Jaundice: diagnosis

Of great importance in the diagnosis of jaundice are carefully collected history, clinical and laboratory examination and biochemical and clinical blood analysis. It is necessary to study feces, which should include a test for latent blood. In the study of urine, an increase in the content of bilirubin and urobilinogen should be avoided. Additional methods of research - ultrasound (ultrasound), liver biopsy and cholangiography (endoscopic or transcutaneous) - are used according to the indications depending on the type of jaundice.

Initial stages of diagnosis in jaundice

• Anamnesis and physical examination
• Analysis of urine, feces
• Biochemical parameters of serum
• Bilirubin, AsAt, FA, GGTP, Albumin
• Quantitative determination of immunoglobulins
• General clinical signs of blood
• The level of hemoglobin, the number of leukocytes, platelets
• Blood smear
• Prothrombin time (before and after intramuscular injection of vitamin K)
• Chest X-ray

Anamnesis

Clarify the profession of the patient; it is especially important to establish whether the patient's work is related to contact with rats that carry leptospira (Weil's disease), as well as with alcohol consumption.

The nationality of the patient is of great importance . For example, people from countries of the Mediterranean, Africa or the Far East can be suspected of carrying HBV and HCV.

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

Find out if there were any contacts with icteric patients, especially in day care centers, camps, hospitals and schools, with patients with hemodialysis departments and drug addicts. Diagnostic value may have indications for injections during the last 6 months, for example blood or plasma transfusion, taking blood for analysis, injecting drugs, setting tuberculin test, tattooing, and dental interventions. Indications are also needed for eating crustaceans, as well as for trips to regions endemic for hepatitis. Find out whether the patient does not take medications that can cause the development of jaundice.

Presence in the anamnesis of a dyspepsia, a biliary colic and intolerance of fats allows to suspect a choledocholithiasis.

The development of jaundice after operations on the biliary tract is possible with abandoned stones, 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 with alcoholism is usually accompanied by signs such as anorexia, nausea in the morning, diarrhea and a slight increase in body temperature. The pain of enlarged liver is also possible.

A steady deterioration in the 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. Beginning with nausea, anorexia, aversion to cigarettes (smokers), as well as the development of jaundice within a few hours and its rapid progress make it suspected viral hepatitis or drug jaundice. Cholestatic jaundice develops more slowly, often accompanied by persistent itching. A fever with chills is characteristic of cholangitis associated with stones or stricture of the bile ducts.

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

With hepatic-cell jaundice, the general condition of the patient suffers; with cholestatic jaundice, the only complaint can be itching or jaundice, and the symptoms are caused by the underlying disease that caused the obstruction.

Soft persistent jaundice of varying intensity allows us to presume hemolysis. In cirrhosis, jaundice is usually moderate, varies in intensity and is not accompanied by a change in color of the stool, but with the adherence of acute alcoholic hepatitis, jaundice can be intense with discoloration of the stool.

Pain in biliary colic can last several hours, rarely they are intermittent. Pain in the back or in the epigastric region may be due to pancreatic cancer.

Examination

Age and sex. Gallstones are more common in middle-aged obese women. The prevalence of viral hepatitis A decreases with age, but with viral hepatitis B and C this pattern is not observed. With age, the likelihood of obstructing the biliary tract with a malignant tumor increases. Drug-related jaundice in children develops very rarely.

Inspection. Anemia can indicate hemolysis, tumor or cirrhosis. With a pronounced decrease in body weight, one should suspect a tumor. With hemolytic jaundice the skin is pale yellow, with hepatic cell jaundice - with an orange tinge, and with prolonged biliary obstruction get a green color. In pancreatic cancer patients often slouch. In patients with alcoholism, stigmata of liver cirrhosis can be observed. Particular attention is drawn to the organs in which the source of metastases in the liver can be localized (mammary glands, thyroid gland, stomach, thick and rectum, lungs), and also the condition of regional lymph nodes.

Mental status. A slight decrease in intelligence with minimal personality changes is indicative of liver-cell jaundice. The appearance of a liver odor and a "clapping" tremor indicates the possibility of developing a hepatic coma.

Skin changes. Bruising may indicate a blood clotting disorder. Developing with cirrhosis of thrombocytopenia can be manifested by purpura on the forearms, in the armpits or on the shins. Other skin changes with cirrhosis include vascular sprouts, palmar erythema, white nails and hair loss in areas of secondary hair.

In chronic cholestasis, you can identify traces of scratching, pigmentation caused by excessive deposition of melanin, change of fingers in the form of tympanic sticks, xanthoma on the eyelids (xanthelasm), extensor surfaces and in folds of the palms, and hyperkeratosis.

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

Care should be taken to the nodes on the skin, which can be a malignant tumor. With multiple vein thrombosis, pancreatic cancer is excluded. Edema of the ankles may indicate cirrhosis, as well as the obstruction of the inferior vena cava with a tumor of the liver or pancreas.

Study the abdomen. Expansion of peri-ocular veins is a sign of increased collateral circulation in the portal vein system (usually due to cirrhosis). Ascites can develop as a result of liver cirrhosis or a malignant tumor. With a significantly increased, bumpy liver, the probability of cancer of this organ is high. The small size of the liver indicates severe hepatitis or cirrhosis and can exclude extrahepatic cholestasis, in which the liver is enlarged and has a smooth surface. In patients with alcoholism, fatty liver and cirrhosis can cause it to increase evenly. The edge of the liver is painful with hepatitis, congestive heart failure, alcoholism, bacterial cholangitis and sometimes with tumors. Arterial noise above the liver indicates acute alcoholic hepatitis or primary liver cancer.

