Would you like to ask this patient a few questions and perform a relevant examination?


Proceed as follows:

Ask the patient about the following:

· His or her age (hepatitis is more common in the young and carcinoma in the elderly).

· Sore throat and rash (infectious mononucleosis).

· Occupation (Well's disease in sewerage and farm workers).

· Contact with jaundice (hepatitis A).

· Drug history (oral contraceptives, phenothiazines).

· Blood transfusions, injections, arthritis, urticaria (hepatitis B).

· Alcohol consumption.

· Pruritus (cholestasis due to hepatitis A, primary biliary cirrhosis).

· Colour of the uriue.

· Colour of the stools (pale stools in obstructive jaundice).

· Abdominal pain (cholecystitis, gallstones, cholangitis, carcinoma of the pancreas).

· Past history (recurrent.jaundice, as in Dubin-Johnson syndrome).

· Fever, rigors and abdominal pain (suggests cholangitis).


· Examine the following:

- Hands (clubbing, palmar erythema, Dupuytren's contracture).

Sclera (to confirm the icterus).

-Conjunctiva (for pallor).

- Neck (lymph nodes).

Upper chest (spider naevi, loss of axillary hair and gynaecomastia).

Abdomen (hepatomegaly, splenomegaly, Murphy's sign, palpable gallbladder, ascites).

Legs (for pitting oedema).

· Tell the examiner that you would like to investigate as follows:

-Examine the urine.

- Perform a per rectum examination.

Remember. The most important question to answer in the evaluation of any jaundiced patient is 'Will this patient require surgery to

relieve biliary obstruction'?'


This patient is markedly icteric and has spider naevi and gynaecomastia (lesions) due to alcoholic liver disease (aetiology).


What do you understand by the term 'jaundice'?

It is the yellowish discoloration of skin, sclera and mucous membrane due to the accumulation of bile pigments. It is usually clinically

manifest when the serum bilirubin concentration is at least 7-8 mg/dl.

How would you differentiate jaundice from carotenaemia?

The discoloration of carotenaemia is differentiated from jaundice by the absence of yellow colour in the sclera and mucous

membranes, normal urine colour and the presence of yellow-brown pigmentation of carotenoid pigment in the palms, soles and

nasolabial folds.

What is Murphy's sign and what does it indicate?

It is the tenderness elicited on palpation at the midpoint of the right subcostal margin on inspiration. It is a sign of cholecystitis.

Have you heard of Courvoisier's law?

It states that in a patient with obstructive jaundice a palpable gallbladder is unlikely to be due to chronic cholecystitis.

What is Charcot's fever?

Intermittent fever associated with jaundice and abdominal discomfort in a patient with cholangitis and biliary obstruction.

How would you investigate this patient?

· Urine for bile pigments. · FBC.

· Serum haptoglobulin, reticulocyte count and Coombs' test (if you suspect haemolysis).

· Liver function tests (serum albumin, bilirubin, enzymes).

· Prothrombin time.

· Viral studies (hepatitis antigen and antibodies, Epstein-Burr virus antibodies).

· Ultrasonography of the abdomen (if you suspect cholestatic jaundice).

· Special investigations: mitochondrial antibodies, endoscopic retrograde cholangiopancreatography (ERCP), CT of the

abdomen, liver biopsy.


What do you know about Dubin-Johnson syndrome?

It is a rare benign condition characterized by jaundice and pigmentation secondary to a failure of excretion of conjugated bilirubin.

The liver is stained by melanin in the centrilobular zone. The bromsulphthalein test shows a late secondary rise at 90 minutes.

Mention a few causes of postoperative jaundice.

Causes of postoperative jaundice (usually occurring in the first 3 postoperative weeks) include:

· Resorption of haematomas, haemoperitoneum, haemolysis of transfused erythrocytes (particularly when stored blood products are

used), haemolysis due to glucose-6-phosphate dehydrogenase deficiency.

· Impaired hepatocellular function due to halogenated anaesthetics, sepsis, hepatic ischaemia secondary to perioperative


· Extrahepatic biliary obstruction due to biliary stones, unsuspected injury to biliary tree.

How does estimation of serum hilirubin concentration help in discerning the aetiology of jaundice?

Normal serum bilirubin concentration is no greater than 1.5 mg/dl and consists predominantly of the unconjugated form. When

jaundice is primarily due to haemo-lysis or a disorder of bilirubin conjugation, the unconjugated form constitutes at least 85% of the

total. With normal liver function, haemolysis alone does not produce a serum bilirubin level greater than 4 mg/dl. A rise in serum

bilirubin levels

of up to 2 mg/dl per day is compatible with extrahepatic cholestasis, but a greater rate indicates haemolysis, hepatitis or hepatic cell necrosis. The

serum bilirubin level of patients with pure biliary obstruction seldom exceeds 30 mg/dl; a greater value indicates that there is associated hepatocellular

jaundice as well.

A. Gilbert (1858-1927), Professor of Medicine at I'H6tel Dieu in Paris.

P.S.A. Weil (1848-1916), Professor of Medicine in Tartu, Estonia and Berlin.

J.B. Murphy (1857-1916), Professor of Surgery at Northwestern University in Chicago.

J. Courvoisier (1843-1918), Professor of Surgery, Basel, Switzerland.

I.N. Dubin, Professor of Pathology, Pennsylvania, and EB. Johnson, pathologist, Veterans Administration Hospital, Washington.