Obstructive Jaundice

History

·         50 yrs old male

·         Low socio-economic

·         H/O fever – 1 month

·         H/O pain and lump Right upper abdomen – 15 days

·         H/O yellowish discoloration of eyes – 10 days

·         Fever  -  Off and on – 1month, sudden onset, high grade, intermittent and associated with chills and rigors, reduced on taking oral medicines.

·         Pain over right upper abdomen – 15 days, insidious onset, dull aching, non-shifting, non-radiating and decreased on medication.

·         Patient noticed lump in right upper abdomen since past 15 days of size 6*4cms and progressively increased in size to present size.

·          Yellowish discoloration of eyes -  insidious onset and deepened since then.

·         H/O of passing clay coloured stools since 10 days.

·         H/O loss of appetite and weight loss – 5 kgs – 2 months

·         No H/O itching, vomiting, abdominal distension, obstipation, haematemesis, malena, other constitutional symptoms and urinary complaints.

·         No H/O contact, IV drug abuse, blood transfusions.

·          No H/O respiratory distress, bone pains, headache, or seizures.

·         No H/O diabetes mellitus, hypertension, Kochs

·         Alcoholic and smoker since 20 years

Prodromal symptoms	Constitutional symptoms
Eg. – infective hepatitis Short history Loss of appetite Smoker will lose taste of smoking Jaundice appearing and then receding

Is Clay coloured stool always means obstructive jaundice?

-          No

-          In some cases of infective type of hepatitis initially obstructive type of features are present due to oedema of liver cells- stools can be clay coloured, alkaline phosphatase may be raised.

-          But they (obstructive jaundice) do not progress.

Examination-

-          Elderly male, conscious, co-operative, well oriented to time, place and person

-          Performance status – 80 Kornoffosky

-          Nutritional status – poor

-          Hydration status – adequate

-          Pulse – 86/min, regular

-          BP – 124/78 mm Hg

-          RR – 18/min, abdominothoracic

-          Afebrile

-          Patient is albino with yellowish discoloration of skin

-          Icterus – present, pedal edema+

-          Pallor +, no generalised lymphadenopathy

-          Respiratory system – WNL

-          Cardiovascular – WNL

-          Central and peripheral Nervous system – WNL

-          Stigma of liver disease-

o   Hair texture – change or alopecia

o   Icterus

o   Spider naevi

o   Palmar erythema

o   Dupeytren’s contracure

o   Clubbing

o   Gynaecomastia

o   Caput medussae

o   Ascites

o   Testicular atrophy

o   Pedal  oedema

-          Liver failure (include more feature)-

o   Posterior column disorders eg. Flapping tremors

o   Fetor hepaticus

How do you look for hydration status?

-          Tongue

-          Skin turgor- over dorsum of hand.

Abdominal examination-

Inspection:

·         Visible fullness in Rt Hypochondrium

·         All the quadrants moving well with respiration

·         Umbilicus is central

·         Skin over abdomen is normal

·         No dilated veins, scars

·         No visible peristalsis or pulsations

·         Hernia orifices are normal

·         Flanks are not full

Palpation:

·         Tender hepatomegaly with span of around 17cms, palpable 7 cms below the costal margin in MCL, round borders, firm in consistency with small area of softening around 5*6cms present at the middle of swelling.

·         No other organomegaly, no free fluid+

·         Spine, Genitals and Hernial orifices are normal

·         Left supraclavicular lymph node not enlarged

·         P/R examination – WNL.

What gives the colour to stool?

·         Stercobilinogen (formed by bacteria acting upon bilirubin:  Bilirubin=Urobilinogen+Stercobilinogen

In a patient of jaundice what happens to cardiovascular system?

·         In jaundice there is rise in serum bilirubin.

·         Serum bilirubin directly acts on SA nodes.

·         It causes bradycardia or even blocks occur.

Effect of jaundice on CNS?

·         Kernicterus (in children)- kernicterus is deposition of unconjugated bilirubin on basal ganglia after crossing blood brain barrier.

·         Adult and elderly-  (posterior column affected)

o   Tremor

o   Gait of patient

Provisional diagnosis-

·         Obstructive  jaundice due to rapidly progressive malignancy with superimposed infection

Features of infective jaundice:-

·         Prodromal symptoms

·         Jaundice initially progresses and then start receding

·         Clay coloured stool intially which later on disappears

Itching in obstructive type of jaundice take more than one month time to manifest. Deposited in subcutaneous plane. Affinity for elastin.

Points in favour of malignant obstructive jaundice – painless progressive jaundice

Ca Stomach (features)-  LOADS

-          Lump

-          Obstructive features (vomiting, pain abdomen)

-          Anaemia, asthenia, anorexia

-          Dyspepsia (new onset)

-          Silent (jaundice, ascites, Krukenberg’s tumour, Sister Joseph nodules or Virchows nodules)

Investigation-(confirm the diagnosis, support the diagnosis, treat the patient)

-          USG abd-

-          LFT-