With choledocholithiasis, the pain of the gallbladder and the symptom of Murphy are possible. Palpable an enlarged gallbladder, sometimes visible in the right hypochondrium, requires the exclusion of pancreatic cancer.

The abdominal cavity should be carefully examined to exclude the primary tumor. Rectal examination is mandatory.

Urine and feces. Bilirubinuria is an early sign of viral hepatitis and drug jaundice. The absence of urobilinogen in the urine makes it possible to assume complete obstruction of the common bile duct. Long urobilinogenuria, in which there is no bilirubin in the urine, indicates a hemolytic jaundice.

Aholichny chair, which exists for a long time, confirms the diagnosis of biliary obstruction. With a positive sample for hidden blood, the cancer of the liver-pancreatic ampulla, pancreas, intestine, and portal hypertension is excluded.

Biochemical parameters of serum

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

Levels of albumin and globulins in serum during a short-term jaundice vary slightly. With a longer liver-cell jaundice, the albumin level decreases, and the globulin increases. With cholestatic jaundice (with electrophoresis), an increase in the level of a ₂ - and b-globulins is revealed , and for hepatocellular jaundice - g-globulins.

With hepatitis, the activity of serum transaminases increases more than with cholestatic jaundice. A significant transient increase in the activity of transaminases is sometimes observed with acute obstruction of the bile ducts with a stone.

Clinical examination of blood

Hepatic cell jaundice is characterized by a decrease in the number of leukocytes with relative lymphocytosis. With alcoholic and severe viral hepatitis, polymorphonuclear leukocytosis is possible. The number of leukocytes increases with acute cholangitis and tumors. If suspected of hemolysis, count the number of reticulocytes, examine the blood smear, determine the osmotic resistance of erythrocytes, put a Coombs test, and examine the bone marrow.

With an increase in prothrombin time, a sample with vitamin K is administered: its intramuscular injection of 10 mg for 3 days leads to a normalization of prothrombin time in cholestasis, while no significant changes occur in the liver-jaundice.

Routine diagnostic tests

Clinical examination of patients with jaundice can be attributed to one of the following groups: patients with hepatic-cellular jaundice; patients who cause jaundice is a malignant tumor; patients who can not exclude an extrahepatic obstruction of the biliary tract; patients, in whom the probability of extrahepatic obstruction of the biliary tract is great. Further examination depends on the group to which the patient is assigned, as well as on the suitability of the medical institution, the degree of risk of the diagnostic procedure and its cost.

In a small number of patients with extrahepatic biliary obstruction, intrahepatic cholestasis is mistakenly diagnosed; much more often in patients with intrahepatic lesions mistakenly diagnosed extrahepatic obstruction of the biliary tract.

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

X-ray examination

Chest X-ray is performed to identify tumors and their metastases, as well as irregularities in the contour of the right dome and the high diaphragm standing, caused by an increase in the liver or the presence of nodes in it.

Visualization of bile ducts

Indication for the use of methods of visualization of bile ducts is cholestasis. Firstly, hepatic-cellular jaundice is differentiated from obstructive jaundice caused by obstruction of the common bile duct and requiring surgical treatment. The method of choice is ultrasound (ultrasound) or computed tomography (CT), which can determine whether intrahepatic bile ducts are dilated. Then, according to the indications, endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography is performed.

Markers of viral hepatitis

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

Puncture liver biopsy

In acute jaundice, the need for liver biopsy is rare; it is performed mainly in a patient with an unclear diagnosis and with suspicion of intrahepatic genesis of jaundice. The presence of jaundice increases the risk of a biopsy. The most safe is a needle biopsy Mengini. Severe jaundice is not a contraindication to liver biopsy.

With violations of blood clotting, the usual transcutaneous biopsy is dangerous, in such cases, a transgular biopsy or biopsy is performed under the control of CT or ultrasound with the filling of the puncture channel.

Diagnosis of acute viral hepatitis usually presents no difficulties. The most difficult is the diagnosis of jaundice in cholestasis. Nevertheless, in most cases, an experienced histologist can distinguish between intrahepatic cholestasis, for example, with drug damage or primary biliary cirrhosis, from changes caused by obstruction of the common bile duct. However, the very cause of cholestasis can only be established with much less certainty.

Laparoscopy

The dark green color of the liver and the enlarged gallbladder support the extrahepatic biliary obstruction. Laparoscopy can also detect tumor nodes and perform their biopsy under visual control. With hepatitis, the liver is yellow-green; The cirrhotically altered liver has a characteristic appearance. Laparoscopy does not allow to differentiate extrahepatic biliary obstruction, especially caused by cancer of large bile ducts, and intrahepatic cholestasis caused by medications.

During the study, it is necessary to obtain liver shots. With jaundice, peritoneoscopy is safer than puncture liver biopsy, but if necessary, these two methods can be combined.

Test with prednisolone

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

"Whitening" effect in the appointment of corticosteroids can not be explained by a change in the lifespan of erythrocytes (reflecting changes in hemoglobin catabolism) or the release of urobilinogen with feces and urine or bilirubin with urine. Perhaps the exchange of bilirubin in this case occurs along a different metabolic pathway.

Laparotomy

Jaundice rarely requires emergency surgery. When doubting the diagnosis, it is advisable to continue the examination, since diagnostic laparotomy is associated with a high risk of developing acute hepatic or renal insufficiency. Delay in surgery rarely harms the patient

[1], [2], [3], [4]