Jaundice, or icterus, is a yellowish discoloration of tissue resulting from the deposition of bilirubin.
Bilirubin pigment has high affinity for elastic tissue and hence jaundice is particularly noticeable in tissue rich in elastin content.
Tissue deposition of bilirubin occurs only in the presence of serum hyperbilirubinemia and is a sign of either liver disease or, less often, a hemolytic disorder.
The degree of serum bilirubin elevation can be estimated by physical examination. Slight increases in serum bilirubin are best detected by examining the sclerae which have a particular affinity for bilirubin due to their high elastin content.
Normal serum bilirubin concentration ranges from 0.2-0.8 mg/dL, about 80 % of which is unconjugated. The presence of scleral icterus indicates a serum bilirubin of at least 3.0 mg/dL.
The ability to detect scleral icterus is made more difficult if the examining room has fluorescent lighting. If the examiner suspects scleral icterus, a second place to examine is underneath the tongue. As serum bilirubin levels rise, the skin will eventually become yellow in light-skinned patients and even green if the process is longstanding; the green
color is produced by oxidation of bilirubin to biliverdin.
Another sensitive indicator of increased serum bilirubin is darkening of the urine, which is due to the renal excretion of conjugated bilirubin. Bilirubinuria indicates an elevation of the direct serum bilirubin fraction and therefore the presence of liver disease.
Increased serum bilirubin levels occur when an imbalance exists between bilirubin production and clearance.
Types of Jaundice
Other important questions include recent travel history, exposure to people with jaundice, exposure to possibly contaminated foods, occupational exposure to hepatotoxins, alcohol consumption, the duration of jaundice, and the presence of any accompanying symptoms such as arthralgias, myalgias, rash, anorexia, weight loss, abdominal pain, fever,
pruritis, and changes in the urine and stool. While none of these latter symptoms are specific for any one condition, they can suggest a particular diagnosis.
The general assessment should include assessment of the patient's nutritional status. Temporal and proximal muscle wasting suggests longstanding diseases such as pancreatic cancer or cirrhosis. Stigmata of chronic liver disease, including spider nevi, palmar erythema, gynecomastia, caput medusae, Dupuytren's contractures, parotid gland enlargement, and testicular atrophy are commonly seen in advanced alcoholic (Laennec's) cirrhosis and occasionally in other types of cirrhosis.
An enlarged left supraclavicular node (Virchow's node) or periumbilical nodule (Sister
Mary Joseph's nodule) suggest an abdominal malignancy. Jugular venous distention, a sign of right-sided heart failure, suggests hepatic congestion. Right pleural effusion, in the absence of clinically apparent ascites, may be seen in advanced cirrhosis.
The abdominal examination should focus on the size and consistency of the liver, whether the spleen is palpable and hence enlarged, and whether there is ascites present. Patients with cirrhosis may have an enlarged left lobe of the liver which is felt below the xiphoid and an enlarged spleen.
A grossly enlarged nodular liver or an obvious abdominal mass suggests malignancy. An enlarged tender liver could be viral or alcoholic hepatitis or, less often, an acutely congested liver secondary to right-sided heart failure. Severe right upper quadrant tenderness with respiratory arrest on inspiration (Murphy's sign) suggests cholecystitis or, occasionally, ascending cholangitis. Ascites in the presence of jaundice suggests either cirrhosis or malignancy with peritoneal spread.
Here are few clinical clues according to symptom for assessing disease and patient condition.
1. Jaundice occurring suddenly in apparent health , and painlessly, is usually of emotional origin and transitory.
2. When it depends on disease or injury of brain, acute atrophy of liver, snake poisoning, or infectious fever, it is
always associated with mental disturbances.
3. If it be attended with fever and well marked, it is secondary to inflammation of biliary passages, pneumonia,
toxemia, or infective inflammation of the portal vein.
4. If it occurs suddenly and is preceded by paroxysmal pain and vomiting, it is caused nine times out of ten by biliary
5. Impassable obstruction of the common bile duct is shown by great intensity of jaundice, clay colored stools, and in
recent cases by distention of the gall bladder.
6. Jaundice caused by sudden obstruction of the biliary passages is always associated with paroxysmal pain and nausea.
In the rare cases of sudden obstruction by cancerous, hydatid and aneurismal tumors, there is almost always a history of
impaired health, enlargement and deformity of the liver, ascitis etc. In theses cases USG is must and may pin point the
7. Sudden return of normal colouration of stool confirms the diagnosis of obstruction.
8. Occlusion of the cystic duct may be attended with as much pain, nausea and distension of gall bladder as occlusion of the common duct, but there is no jaundice. In occlusion of the hepatic duct, the same symptoms are present, including jaundice and excluding distension of gall bladder.
9. A history of repeated attacks points to the probability of gall stone.
10. Slight but persistent jaundice may be due to incomplete occlusion of the common bile duct, or the complete occlusion
of branch of the hepatic ducts.
11. If ascitis be associated with it, the disease is either cirrhosis or cancer of the liver; if the liver be abnormally small, the disease is cirrhosis; if it be large, the disease is either hypertrophic cirrhosis or cancer.
12. Absence of jaundice does not imply absence of hepatic disease; since the liver may be destroyed by disease or extirpated by operation without jaundice ensuing.
A detailed history of patient should be taken including previous illness, mental disposition and general symptoms. Below are some clinical rubrics from Synthesis Repertory 9.1. These are mostly general rubric but must not be utilized as eliminating rubrics. These can be used as additional confirmation of remedy. Besides these rubrics any particular and general rubrics may be considered.
1- EYE - DISCOLORATION - yellow
2 -MOUTH - DISCOLORATION - Tongue - white
3 -MOUTH - TASTE - bitter
4 -MOUTH - TASTE - sour
5 -EXTERNAL THROAT - SWELLING - Cervical Glands
6 -STOMACH - APPETITE - wanting
7 -STOMACH - VOMITING - heat - during
8-ABDOMEN - ATROPHY - Liver
9 -ABDOMEN - ENLARGED - Liver
10-ABDOMEN - ENLARGED - Spleen
11-ABDOMEN - INFLAMMATION - Liver
12-ABDOMEN - PAIN - Liver
13-ABDOMEN - PAIN - Liver - sore
14 -RECTUM - CONSTIPATION
15 -RECTUM - DIARRHEA
16-STOOL - CLAY COLORED
17-STOOL - GRAY
18 -STOOL - LIGHT COLORED
19 -STOOL - WHITE
20 -URINE - BILE, containing
21-URINE - SCANTY
22 -SLEEP - SLEEPINESS - heat - during
23 -FEVER - CHILL; with
24 -SKIN - DISCOLORATION - yellow
25 -SKIN - ITCHING
26 -SKIN - ITCHING - jaundice; during
27 -SKIN - NETWORK of blood vessels
28 -GENERALS - SWELLING - Glands; of
Next Article : Achalasia Cardia - Esophageal Dymotility Disorder