Clinical Rounds
By
Asst.Professor of General and Pediatric Surgery
Ask the patient some questions about his/her jaundice to find out whether
the cause of jaundice is;
 Pre-hepatic
 Hepatic
 Post-hepatic
 Remember that in the exam, post-hepatic is the most likely cause and is the easiest to be
diagnosed from the history.
1. Have you noticed any change in the color of your urine?
2. Have you noticed any change in the color of your stool?
3. Have you noticed yourself feeling itchy?
If the patient has noticed pale stools and dark urine then explore possible
cause.
4. Weight loss, change in bowel habit, loss of appetite and back pain
1ry and 2ry intra-abdominal malignancies.
5. Younger age, previous biliary colic or episodic right upper quadrant pain
Gallstones.
Continue to ask about;
6. Foreign travel
hepatitis A
7. Blood transfusion
hepatitis B & C
8. Sore throat
ESBV
9. Alcohol intake, OCP, Phenothiazine.
Expose the patient as previously mentioned and begin by;
 General examination ( look for signs of chronic liver disease)

Hand


Eyes
jaundice in the sclera, pallor in the conjunctiva
Mouth
angular stomatitis, glossitis, foetor hepaticus, pallor, jaundice in the soft
palate, and central cyanosis on the undersurface of the tongue.
Neck
palpate for supraclavicular L.Ns (Virchow’s node)
Shoulder
spider nevi
Breast
gynaecomastia
Lower limb
pitting edema




clubbing, koilonychia, leukonychia, palmar erythema, Dupuytren’s contracture,
flappy tremors.
 Local examination
1. Inspection



The abdomen may be distended with ascites
There may be dilated veins around the umbilicus (Caput medusae)
Scratch marks
2. Palpation
 Palpate carefully in the right upper quadrant for any
tenderness or masses
 Courvoisier’s law .i.e. jaundice + palpable gallbladder in the
right upper quadrant, the cause is unlikely to be malignant.
3. Percussion….as before
4. Auscultation ….as before
Complete your examination as before, say that you would like to;




PR
Back
Scrotum
Femoral pulse
Causes of jaundice and effects on liver function tests (LFT)
Pre-hepatic
Major
causes
Hepatic
 Haemolysis
 Hereditary e.g.
 Hepatitis
 Decompensated
‘CLD’
 Drugs
Gilbert’s syndrome
Bili type
Bili level
ALT
ALP
unconjugated
++
+/++
-/+
conjugated
+++/++++
++/+++
+/++
Post-hepatic
 Gall stones
 Ca. head of
pancreas
 Lymph
nodes
Conjugated
++
+/++
++/+++
Bili=bilirubin
ALT=alanine aminotransferase
AST=aspartate aminotransferase
ALP=alkaline phosphatase
CLD=chronic liver disease
What is the normal level of bilirubin, and the level before jaundice
can be detected clinically?
 Normal level is < 17 mmol/L
 It has to reach at least 3 times before the sclera is discolored i.e. > 50
mmol/L
 Very high levels are usually associated with hepatic jaundice.
How should jaundiced patient be investigated?
You have to start by the cheapest investigations first then go through according to the demands.

Blood tests
1. Urine analysis
raised bilirubin
2. CBC
anaemia suspecting GI malignancies, or associated infection
3. Renal function tests (RFT)
any evidence of hepatorenal syndrome
4. LFT
ALT, AST, ALP, Bilirubin, Albumin
5. Clotting
BT, CT, PT, PC, PTT, INR
 Radiological investigations
1. US





Liver cirrhosis
Gall stones
Dilated CBD > 8mm is abnormal
Pancreatic mass
Lymphadenopathy
2. CT
3. ERCP
4. MRCP
What are the causes of post-operative jaundice?
1. Pre-hepatic jaundice due to hemolysis 2ry to blood transfusion
2. Hepatic jaundice 2ry to the use of halogenated anesthetics, sepsis, or
intra- or post-operative hypotension
3. Post-hepatic jaundice due to biliary injury such as Lap.Chole
Lap.Chole= Laparoscopic Cholecystectomy
Good luck
Dr.Hisham H Ahmed.M.D, PhD, MRCS.Eng
Asst.Prof.of of General and Pediatric Surgery