63-Year-Old Female with Jaundice (Case 18)

Chapter 29 63-Year-Old Female with Jaundice (Case 18)



J. David Schmidt, MD, James R. Oullette, DO, Giancarlo Mercogliano, MD, MBA




Differential Diagnosis




















Hepatocellular Causes Extrahepatic/Obstructive Causes
Viral hepatitis Choledocholithiasis
Alcoholic hepatitis Cholangitis
Drug-induced hepatitis Benign stricture
End-stage liver disease Periampullary cancer*

* Includes pancreatic cancer, cholangiocarcinoma, ampullary carcinoma, and duodenal carcinoma.




Speaking Intelligently


When I am asked to see a 63-year-old patient who presents with jaundice, I am concerned about malignancy. Associated symptoms are helpful in differentiating between hepatocellular causes and obstructive causes. These two categories serve as a useful framework to think about conjugated (direct) hyperbilirubinemia. The tx for most hepatocellular causes is supportive, while obstructive causes are managed by intervention (either surgical or endoscopic).


I use hx taking to develop a diagnostic hypothesis and I use LFTs to corroborate it. Ultrasonography is helpful: intrahepatic bile duct dilatation will further corroborate an obstructive etiology, and other ultrasound findings will often reveal its underlying cause.



PATIENT CARE



Clinical Thinking



• Use the framework suggested above to focus hx taking.

• Use LFTs to corroborate your hypothesis, which should be based on hx taking.

• Pattern recognition for LFTs is considered below.


History



• Elicit a hx of associated pain (or lack of pain).

• In an elderly patient presenting with painless jaundice, think malignancy: look for weight loss and poor appetite.

• If the jaundiced patient has abdominal pain, the specifics of the pain are important: intermittent RUQ pain followed by a severe, more constant pain could represent choledocholithiasis with a stone impacted in the distal CBD. Vague RUQ pain may be the result of distention of the liver capsule associated with hepatitis; chronic epigastric/RUQ pain that is boring in nature may be related to pancreatic cancer as it invades adjacent tissue.

• Past medical hx is essential: known hx of gallstones (now presenting as choledocholithiasis); previous colon cancer (now presenting with liver metastasis); or chronic pancreatitis (now presenting with stricture at the distal CBD).


Physical Examination



• Jaundice is visible as a yellow color in the skin, under the tongue, or in the sclera of the eyes. This occurs when the bilirubin level rises above 3.5 mg/dL.

• Fever: may indicate cholangitis.

• Encephalopathy or asterixis (flapping of hands with arms fully extended) point to hepatocellular/liver disease.

• Look for signs of chronic liver disease such as spider telangectasias, palmar erythema, and caput medusa.

• Abdominal examination should be thorough: assess for hepatic size and splenomegaly; look for bulging flanks seen in ascites (advanced malignancy or cirrhosis). Listen for bowel sounds. Palpate for tenderness in RUQ (cholangitis, choledocholithiasis, acute hepatitis).


Intepretation of Liver Function Tests


In general, AST and ALT are liver enzymes that can be elevated in hepatic inflammation. Prothrombin time and albumin (prothrombin and albumin are synthesized in the liver) are the true markers of liver function.


A “hepatocellular pattern” is a scenario in which the transaminases are elevated more than the bilirubin and alkaline phosphatase. This pattern is seen commonly in intrinsic liver disease such as viral hepatitis.


A “cholestatic pattern” is one in which the bilirubin and alkaline phosphatase are elevated to a greater degree than the transaminases (ALT/AST). A typical example of this pattern would be choledocholithiasis.


An AST : ALT ratio of 2 : 1 is indicative of alcoholic liver disease. See Table 29-1 for laboratory data typical for certain disorders.



Table 29-1 Typical Laboratory Numbers*

image


Tests for Consideration












• CBC: Leukocytosis is nonspecific, but marked elevation may suggest cholangitis; low platelets may indicate underlying cirrhosis.
 $30

• LFTs: See Table 29-1 and comment.
 $56



IMAGING CONSIDERATIONS





















→ Abdominal ultrasonography: The best test for looking at gallstones and biliary dilation. Detects bile duct dilation with 95% accuracy
 $330

→ CT: Allows examination of the entire abdomen; key for assessing head of pancreas. Perform with oral and IV contrast.
 $520

→ MRCP: MRI scan noninvasively shows excellent anatomic view of bile and pancreatic ducts.
 $610

→ ERCP: Invasive test performed with a combination of endoscopy and fluoroscopy to directly examine ampulla of Vater and bile ducts. Allows intervention on biliary tree or pancreatic duct if necessary.
 $5,600

→ Hepato-iminodiacetic acid (HIDA) scan: Nuclear medicine examination showing hepatic uptake and biliary excretion; when gallbladder is visualized, the cystic duct is not obstructed.
 $625























Clinical Entities Medical Knowledge
Choledocholithiasis
PΦ Choledocholithiasis refers to the presence of gallstones in the CBD. These stones typically originate in the gallbladder and traverse the cystic duct to enter the common bile duct. Occasionally stones may form primarily in the bile ducts, but this is difficult to prove unless the gallbladder has been removed more than 1 to 2 years previously. CBD stones found less than 2 years from cholecystectomy are assumed to be “retained” stones. Stones may bounce around the ducts, pass through the ampulla of Vater, or become lodged, causing obstruction.
TP The typical patient presents with RUQ abdominal pain associated with episodic jaundice. Intermittent obstruction may occur several times before medical attention is sought.
Dx Dx begins with the observation of jaundice followed by LFTs, which will demonstrate an obstructive pattern, and ultrasonography, which will often demonstrate dilatation of the intrahepatic ducts. Stones are frequently identified in the gallbladder, but are often not visualized in the CBD.
Tx Tx of CBD stones depends on local expertise. Most patients will need laparoscopic cholecystectomy in the near future. If cholecystectomy with laparoscopic CBD exploration can be performed with good results, this may be the tx of choice as it requires only a single procedure. In most centers, however, the practice is to perform a laparoscopic cholecystectomy with either a pre or postoperative ERCP for clearance of the CBD by endoscopic sphincterotomy with stone extraction. See Sabiston 54, Becker 17.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on 63-Year-Old Female with Jaundice (Case 18)

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