Jaundice - Diagnosis

A carefully collected anamnesis, clinical and laboratory examination, and biochemical and clinical blood tests are of great importance in establishing a diagnosis of jaundice. A stool test is necessary, which should include an analysis for occult blood. When examining urine, an increase in bilirubin and urobilinogen should be excluded. Additional research methods - ultrasound examination (US), liver biopsy, and cholangiography (endoscopic or percutaneous) - are used according to indications depending on the type of jaundice.

Initial stages of diagnostics for jaundice

• History and physical examination
• Urine and stool analysis
• Serum biochemical parameters
• Bilirubin, AST, ALP, GGTP, Albumin
• Quantitative determination of immunoglobulins
• General clinical blood parameters
• Hemoglobin level, white blood cell count, platelet count
• Blood smear
• Prothrombin time (before and after intramuscular administration of vitamin K)
• Chest X-ray

Anamnesis

The patient's profession is determined; it is especially important to establish whether the patient's work involves contact with rats, which are carriers of leptospirosis (Weil's disease), or with alcohol consumption.

The nationality of the patient is important. For example, people from Mediterranean countries, Africa or the Far East may be suspected of being carriers of HBV and HCV.

When studying the family history, jaundice, hepatitis, anemia, as well as splenectomy and cholecystectomy in close relatives are taken into account. An aggravated family history facilitates the diagnosis of hemolytic jaundice, hereditary hyperbilirubinemia, hepatitis and cholelithiasis.

They find out whether there have been contacts with jaundice patients, especially in nurseries, camps, hospitals and schools, with patients in hemodialysis departments and drug addicts. Diagnostic value may be given to indications of injections during the last 6 months, for example, blood or plasma transfusions, blood sampling, drug administration, tuberculin test, tattoos, and dental interventions. Also important are indications of eating crustaceans, as well as travel to regions endemic for hepatitis. They find out whether the patient is taking medications that can cause jaundice.

A history of dyspepsia, biliary colic and fat intolerance suggests choledocholithiasis.

The development of jaundice after operations on the bile ducts is possible with stones left behind, traumatic stricture of the bile duct, and also with hepatitis. The cause of jaundice after the removal of malignant neoplasms may be metastases to the liver.

Jaundice in alcoholism is usually accompanied by symptoms such as anorexia, morning sickness, diarrhea, and a slight increase in body temperature. Pain in the enlarged liver is also possible.

A steady deterioration in general condition and a decrease in body weight are characteristic of a malignant tumor.

The nature of the onset of the disease is extremely important. The onset with nausea, anorexia, aversion to cigarettes (in smokers), as well as the development of jaundice within a few hours and its rapid progression, make one suspect viral hepatitis or drug-induced jaundice. Cholestatic jaundice develops more slowly, often accompanied by persistent itching. Fever with chills is characteristic of cholangitis associated with stones or stricture of the bile ducts.

A few days before the development of hepatocellular or cholestatic jaundice, urine darkens and feces become light. With hemolytic jaundice, the color of feces does not change.

In hepatocellular jaundice, the general condition of the patient suffers significantly; in cholestatic jaundice, the only complaint may be itching or jaundice, and the symptoms are due to the underlying disease that caused the obstruction.

Mild persistent jaundice of varying intensity suggests hemolysis. In cirrhosis, jaundice is usually moderate, varies in intensity, and is not accompanied by a change in stool color, but with the addition of acute alcoholic hepatitis, jaundice can be intense with discoloration of the stool.

Pain in biliary colic can last for several hours, less often it is intermittent. Pain in the back or in the epigastric region can be caused by pancreatic cancer.

Survey

Age and gender. Gallstones are more common in obese middle-aged women who have given birth. The prevalence of viral hepatitis A decreases with age, but this pattern is not observed with viral hepatitis B and C. The likelihood of bile duct obstruction by a malignant tumor increases with age. Drug-induced jaundice in children is very rare.

Examination. Anemia may indicate hemolysis, tumor, or cirrhosis. If there is a significant decrease in body weight, a tumor should be suspected. In hemolytic jaundice, the skin is pale yellow, in hepatocellular jaundice - with an orange tint, and in long-term biliary obstruction it becomes green. In pancreatic cancer, patients often stoop. In patients with alcoholism, stigmas of liver cirrhosis may be observed. Particular attention is paid to the organs in which the source of liver metastases may be localized (mammary glands, thyroid gland, stomach, colon and rectum, lungs), as well as to the state of regional lymph nodes.

