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Thread: Gastrointestinal System Symptoms - Jaundice

  1. #1

    Default Gastrointestinal System Symptoms - Jaundice

    Alarm Symptoms

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-25-47-am-png
    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-26-10-am-png

    Open-Ended Questions

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    Focused Questions

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-30-12-am-png
    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-30-27-am-png
    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-32-33-am-png

    Differential Diagnosis

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-36-23-am-png

    Etiology
    Impaired bilirubin metabolism
    • Excess bilirubin production
    • Impaired bilirubin production
    • Impaired conjugation of bilirubin

    Impaired secretion of bile into bile canaliculi
    Liver disease
    Obstruction of the bile ducts

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-07-15-at-9-40-54-am-png
    Last edited by Janis.Y.Chen; Fri 15th July '16 at 10:41am.
    Clinical Pharmacy Specialist - Infectious Diseases

  2. #2

    Default Re: Gastrointestinal System Symptoms - Jaundice

    Diagnostic Approach

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    Clinical Pharmacy Specialist - Infectious Diseases

  3. #3
    PharmD Year 1 TomHsiung's Avatar
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    Default Re: Gastrointestinal System Symptoms - Jaundice

    Physical Exam of Jaundice
    Jaundice is an abnormal yellowish discoloration of the skin and mucous membranes caused by accumulation of bile pigment. There are three forms: 1) hemolytic jaundice, 2) hepatocellular jaundice, and 3) obstructive jaundice. In most published series of jaundiced patients, hemolysis is uncommon, and the usual task of the clinician at the bedside is to differentiate hepatocellular disease from obstructed biliary ducts.

    Jaundice is usually first noted in the eye, but the traditional term for this finding (scleral icterus) is actually a misnomer because pathologic studies reveal most of the pigment to be deposited in the conjunctiva, not the avascular sclera. As jaundice progresses and the serum bilirubin increases, the face, mucous membranes, and eventually the entire skin acquire a yellow or orange hue.

    Prominent yellowish subconjunctival fat may be mistaken for conjunctival jaundice, but fat usually is limited to the conjunctival folds and, unlike jaundice, spares the area near the cornea. Patients with carotenemia also develop a yellowish discoloration of the skin, especially the palms, soles, and nasolabial fold, but, in contrast to jaundice, the conjunctiva are spared.

    Below we describe the associated findings along with jaundice to distinguish hepatocellular disease from obstructed biliary ducts.

    1.Hepatocellular Jaundice
    Characteristic findings are spider telangiectasias, palmar erythema, gynecomastia, dilated abdominal wall veins, splenomegaly, asterixis, and fetor hepaticus.

    2.Obstructive Jaundice: Palpable Gallbladder (Courvoisier Sign)
    The presence of a smooth, nontender, distended gallbladder in a patient with jaundice is a traditional sign of obstructive. Courvoisier sign refers to the association of the palpable gallbladder and extra hepatic obstruction.

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-12-28-at-7-23-18-pm-png
    Last edited by TomHsiung; Wed 28th December '16 at 7:25pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: Gastrointestinal System Symptoms - Jaundice

    Diagnosis of Cirrhosis
    The diagnosis of cirrhosis in patients with liver disease has important prognostic and therapeutic implications. EBM Box 7-2 displays the diagnostic accuracy of physical findings in detecting cirrhosis, determined from hundreds of patients presenting with diverse chronic liver diseases. Of note, the only findings decreasing the probability of cirrhosis in these patients are absence of a palpable liver in the epigastrium (LR = 0.3) and absence of a firm liver edge (LR = 0.4).

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-12-28-at-7-32-50-pm-png
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: Gastrointestinal System Symptoms - Jaundice

    Detecting Large Gastroesophageal Varices in Patients with Cirrhosis
    In studies of more than 700 patients with cirrhosis who have not had prior gastrointestinal bleeding, no physical finding reliably predicts which patients have significant gastroesophageal varices (as detected by endoscopy). For most findings - caput medusae, spider angiomas, jaundice, hepatomegaly, splenomegaly, and hepatic encephalopathy - the LR is not significant; only for ascites is the LR statistically significant (LR = 1.5), although its clinical significance is minimal.
    Last edited by TomHsiung; Wed 28th December '16 at 7:46pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    PharmD Year 1 TomHsiung's Avatar
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    Default Re: Gastrointestinal System Symptoms - Jaundice

    Detecting Hepatopulmonary Syndrome
    Hepatopulmonary syndrome is a serious complication of cirrhosis causing intrapulmonary vascular shunting and significant hypoxemia. In five studies of over 400 patients with cirrhosis (EBM Box 7-3), most awaiting liver transplantation, the findings of finger clubbing (LR = 4.6) and cyanosis (LR = 4.3) increased the probability of hepatopulmonary syndrome.

    Gastrointestinal System Symptoms - Jaundice-screen-shot-2016-12-28-at-7-49-22-pm-png
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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    Default Re: Gastrointestinal System Symptoms - Jaundice

    Direct hyperbilirubinemia
    Conjugated hyperbilirubinemia is defined as bilirubinemia with >50% in the direct fraction. In the normal course bilirubin metabolism, direct bilirubin is synthesized in hepatocytes and secreted into bile. Therefore, elevated direct bilirubin implies hepatic or biliary tract disease that interferes with secretion of bilirubin from the hepatocytes or clearance of bile from the liver.

    Indirect hyperbilirubinemia
    Less than 30% direct bilirubin indicates indirect hyperbilirubinemia.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

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