Please enable JavaScript.
Coggle requires JavaScript to display documents.
JAUNDICE - ADULTS - Coggle Diagram
JAUNDICE - ADULTS
Investigation
If well and no need for admission - Blood test FBC,LFT, Clotting screen (abnormal for biliary obstruction), U&E's, Amylase, Hepatitis A/B/C. Urine dip stick
-
Immunoglobulins. High levels of IgM indicate primary biliary cirrhosis and high levels of IgG indicate chronic active hepatitis. Auto-antibody profile- detect autoimmune liver disease.
Ferritin - hereditary haemochromatosis
Alpha-1-antitrypsin- to detect metabolic liver disease
-
-
Caeruloplasmin in poeple under 40, to detect metabolic liver disease.
-
-
Red Flags
Same day emergency assessment - signs of confusion/altered mental state/altered neuromuscular function e.g. poor coordination, ataxia, nystagmus,asterixis
-
-
Sepsis -fever, hypotension/tachycardia
-
-
Urgent Referral for jaundice and weight loss may indicate underlying malignancy - refer using suspected cancer pathway appt within 2 weeks
-
Management
Admission if indicating red flag, bilirubin level > 100micromol/L, abnormal clotting, abnormal renal function, suspected taken paracetamol overdose, frail or has significant co-morbidities
Refer age 40 years and over using suspected cancer pathway within 2 weeks to exclude pancreatic cancer
Refer people with cholestatic or obstructive picture on LFT to an upper GI surgeon, gastroenterologist/liver clinic
-
-
Refer with suspected inherited liver disease e.g. haemochromatosis or Wilson's disease to gastroenterologist
Manage in Primary Care - those well and have been diagnosed with Gilbert's syndrome /hepatitis A.
Gilbert's Syndrome - information on CKS.
Hepatitis A - serologically confirmed in a well person for management in primary care, if unwell admit. See CKS for more information
-
Causes
-
Intra-hepatic jaundice - Viral infection/alcohol/NAFLD/metabolic/ drugs/malignancy of biliary system
Post hepatic obstruction jaundice - Gallstones/surgical strictures/extra hepatic malignancy/pancreatitis/parasitic infeciton
Haemolytic anaemias- homozygous sickle cell disease/thalassemia major. Hereditary spherocytosis
Glucose -6-phosphate dehydrogenase deficiency
Vitamin B12 deficiency
Autoimmune disorders
Drugs - Antibiotics/anti-epileptics/ paracetamol, rifampicin/isoniazid/oral contraceptives/Corticosteroids /NSAIDS/Aspirin/Amiodarone/ non prescribed drugs/dietary supplements
Diagnosis
History
Duration, previous episodes of jaundice. Colour of urine/stools/tarry bloody stools suggest melaena
Pain to site, severity and radiation/itching
-
Alcohol intake. Travel abroad, viral hepatitis/parasites. Other risks intravenous drug use/tattoos/body piercings/blood transfusions/multiple sexual partners/sex between men or with sex workers. PMH biliary surgery/gallstones/hepatitis/autoimmune live disease, thyroid disease, NAFLD.
Co-morbidities like inflammatory bowel disease, obesity, diabetes/metabolic syndrome. Drugs/Occupation/Family history if inherited anaemias or haemoglobinopathies/ Possibility of pregnancy associated jaundice is an emergency
Examination
-
Signs of Chronic liver disease- Palmer erythema/spider naevi/ finger clubbing/leuknoychia/Dupuytren's contractures/Gynaecomastia.
Signs of liver failure - altered mental state e.g. drowsiness/confusion/disorientation/coma. Altered neurouscular function e.g. ataxia, nystagmus/asterixis. Bruising/petechiae/purpura.
Lymphadenopathy - enlarged supraclavicular lymph nodes (metastatic pancreatic/gastric cancer/wide spread lymphadenopathy with hepatosplenomegaly -lymphoma
Masses - hepatomegaly/alcoholic liver disease/viral hepatitis/malignancy/Splenomegaly (glandular fever, portal hypertension, rheumatological conditions) /palpable gallbladder due to extra-hepatic obstruction e.g. pancreatic cancer
Abdominal tenderness - RUQ below costal margin on deep inspiration indicate cholecystitis. Widespread abdominal tenderness -pancreatitis or peritonitis
Visible veins - chronic liver disease. Ascites indicate intra-abdominal malignancy/ chronic liver disease or severe heart failure.