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Case presentation & viva Questions of a jaundice patient

 

Q: What is jaundice?why upper sclera is seen in jaundice?

A: It is a clinical condition characterized by yellow discolouration of skin and mucous membrane due to excess bilirubin in the blood.

Clinically, jaundice is seen when serum bilirubin is 0.3 mg/dL. If it is ,2.5 mg/dL, called subclinical (or anicteric hepatitis).

Jaundice should be seen in natural daylight. Bilirubin has strong affinity for elastic tissue, sclera contains plenty of elastic tissue (alsoin the skin). So, it is seen in sclera.

 

Q: What are the types of jaundice?

A: Jaundice is 3 types:
1. Prehepatic –  (predominantly unconjugated hyperbilirubinaemia).
2. Hepatocellular – (both conjugated and unconjugated hyperbilirubinaemia).
3. Posthepatic or obstructive – (predominantly conjugated hyperbilirubinaemia).

 

Q: What are the causes of jaundice?

A: Causes of jaundice: Varies according to types.

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A. Causes of Prehepatic jaundice:

1. Excess production of bilirubin (due to breakdown of RBC)—It is found in haemolytic anaemia due to any cause.
2. Reduced hepatic uptake of bilirubin or impaired conjugation:
• Gilbert syndrome.
• Drugs—sulphonamides, penicillin, rifampicin.
• Crigler–Najjar syndrome Type 1 and 2.
• Physiological jaundice of newborn.

 

B. Causes of Hepatocellular jaundice:
1. Viral hepatitis due to A, B, C, D, E,
2. Drugs—Antitubercular drugs (rifampicin, pyrazinamide, INH)
3. Metabolic—Wilson’s disease, haemochromatosis.
4. Autoimmune hepatitis.
5. Inherited disorders (Dubin–Johnson syndrome, Rotor syndrome).

 

C. Causes of Posthepatic or Obstructive jaundice:
1. Extrahepatic:
• Choledocholithiasis.
• Carcinoma of head of pancreas.
• Cholangiocarcinoma.
• Periampullary carcinoma.
• Extrahepatic biliary atresia.
• Biliary stricture (due to trauma, sclerosing cholangitis).

2. Intrahepatic:
• Primary biliary cirrhosis (PBC).
• Primary sclerosing cholangitis.
• Viral hepatitis (causes transient intrahepatic cholestasis).

 

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Q: What history should be taken in jaundice patient?

A: History to be taken in a jaundice patient:
Anorexia, nausea and vomiting (indicates viral or drug induced hepatitis).
• Colour of the stool (yellowish, pale, dark), itching indicates obstructive jaundice.
Family history of jaundice, consanguinity of marriage among parents, associated with pallor
(indicates hereditary haemolytic anaemia, in prehepatic jaundice).
• History of contact with jaundiced patient or sexual exposure.
History of injection, infusion or blood transfusion, I/V drug abuse, tattooing or surgery
(HBV or HCV).
History of travelling abroad (hepatitis B).
• History of possible contaminated food, water, milk, other items.
• History of alcohol or any drugs.
Associated history of high fever, urinary complain (indicates leptospirosis).
Recurrent jaundice associated with any neurological abnormality (indicates Wilson’s
disease).
• Associated abdominal pain and fluctuating jaundice (indicates bile duct stricture or stone).

 

Q. What is the features of obstructive jaundice?

A: Below common

Pale, dark or clay coloured stool.
Itching of whole body.

Q. What investigations you would order in jaundice patient?

A: Investigations in jaundice:
1. Liver function tests such as serum bilirubin, SGPT, SGOT, alkaline phosphatase, prothrombin time.
2. USG of hepatobiliary system.
3. Viral markers:
• For A—anti-HAV IgM.
• For E—anti-HEV IgM.
• For B—HBsAg, HBeAg, anti-HBc.
• For C—anti-HCV.
4. Other investigation should be done according to the suspicion of cause. Such as:
• For haemolytic anaemia—Hb electrophoresis
• In obstructive jaundice—ERCP, MRCP.
• CT scan of whole abdomen.

 

Q: What is the Cause of painless progressive jaundice with palpable gallbladder:

A: Carcinoma of head of the pancreas.

 

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Q: Causes of jaundice with itching:

A:
• Obstructive jaundice
• Primary biliary cirrhosis.

 

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