altered neuromuscilar function
Signs of sepsis - fever, hypotension and tachycardia
Arrange same day emergency assessment if
Signs of ascending cholangitis - fever and right upper quadrant pain, marked abdominal tenderness or pain, vomiting, or suspected paracetamol overdose.
Urgent referral for those presenting with jaundice and weight loss that may indicate underlying malignancy, or chronic disease.
Interpretation of Liver Function tests
Hepatitic picture - raised ALT and AST, ALP may also be raised. Cause hepatocellular liver injury secondary to viral hepatitis, non-alcoholic fatty liver disease, alcohol-related liver disease, autoimmune hepatitis, or drug induced liver injury.
Cholestatic picture - raised alkaline phosphatase (ALP) predominant feature. Causes primary bilary cholangitis, liver congestion, drug-induced liver injury. Repeat LFTs - urgency dependent on clinical judgement, add GGT to confirm liver cause.
Mixed picture - occasionally LFTs may indicae both cholestasis and hepatocyte damage
Isolated raised bilirubin - most often due to Gilbert's syndrome, repeat LFTs and FBC to ensure no evidence of anaemia or haemolysis.
Albumin - low serum albumin suggests chronic liver disease
Management
Refer - Jaundice is not a common presentation in primary care but is usually indicative of serious illness that requires urgent investigation and treatment. All people with unexplained jaundice should therefore be referred immediately.
Primary care management: Most presenting with jaundice should be admitted or referred. People who are well and have been diagnosed with Gilbert's syndrome or Hepatitis A can be managed in primary care.
Arrange same day secondary care assessment - red flag signs/symptoms, bilirubin level greater than 100micromol/l, abnormal clotting profile or shows signs of coagulopathy, abnormal renal function, suspected paracetamol overdose. frail or significant co-morbidities
Definition: Jaundice describes the yellow pigmentation of the skin, sclera and mucous membranes resulting from raised plasma bilirubin. Normal plasma bilirubin levels are below 21 micromol/L, clinical jaundice may not become apparent until serum bilirubin is greater than 51 micromol/L. Bilirubin is the breakdown of haem molecules in red blood cells and other proteins, which occurs in three phases: pre-hepatic, intra-hepatic and post-hepatic. Jaundice can occur due to disfunction at any of these three stages. There can be many causes of jaundice.