STUDY - Technical - New Dacian's Medicine
jaundice
(Classical / Allopathic Medicine)
The yellow
discoloration of the skin or mucous membranes, jaundice
indicates excessive levels of conjugated or unconjugated
bilirubin in the blood. In fair-skinned patients, it's most
noticeable on the face, trunk, and sclerae; in dark-skinned
patients, on the hard palate, sclerae, and conjunctivae.
Jaundice is most
apparent in natural sunlight. In fact, it may be undetectable
in artificial or poor light. It's commonly accompanied by
pruritus (because bile pigment damages sensory nerves), dark
urine, and clay-colored stools.
Jaundice presents
in one of three forms: prehepatic jaundice, hepatic jaundice,
and posthepatic jaundice. It may be the only warning sign of
certain disorders such as pancreatic cancer. (See Classifying
jaundice.)
HISTORY:
Ask the patient when he first noticed the jaundice.
Ask the patient if he also has pruritus, clay-colored stools, or dark urine.
Ask the patient if he has ever had past episodes of jaundice. Is there a family history of the disease?
Ask the patient whether he has experienced associated signs and symptoms, such as fatigue, fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations.
Review the patient's medical history for liver or gallbladder disease and cancer.
Ask the patient if he recently lost weight.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Ask the patient when he first noticed the jaundice.
Ask the patient if he also has pruritus, clay-colored stools, or dark urine.
Ask the patient if he has ever had past episodes of jaundice. Is there a family history of the disease?
Ask the patient whether he has experienced associated signs and symptoms, such as fatigue, fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations.
Review the patient's medical history for liver or gallbladder disease and cancer.
Ask the patient if he recently lost weight.
Obtain a drug history, including prescription and over-the-counter drugs, herbal remedies, and recreational drugs. Also, ask the patient about alcohol intake.
Classifying
jaundice
Jaundice occurs in three forms: prehepatic, hepatic, and posthepatic. In all three, bilirubin levels in the blood increase due to impaired metabolism.
With prehepatic jaundice, certain conditions and disorders, such as transfusion reactions and sickle cell anemia, cause massive hemolysis. Red blood cells rupture faster than the liver can conjugate bilirubin, so large amounts of unconjugated bilirubin pass into the blood, causing increased intestinal conversion of this bilirubin to water-soluble urobilinogen for excretion in urine and stools. (Unconjugated bilirubin is insoluble in water, so it can't be directly excreted in urine.)
Hepatic jaundice results from the liver's inability to conjugate or excrete bilirubin, leading to increased blood levels of conjugated and unconjugated bilirubin. This occurs in such disorders as hepatitis, cirrhosis, and metastatic cancer and during prolonged use of drugs metabolized by the liver.
With posthepatic jaundice, which occurs in patients with biliary or pancreatic disorders, bilirubin forms at its normal rate, but inflammation, scar tissue, a tumor, or gallstones block the flow of bile into the intestine. This causes an accumulation of conjugated bilirubin in the blood. Water-soluble, conjugated bilirubin is excreted in the urine.
Jaundice occurs in three forms: prehepatic, hepatic, and posthepatic. In all three, bilirubin levels in the blood increase due to impaired metabolism.
With prehepatic jaundice, certain conditions and disorders, such as transfusion reactions and sickle cell anemia, cause massive hemolysis. Red blood cells rupture faster than the liver can conjugate bilirubin, so large amounts of unconjugated bilirubin pass into the blood, causing increased intestinal conversion of this bilirubin to water-soluble urobilinogen for excretion in urine and stools. (Unconjugated bilirubin is insoluble in water, so it can't be directly excreted in urine.)
Hepatic jaundice results from the liver's inability to conjugate or excrete bilirubin, leading to increased blood levels of conjugated and unconjugated bilirubin. This occurs in such disorders as hepatitis, cirrhosis, and metastatic cancer and during prolonged use of drugs metabolized by the liver.
With posthepatic jaundice, which occurs in patients with biliary or pancreatic disorders, bilirubin forms at its normal rate, but inflammation, scar tissue, a tumor, or gallstones block the flow of bile into the intestine. This causes an accumulation of conjugated bilirubin in the blood. Water-soluble, conjugated bilirubin is excreted in the urine.
PHYSICAL
CONSIDERATIONS:
Inspect the skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia.
If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops. For all patients, auscultate for crackles and abnormal bowel sounds.
Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling.
Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques.
Obtain baseline data on the patient's mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
Inspect the skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia.
If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops. For all patients, auscultate for crackles and abnormal bowel sounds.
Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling.
Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques.
Obtain baseline data on the patient's mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function.
SPECIAL
CONSIDERATIONS:
To help decrease pruritus, bathe the patient frequently, and apply an antipruritic lotion such as calamine.
To help decrease pruritus, bathe the patient frequently, and apply an antipruritic lotion such as calamine.
PEDIATRIC
POINTERS:
Physiologic jaundice is common in neonates, developing 3 to 5 days after birth.
In infants, obstructive jaundice usually results from congenital biliary atresia.
A choledochal cyst - a congenital cystic dilation of the common bile duct - may also cause jaundice in children, particularly those of Japanese descent. Other causes of jaundice include Crigler-Najjar syndrome, Gilbert's disease, Rotor's syndrome, thalassemia major, hereditary spherocytosis, erythroblastosis fetalis, Hodgkin's disease, and infectious mononucleosis.
Physiologic jaundice is common in neonates, developing 3 to 5 days after birth.
In infants, obstructive jaundice usually results from congenital biliary atresia.
A choledochal cyst - a congenital cystic dilation of the common bile duct - may also cause jaundice in children, particularly those of Japanese descent. Other causes of jaundice include Crigler-Najjar syndrome, Gilbert's disease, Rotor's syndrome, thalassemia major, hereditary spherocytosis, erythroblastosis fetalis, Hodgkin's disease, and infectious mononucleosis.
AGING ISSUES:
In patients older than age 60, jaundice is usually caused by cholestasis resulting from extrahepatic obstruction.
In patients older than age 60, jaundice is usually caused by cholestasis resulting from extrahepatic obstruction.
PATIENT
COUNSELING:
Encourage the patient with a hepatic disorder to decrease protein intake and increase carbohydrate intake. If he has obstructive jaundice, encourage a balanced, nutritious diet (avoiding high-fat foods) and frequent small meals.
Encourage the patient with a hepatic disorder to decrease protein intake and increase carbohydrate intake. If he has obstructive jaundice, encourage a balanced, nutritious diet (avoiding high-fat foods) and frequent small meals.
Bibliography:
1. Rapid Assessment, A
Flowchart Guide to Evaluating Signs & Symptoms, Lippincott
Williams & Wilkins, 2004.
2. Professional Guide to
Signs and symptoms, Edition V, Lippincott
Williams & Wilkins, 2007.
3. Guide to common
symptoms, Edition V, McGraw - Hill, 2002.
Dorin,
Merticaru (2010)