Mental status. A slight decrease in intelligence with minimal personality changes suggests hepatocellular jaundice. The appearance of a liver odor and "flapping" tremor indicates the possibility of developing hepatic coma.

Skin changes: Bruising may indicate a clotting disorder. Thrombocytopenia that occurs with cirrhosis may manifest as purpura on the forearms, axillae, or shins. Other skin changes in cirrhosis include spider veins, palmar erythema, white nails, and hair loss in areas of secondary hair growth.

In chronic cholestasis, traces of scratching, pigmentation caused by excessive melanin deposition, clubbing of the fingers, xanthomas on the eyelids (xanthelasma), extensor surfaces and in the folds of the palms, and hyperkeratosis can be detected.

Pigmentation and ulcers on the shins appear in some forms of congenital hemolytic anemia.

Skin nodules should be carefully considered as they may be malignant. In the case of multiple venous thromboses, pancreatic body cancer is ruled out. Swollen ankles may indicate cirrhosis, as well as obstruction of the inferior vena cava by a liver or pancreatic tumor.

Abdominal examination. Dilation of the umbilical veins is a sign of increased collateral circulation in the portal vein system (usually due to cirrhosis). Ascites may develop as a result of cirrhosis of the liver or a malignant tumor. With a significantly enlarged, lumpy liver, there is a high probability of cancer of this organ. A small liver indicates severe hepatitis or cirrhosis and allows us to exclude extrahepatic cholestasis, in which the liver is enlarged and has a smooth surface. In patients with alcoholism, fatty liver and cirrhosis can cause its uniform enlargement. The edge of the liver can be painful in hepatitis, congestive heart failure, alcoholism, bacterial cholangitis, and sometimes in tumors. Arterial bruit over the liver indicates acute alcoholic hepatitis or primary liver cancer.

In choledocholithiasis, gallbladder pain and Murphy's sign are possible. A palpable enlarged gallbladder, sometimes visible in the right hypochondrium, requires the exclusion of pancreatic cancer.

The abdominal cavity should be carefully examined to exclude a primary tumor. A rectal examination is mandatory.

Urine and feces. Bilirubinuria is an early sign of viral hepatitis and drug-induced jaundice. The absence of urobilinogen in the urine suggests complete obstruction of the common bile duct. Long-term urobilinogenuria, in which bilirubin is absent from the urine, indicates hemolytic jaundice.

Acholic stools that persist for a long time confirm the diagnosis of biliary obstruction. A positive occult blood test excludes cancer of the hepatopancreatic ampulla, pancreas, intestines, and portal hypertension.

Serum biochemical parameters

An increase in the serum bilirubin level confirms the presence of jaundice, allows us to judge its intensity and monitor its dynamics. If the activity of alkaline phosphatase is more than 3 times higher than normal, the activity of GGT is increased and there are no signs of bone damage, the probability of cholestasis is very high; high activity of alkaline phosphatase is also observed in non-biliary cirrhosis.

Serum albumin and globulin levels change slightly in short-term jaundice. In longer-term hepatocellular jaundice, albumin levels decrease and globulins increase. Electrophoresis reveals an increase in a ₂ - and b-globulins in cholestatic jaundice and g-globulins in hepatocellular jaundice.

In hepatitis, the activity of serum transaminases increases to a greater extent than in cholestatic jaundice. A significant transient increase in transaminase activity is sometimes observed in acute obstruction of the bile ducts by a stone.

Clinical blood test

Hepatocellular jaundice is characterized by a decrease in the number of leukocytes with relative lymphocytosis. In alcoholic and severe viral hepatitis, polymorphonuclear leukocytosis is possible. The number of leukocytes increases in acute cholangitis and tumors. If hemolysis is suspected, the number of reticulocytes is counted, a blood smear is examined, the osmotic resistance of erythrocytes is determined, the Coombs test is performed, and the bone marrow is examined.

When prothrombin time increases, a test with vitamin K is performed: its intramuscular administration at 10 mg for 3 days leads to normalization of prothrombin time in cholestasis, while in hepatic cell jaundice no significant changes occur.

