challenge of diagnosing the cause of jaundice, The

Nurse Practitioner, Oct 1999 by Stegbauer, Cheryl Cummings

ABSTRACT

The patient presenting with jaundice may have a variety of hepatobiliary or hematologic conditions. Understanding the causes of jaundice and the history and physical examination hallmarks provide the basis for choosing the most efficacious laboratory and diagnostic studies. A case report Illustrating the reasoning involved in distinguishing between the different causes of jaundice is presented.

The patient who presents with jaundice may have a variety of hepatobiliary or hematologic abnormalities, the causes of which can include hereditary disorders, acute or chronic hepatocellular disease, hemolytic disorders, or obstructive processes.1 A thorough history and physical examination provide the basis for choosing laboratory and radiologic studies that have the greatest diagnostic value while providing the safest and most cost-effective care.

Jaundice, also known as icterus, is the yellow discoloration of the skin, sclera, and mucous membranes resulting from increased deposition of bilirubin into the tissues.

An exact bilirubin level at which jaundice develops is not known, but it is usually not clinically observed until the serum bilirubin reaches 2.5 to 3 mg/dl (normal values are 0.2 to 1.2 mg/dl).1 Generally, yellowing of the sclera is observed first.

The differential diagnosis process should be methodical because each type of jaundice has a discernible pattern of disease presentation. The information gathered during the history and physical examination is integral in choosing a diagnostic pathway. Noting the time progression of events with the present signs and symptoms is especially important.

The Case

R.S., a 63-year-old white man, presented to a clinic with jaundice after the fourth day of taking Bactrim DS, which had been prescribed for a urinary tract infection (UTI). On the third day of treatment, he said he "wasn't feeling well" and his complexion "wasn't right." On the morning of the fourth day, he knew something was wrong because he was turning yellow.

History of Present Illness

R.S. had a history of squamous cell cancer of the anus, which was diagnosed 2 years ago after biopsy of a protruding anal mass. Colonoscopy confirmed the diagnosis and showed no involvement of the colon. R.S. received radiation therapy and chemotherapy with fluorouracil.

His chemotherapy course was complicated by a staphylococcus bacteremia with subsequent septic shock, cardiac arrest, and renal failure. He was hospitalized for 4 weeks and discharged in relative good health.

One month later, R.S. was admitted to a local hospital with severe abdominal pain. The diagnostic evaluation consisted of an upper GI, abdominal ultrasound, and computed tomography (CT) of the abdomen. The results were inconclusive, and he was discharged.

Five months later, R.S. was seen at the clinic for a suspected UTI. His liver function tests on this visit were all within normal limits. He was prescribed Bactrim DS twice a day.

Four days later, he developed jaundice. He reported tangerine colored urine and oatmeal colored stools at the same time that his skin turned yellow. He also experienced bloating, with mild to moderate abdominal discomfort. He reported a poor appetite and experienced a 40pound weight loss since his cancer was first diagnosed 2 years ago. He continued to have persistent mild nausea but denied vomiting. He denied pyrosis, hematochezia, hematemesis, or bright red blood from the rectum. His past surgical history was noncontributory.

Social and Family History

R.S. had been divorced for 10 years. He had one 40-year-old son who was alive and well. His mother died at age 74 of a brain tumor and his father died of cardiac causes at age 60. R.S. had worked as a doorman but retired after his chemotherapy. He reported that he drank alcohol only occasionally and denied illicit or herbal drug use. He currently smokes four cigarettes per day but had a 20-pack per year history. He denied a history of sexually transmitted infections, LV. drug use, blood transfusion, or tattooing. He denied homosexuality or sexual promiscuity.

His recent medications included Bactrim DS, which was discontinued, and an antacid that he took on an as-needed basis. He was allergic to penicillin and aminoglycosides.

A review of physical systems was unremarkable except for his presenting symptoms. Specifically, R.S. denied any history of liver disease or hepatitis. He denied a history of peptic ulcer disease, gallstones, or pancreatic problems.

Physical Examination

The physical examination revealed a very thin, jaundiced white man. He denied fever, chills, or night sweats but complained of mild nausea with associated anorexia but no vomiting. His sclera and skin were jaundiced and his skin turgor was poor, but he denied pruritus. Numerous ecchymotic areas were present on his upper extremities.

His neck was supple without adenopathy, jugular venous distention, or bruits. His cardiopulmonary assessment was unremarkable. His abdomen was scaphoid, soft, and nontender to palpation. A firm, smooth liver edge was palpable 5 cm below the right costal margin and was dull to percussion. The spleen was not palpable. Bowel sounds were auscultated in all four quadrants. Rectal examination revealed good sphincter tone, a firm prostate without nodularity, and guaiac negative stool. The neurologic examination was unremarkable. No tremor or asterixis was found.