Diagnosis of jaundice

Jaundice is an isolated symptom that is considered only in combination with the patient's complaints, other examination and survey data. Jaundice is most easily detected by examining the sclera in natural light. It usually occurs when the bilirubin concentration in the blood serum is 40-60 μmol/l (exceeding normal values by 2-3 times). The level of bilirubinemia does not indicate the severity of the liver disease, but the degree of jaundice.

An important role is played by the epidemiological anamnesis, which allows one to assume the correct diagnosis already at the stage of questioning the patient. The patient's age, type of work and occupational hazards are determined. For a number of infectious diseases occurring with jaundice syndrome, trips to regions endemic for these diseases, to rural areas, contacts with wild and domestic animals, soil, swimming in water bodies, hunting or fishing, etc. are important. The presence, nature and sequence of appearance of concomitant clinical symptoms are necessarily determined.

Differential diagnostics of jaundice - suprahepatic, hepatic and subhepatic - is of practical importance. Mild jaundice without changes in urine color and deterioration of the patient's well-being is more likely to indicate indirect hyperbilirubinemia associated with hemolysis or Gilbert's syndrome than the development of hepatic jaundice. The presence of hemolysis can be confirmed by detecting an increased level of indirect bilirubin in the blood serum, the absence of bilirubinuria, a decrease in the osmotic resistance of erythrocytes, reticulocytosis, a decrease in the iron content in erythrocytes and other signs of anemia. Gilbert's syndrome can be easily distinguished from hepatitis by normal transaminase activity and other functional liver tests. A bilirubin level exceeding 400-500 μmol/l is usually associated with impaired renal function or hemolysis against the background of severe liver damage.

Bright jaundice or dark urine indicate liver (bile duct) damage with the development of hepatic or subhepatic jaundice. According to the biochemical blood test, these conditions cannot be distinguished from each other, since in both cases jaundice will be caused by an increase in the concentration of direct bilirubin. Anamnestic data are of great importance in distinguishing them. Jaundice in acute viral hepatitis is the most striking and main symptom of the disease, appearing after the symptoms of the pre-icteric period. Detection of increased transaminase activity (exceeding normal values by 20 times or more), markers of the acute phase of viral hepatitis, often allows confirming the diagnosis of acute viral hepatitis. In other diseases occurring with jaundice syndrome, the activity of ALT, AST does not change or increases by no more than 2-4 times. A significant increase in alkaline phosphatase activity indicates cholestatic or infiltrative liver damage. Jaundice in combination with ascites, other symptoms of portal hypertension, skin and endocrine disorders, low albumin levels and high serum globulin levels usually indicate a chronic process in the liver (chronic hepatitis, liver cirrhosis).

The possibility of a systemic disease rather than a primary liver lesion should be considered. For example, jugular venous distension is an important sign of heart failure or constrictive pericarditis in a patient with jaundice, hepatomegaly, or ascites. Cachexia and a markedly enlarged, tender, unusually hard, or nodular liver often indicate metastases or primary liver cancer. Generalized lymphadenopathy and rapid development of jaundice in an adolescent or young patient suggest infectious mononucleosis, lymphoma, or chronic leukemia. Hepatosplenomegaly without other signs of chronic disease may be due to infiltrative liver disease due to lymphoma, amyloidosis, or sarcoidosis, although jaundice in such conditions is minimal or absent. Acute onset of the disease with nausea and vomiting, abdominal pain, rigidity of the abdominal wall muscles (especially in mature or elderly individuals), the appearance of jaundice shortly after the onset of the disease may indicate its subhepatic origin (for example, obstruction of the common bile duct by a stone). Biochemical and general blood tests, blood tests for markers of the pathogens HAV, HBV, HCV, HDV, HEV and data from instrumental research methods help to clarify the diagnosis.

All patients with jaundice syndrome undergo a complete blood count and urine analysis, a biochemical blood test to determine prothrombin activity, cholesterol levels, total protein and protein fractions, aminotransferase activity, GGT, alkaline phosphatase, and a blood test for HAV, HBV, HCV, HDV, and HEV markers. After receiving the results of the initial study, if the diagnosis is unclear, an ultrasound or CT scan of the abdominal organs should be performed. If dilated bile ducts are visible on scanograms, especially in patients with progressive cholestasis, mechanical obstruction of the ducts can be assumed; additional information can be obtained using direct cholangiography or endoscopic retrograde cholangiopancreatography. If ultrasound does not reveal dilated bile ducts, then intrahepatic pathology is more likely and a liver biopsy should be considered. It is of crucial importance (along with the study of the spectrum of autoantibodies) in the diagnosis of chronic cholestatic liver diseases. If it is impossible to perform ultrasound or CT, patients with increasing cholestasis symptoms and suspected mechanical obstruction of the bile ducts undergo diagnostic laparoscopy.

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