Routine diagnostic tests

Clinical examination of patients with jaundice allows us to classify them into one of the following groups: patients with hepatocellular jaundice; patients whose jaundice is caused by a malignant tumor; patients in whom extrahepatic biliary obstruction cannot be ruled out; patients in whom the probability of extrahepatic biliary obstruction is high. Further examination depends on the group to which the patient is assigned, as well as on the equipment of the medical institution, the degree of risk of the diagnostic procedure and its cost.

A small number of patients with extrahepatic biliary obstruction are misdiagnosed with intrahepatic cholestasis; more commonly, patients with intrahepatic disease are misdiagnosed with extrahepatic biliary obstruction.

Computer diagnostic models were developed based on the anamnesis, examination, clinical and biochemical blood tests obtained during the first 6 hours after hospitalization. In terms of efficiency, they are not inferior to diagnostics performed by a hepatologist and are superior to diagnostics performed by a general practitioner. The frequency of establishing correct diagnoses based on the computer algorithm was 70%, which coincides with the results of examination by an experienced hepatologist, but the latter required less information.

X-ray examination

A chest X-ray is performed to detect tumors and their metastases, as well as irregularities in the contour of the right dome and a high diaphragm caused by an enlarged liver or the presence of nodes in it.

Visualization of the bile ducts

The indication for the use of bile duct visualization methods is cholestasis. First of all, hepatocellular jaundice is differentiated from obstructive jaundice, caused by blockage of the common bile duct and requiring surgical treatment. The method of choice is ultrasound (US) or computed tomography (CT), which allows us to determine whether the intrahepatic bile ducts are dilated. Then, according to indications, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography is performed.

Viral hepatitis markers

Serological testing can detect markers of HAV and HBV, as well as CMV and EBV. Anti-HCV can only be detected 2-4 months after infection.

Liver biopsy

In acute jaundice, liver biopsy is rarely necessary; it is performed mainly in patients with an unclear diagnosis and suspected intrahepatic genesis of jaundice. The presence of jaundice increases the risk of biopsy. Menghini needle biopsy is considered the safest. Severe jaundice is not a contraindication to liver biopsy.

In cases of blood clotting disorders, performing a conventional percutaneous biopsy is dangerous; in such cases, they resort to transjugular biopsy or biopsy under CT or ultrasound control with sealing of the puncture channel.

Diagnosis of acute viral hepatitis is usually straightforward. The most difficult diagnosis is jaundice in cholestasis. However, in most cases, an experienced histologist can distinguish the picture of intrahepatic cholestasis, for example, in drug-induced damage or primary biliary cirrhosis, from changes caused by obstruction of the common bile duct. However, the cause of cholestasis itself can be established only with much less certainty.

Laparoscopy

The dark green color of the liver and the enlarged gallbladder indicate extrahepatic biliary obstruction. Laparoscopy also allows the detection of tumor nodes and their biopsy under visual control. In hepatitis, the liver is yellow-green; cirrhotic liver has a characteristic appearance. Laparoscopy does not allow differentiation between extrahepatic biliary obstruction, especially due to cancer of the large bile ducts, and intrahepatic cholestasis caused by drugs.

During the examination, it is necessary to obtain images of the liver. In case of jaundice, peritoneoscopy is safer than a puncture liver biopsy, but if necessary, these two methods can be combined.

Prednisolone test

In hepatocellular jaundice, prescribing 30 mg of prednisolone per day for 5 days leads to a 40% decrease in bilirubin levels. This test is effective in diagnosing the cholestatic variant of hepatitis A (the diagnosis is established in the absence of HBV markers in the serum).

The "whitening" effect of corticosteroids cannot be explained by changes in the lifespan of red blood cells (reflecting changes in hemoglobin catabolism) or by the excretion of urobilinogen in feces and urine or bilirubin in urine. It is possible that bilirubin metabolism occurs via a different metabolic pathway.

Laparotomy

Jaundice rarely requires emergency surgery. If the diagnosis is in doubt, it is advisable to continue the examination, since diagnostic laparotomy is associated with a high risk of developing acute liver or kidney failure. Delay in surgery rarely causes harm to the patient.

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