Diagnosis of jaundice

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

An important role belongs to the epidemic anamnesis, which suggests a correct diagnosis already at the stage of the patient's interview. Find out its age, nature of work and occupational hazards. For a number of infectious diseases that occur with jaundice, travel to endemic regions, to rural areas, contacts with wild and domestic animals, soil, bathing in the water, hunting or fishing, etc. Are important. Be sure to find out the presence, nature and sequence of the appearance of concomitant clinical symptoms.

Practical value has differential diagnosis of jaundice - superhepatic, hepatic and podepochenochnoy. A slight jaundice without changing the color of urine and disturbing the patient's state of health rather indicates an indirect hyperbilirubinemia. Associated with hemolysis or Gilbert's syndrome, than on the development of hepatic jaundice. Confirm the presence of hemolysis helps detect an increased level of indirect bilirubin in the blood serum, the absence of bilirubinuria, a decrease in the osmotic resistance of red blood cells, reticulocytosis, a decrease in iron in erythrocytes and other signs of anemia. Gilbert's syndrome can be easily distinguished from hepatitis by normal activity of transaminases and other functional hepatic tests. The level of bilirubin exceeding 400-500 μmol / l is usually associated with impaired renal function or hemolysis on the background of severe liver damage.

Bright jaundice or dark color of urine indicates a lesion of the liver (bile ducts) with the development of hepatic or subhepatic jaundice. According to the biochemical blood test, these states can not 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 their delimitation. Jaundice in acute viral hepatitis is the most vivid and basic symptom of the disease, which appears after the symptoms of the pre-jaundiced period. Detection of increased activity of transaminases (exceeding normal values by 20 times and more), markers of the acute phase of viral hepatitis often allows to confirm the diagnosis of acute viral hepatitis. With other diseases. Flowing with jaundice, ALT activity, ACT does not change or increases no more than 2-4 times. A significant increase in the activity of alkaline phosphatase indicates a cholestatic or infiltrative lesion of the liver. Jaundice in combination with ascites, other symptoms of portal hypertension, cutaneous and endocrine disorders, low albumin levels and high serum globulin levels usually indicates a chronic process in the liver (chronic hepatitis, cirrhosis of the liver).

It should be assumed that the patient can develop a systemic disease, rather than a primary lesion of the liver. For example, the expansion of jugular veins is an important sign of heart failure or constrictive pericarditis in a patient with jaundice, hepatomegaly or ascites. Cachexia and a significantly enlarged, painful, unusually hard or lumpy liver often indicate metastases, primary liver cancer. Generalized lymphadenopathy and the rapid development of jaundice in an adolescent or a young patient testify to infectious mononucleosis, lymphoma, or chronic leukemia. Hepatosplenomegaly without other signs of a chronic disease can be caused by infiltrative liver damage with lymphoma, amyloidosis, sarcoidosis, although jaundice is minimal or absent under such conditions. The acute onset of the disease with nausea and vomiting, abdominal pain, stiffness of the muscles of the abdominal wall (especially in mature or elderly people), the appearance of jaundice in a short time after the onset of the disease may indicate a lump of its origin (for example, obturation of the common bile duct with a stone). Biochemical and general blood analysis, blood tests for markers of HAV pathogens, HBV, HCV, HDV, HEV and data of instrumental methods of investigation help to clarify the diagnosis.

All patients with jaundice have a general blood and urine test, a biochemical blood test with determination of prothrombin activity, cholesterol level, total protein and protein fractions, aminotransferase activity, GGT, alkaline phosphatase, blood test for HAV, HBV, HCV, HDV, HEV markers . After receiving the results of the initial study with an unclear diagnosis, an ultrasound scan or CT of the abdominal cavity organs should be performed. If the scans show enlarged bile ducts, especially in patients with progressive cholestasis, mechanical obstruction of the ducts can be assumed; additional information can be obtained by direct cholangiography or endoscopic retrograde cholangiopancreatography. If there is no enlargement of the biliary tract with ultrasound, intrahepatic pathology is more likely and liver biopsy should be considered. It is crucial (along with a study of the spectrum of autoantibodies) in the diagnosis of chronic cholestatic liver diseases. If it is not possible to perform an ultrasound or CT scan, patients with an increase in the cholestasis and suspicion of mechanical obstruction of the bile ducts are diagnosed with a diagnostic laparoscopy.

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