A lady with jaundice

Mrs Murphy, a 48-year-old woman, has presented to hospital with jaundice. Work through the case to reach a diagnosis.


History

Presenting complaint

“Well, I went to my GP because over the last week or two, my skin had been getting more and more yellow. I didn’t think it was too bad, but my husband said I was very yellow, especially the whites of my eyes. I’m also getting a lot of tummy pain, which has been getting much worse!”

           

When did you or your husband first notice you were yellow?

“My husband said he first noticed something was wrong about 12 days ago.”

 

Have you been unwell recently? 

“No, I’ve been well for a while now.”

 

Have you noticed any other associated symptoms?

“Well I’ve had some intermittent pain in my tummy and my bowels have been a bit off, but other than that I’ve been ok, no fevers or anything like that.”

 

What’s changed with your bowels? 

“Well, they just seem a weird colour, pale I’d say.”

 

Have you had any urinary symptoms?

“My urine is definitely a lot darker, but other than that, no other changes.”

Exploring the abdominal pain

Site – Where is this pain specifically?

“Here, on my side.” (*she indicates her right hypochondrium*)

 

Onset – When did you first start experiencing the abdominal pain?

“It’s been on and off for a few months.”

 

Character – What kind of pain is it? Is it sharp or a dull ache?

“It can be quite sharp and when it’s bad it can just completely stop me in my tracks.”

 

Radiation – Does it move anywhere else?

“It used to give me some back pain behind my right shoulder, but now it’s only sore in the same place on my side.”

 

Associated symptoms – Do you experience any other symptoms when you have the abdominal pain?

“I often feel a bit nauseated when it’s happening, but that’s about it.”

 

Timing – How frequently are you experiencing the abdominal pain?

“Well when it started a few months ago, I’d get the pain every week or so, but now I’m getting at least one or two bouts of pain a day.”

 

Exacerbating and/or relieving factors – Does anything seem to trigger the pain or make it better?

“I know that if I eat a big dinner it will get more painful. I don’t eat much at all now because it makes me sore and a bit nauseous.”

 

Severity  – If you were to rate the pain out of 10, how bad would you say it is?

“Right now? I’d say 7 out of 10.”

Past medical and surgical history:

  • Pre-existing medical conditions
  • Previous hospital admissions
  • Previous abdominal surgery
  • Previous blood transfusions

“The only times I was ever in the hospital were for the birth of my two children and for appendix surgery when I was a teenager. I never had a blood transfusion to my knowledge.”

 

Drug history:

  • Regular medications
  • Recent changes to medications
  • Antibiotics
  • Over the counter medication
  • Allergies

“I just take a blood pressure tablet, can’t remember the name, but I’ve taken it for years. Other than that I don’t take anything. I don’t have any allergies.”

 

Social history:

  • Alcohol history
  • Smoking history
  • Recreational drug use (specifically IV drug use if considering blood-borne diseases)
  • Recent foreign travel

“I would usually have a glass of wine each day with dinner. I’ve never smoked and haven’t ever used recreational drugs. I was on holiday last summer but it wasn’t abroad.”

 

Family history:

  • Medical conditions that run in the family

“No, we don’t have any medical conditions that run in the family.”

  • Flucloxacillin and co-amoxiclav are the most common causes of drug-induced jaundice.
  • Others include paracetamol (in overdose), nitrofurantoin, steroids, oral contraceptive pill, tuberculosis drugs and malaria drugs.

Examination

  • Jaundice (skin/sclera)
  • Lymphadenopathy
  • Hepatomegaly
  • Splenomegaly
  • Murphy’s sign

 

Abdominal examination findings

General assessment:

  • Mrs Murphy is sitting on the bed. She is clearly jaundiced and looks uncomfortable.
  • Vital signs are normal and the patient is fully orientated.
  • There are no adjuncts around the bed.
  • The patient is overweight.
  • There is no palpable lymphadenopathy.

