Jaundice is the result of excess bilirubin circulating in the blood. Most bilirubin originates from the catabolism of
haemoglobin in the reticuloendothelial system. Unconjugated bilirubin bound to albumin cannot be excreted into the urine. Following hepatic glucuronidation, bilirubin dtglucuronide enters the gut lumen via the biliary tree and is metabolised by the gut microflora to urobilinogen (Fig. 5.1). Urobilinogen is then reabsorbed anil enters the entero-hepatic cycle: in health, it is excretcd in the urine as a colourless compound in small quantities. In biliary tract obstruction (intrahepatic or extrahepatic in origin), the water-soluble compound bilirubin diglucuronide relluxes into the blood and is excreted in the urine to producc a brownish discoloration (bilirubinuria).
Jaundice may therefore be haemolytic, hepatocellular or obstructive in origin. A checklist for patients with a history of jaundice is shown in Table 5.18.
Haemolytic jaundice. Unconjugated hyperbilirubinemia such as in haemolytic anaemia may occur without either symptoms or urine discoloration (hence the term acholuric jaundice).
Past medical history (pancreatitis, biliary surgery) Previous jaundice or hepatitis Blood transfusions (hepatitis B or C) Family history (congenital spherocytosis) Sexual and contact history (hepatitis B or C) Travel history and immunisations (hepatitis A) Drug and alcohol history Skin tattooing (hepatitis B or C) Pruritus, dark urine, hgors Appetite and weight change Abdominal pain, altered bowel habit Gastrointestinal bleeding
Hepatocellular jaundice. Characteristic symptoms include anorexia with impairment of taste, nausea, vomiting and upper abdominal pain (often associated with hepatic tender ness). Common causes include viral hepatitis and chemical hepatitis, e.g. alcohol abuse and drug therapy.
Obstructive jaundice. Typical symptoms include itching (pruritus), dark urine and pale stools. Obstruction of the biliary tract is usually extrahepatic in origin and caused by either gallstones or pancreatic carcinoma. The former is suggested by a history of fever, rigors, biliary colic or previous biliary surgery; in the latter, chronic persistent back pain, aggravated by recumbency, and palpable enlargement of the gall bladder may occur. Intrahepatic obstruction is most often due to alcohol abuse, drug therapy and primary biliary cirrhosis (a disorder of middle-aged women often preceded by marked pruritus).
• The first history should be as detailed as possible because acutely ill patients lire easily and accuracy may be lost on repetition.
• Symptom progression and symptom patterns are often ol diagnostic value,
• Weight loss as an isolated symptom is rarely the result ot serious underlying organic disease.
• Depression may present as weight loss or even weight gain.
• Melaena Indicates upper gastrointestinal haemorrhage and is usually associated with significant fiaemodynamic changes resulting from loss of blood volume.
• Haemorrhoids are so common that their presence in a patient with rectal bleeding should not lead to the assumption of cause and effect.
• Dysphagia is a cardinal symptom which requires prompt investigation even when transient,
• Difficulty in swallowing fluids rather than solids, associated with spluttering and coughing, suggests neurological disorders.
• Vomiting and anorexia are common manifestations of non-alimentary disorders.
• Changes in bowel habit may be the first symptom of serious underlying disease.
As part of a general history, all patients should he asked about the cardinal symptoms of genitourinary disorders (Table 5.19) even though this may be embarrassing for some patients to discuss.
Renal disease may present with non-specific symptoms such as tiredness or breathlessness due to renal failure and the associated anaemia, or the observation of oedema due to fluid retention. It may also be detected following the finding of hypertension, microscopic haematuria, or proteinuria on routine assessment, such as insurance medical examinations.
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