CASE STUDY #1:  JAUNDICE IN AN ADULT FEMALE

Cesar Mora Jaramillo MD, FAAFP, FCUCM

HISTORY: The patient is a 55-year-old female with past medical history of GERD and HTN, who presents to Urgent Care with 3 days of generalized pruritus without rash. She mentioned that her urine was dark for the past 1 week but denies any other urinary symptoms. In addition, the patient reports epigastric pain with radiation to the back for one week which resolved without intervention one day before her UC visit.  She only takes omeprazole and lisinopril but has been taking acetaminophen 1-gram TID PRN for pain over the past week. She denies taking any herbal medicines, alcohol consumption, or recent travel.

REVIEW OF SYSTEMS: no nausea, vomiting, diarrhea, constipation, fatigue, fevers, chills, headaches, chest pain, shortness of breath.

PHYSICAL EXAM

On physical exam vital signs are normal. No acute distress. No lymphadenopathy. Cardiovascular and respiratory exam were normal. Abdominal exam: no guarding, mild epigastric tenderness, no rebound, no hepatomegaly or splenomegaly. Skin: diffuse jaundice. Sclera icteric.

Urine dip: showed bilirubin large +++, normal urobilinogen, hemolyzed trace occult blood, negative leukocyte esterase and nitrates.

DIFFERENTIAL DIAGNOSIS

  • Cholecystitis
  • Choledocholithiasis
  • Viral hepatitis
  • Nonalcoholic steatohepatitis
  • Primary biliary cholangitis
  • Drugs and toxins
  • Ischemic hepatopathy

DISCUSSION

Evaluation of adult patients with jaundice should consist of detailed history, physical examination, and laboratory studies. The results will assist clinicians to formulate a differential diagnosis and to guide the value of additional testing to narrow the diagnostic possibilities.

Furthermore, the evaluation of jaundice in adults is usually not urgent, but providers should recognize conditions that need immediate care. Hence, clinicians should familiarize themselves with these conditions.

Specific findings can be present during physical examination including Courvoisier sign (a palpable gallbladder, caused by obstruction distal to the takeoff of the cystic duct by malignancy) or signs of chronic liver failure/portal hypertension such as ascites, splenomegaly, spider angiomata, and gynecomastia; hyperpigmentation in hemochromatosis, Kayser-Fleischer rings in Wilson disease, and xanthomas in primary biliary cholangitis.

Initial laboratory evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, γ-glutamyltransferase, alkaline phosphatase, prothrombin time and/or international normalized ratio, albumin, and protein. The presence or absence of abnormalities should assist clinicians distinguishing causes of jaundice.  If the jaundice etiology is unknown after the initial laboratory evaluation, it is necessary to perform additional tests including hepatitis panels and autoimmune panels.

If there is evidence of biliary obstruction or intrahepatic cholestasis, then imaging should be obtained (e.g., ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography). If imaging is negative, the evaluation typically will also include obtaining an antimitochondrial antibody to evaluate for primary biliary cholangitis. 

REFERENCES 

  1. https://www.uptodate.com/contents/diagnostic-approach-to-the-adult-with-jaundice-or-asymptomatic-hyperbilirubinemia?search=adult%20jaundice&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

  2. https://www.aafp.org/afp/2017/0201/p164.html#:~:text=Jaundice%20in%20adults%20can%20be,the%20history%20and%20physical%20examination.