Abdominal examination

  • Inspection:
    • No significant abdominal distension
  • Palpation:
    • No organomegaly
    • No masses
    • Tenderness in the right upper quadrant
    • Murphy’s sign is positive
  • Percussion: Percussion tenderness over the RUQ
  • Auscultation: Bowel sounds present

Murphy’s sign is elicited by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to breathe in. Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down. If the patient stops breathing in and winces with a ‘catch’, the test is considered positive. In order for the test to be considered positive, the same manoeuvre must not elicit pain when performed on the left side

Courvoisier’s law states if a patient presents with jaundice and they have a non-tender, palpable gallbladder on examination, the cause is unlikely to be due gallstones. This is because gallstones form over a prolonged period, which results in a shrunken fibrotic gallbladder which does not distend easily. As a result, the presence of jaundice and a palpable gallbladder should raise suspicion of malignant obstruction of the biliary tree (e.g. pancreatic cancer).

Mirizzi’s syndrome is a rare complication in which a gallstone becomes impacted in the cystic duct or neck of the gallbladder causing compression of the common bile duct (CBD) or common hepatic duct, resulting in obstruction and jaundice. Obstructive jaundice can be caused by direct extrinsic compression by the stone or from fibrosis caused by chronic cholecystitis (inflammation).²

This is when a cholecystoenteric fistula forms and a gallstone passes into the small intestine and obstructs the terminal ileum.


Differential diagnosis

  • Cholecystitis
  • Choledocholithiasis
  • Cholangitis

Investigations

Bloods:

  • Full blood count (Hb, platelets, WCC)
  • Serum lipase and amylase (to help rule out pancreatitis)
  • LFTs (useful when trying to differentiate between obstructive jaundice and primary hepatic pathology)
  • Coagulation screen (helpful to assess the liver’s synthetic function)
  • U&Es (baseline renal function)

Mrs Murphy’s blood results

  • Hb 14 (13-18.5g/dL)
  • Platelets 175 (150 – 450 x109/L)
  • WCC 13 (4-11 x109/L) ↑
  • Na+ 136 (135-145mmol/L)
  • K+ 4.1 (3.5-5mmol/L)
  • Urea 5 (3-7mmol/L)
  • Creatinine 100 (62-106mmol/L)
  • Albumin 44 (35-50g/L)
  • PT and APTT: normal
  • Bilirubin 75 (<17µmol/L) ↑
  • ALT 29 (7-35 IU/L)
  • AST 26 (8-48 IU/L)
  • ALP 137 (45-115 IU/L) ↑
  • γGT 83 (<60 IU/L) ↑
  • Lipase 150 (114-286IU/L)
  • Amylase 80 (25-115 IU/L)
  • USS gallbladder – the gold standard in the investigation of gallstones
  • Abdominal x-ray – not that useful as only 10% of gallstones are calcified are therefore visible on x-ray
  • CT abdomen with contrast – can be useful if other modalities fail however some gallstones are isodense to bile and therefore may not be visible on CT scans
  • MRCP – provides detailed imaging of the biliary tree – often used for pre-operative planning of surgery
Gall bladder USS
USS gallbladder 6

Radiology report

“Large obstructing stone found within gallbladder neck. Thick hypoechoic gallbladder wall. Common bile duct dilated at 8mm.”


Diagnosis

Acute cholecystitis


Management

Initially, acute cholecystitis is usually managed conservatively:

  • Bed rest
  • Gut rest (nil by mouth)
  • Analgesia (NSAIDs and opiates)
  • Antiemetics
  • IV fluids
  • Antibiotics (broad-spectrum)

After initial treatment patients may either undergo an elective laparoscopic cholecystectomy or an early cholecystectomy during their emergency admission.


References

1. Bree, RL (March–April 1995). “Further observations on the usefulness of the sonographic Murphy sign in the evaluation of suspected acute cholecystitis”. Journal of Clinical Ultrasound. 23 (3): 169–72. DOI:10.1002/jcu.1870230304. Available from: [LINK].

2. Vitale M. Mirizzi Syndrome Type IV: An Atypical Presentation That Is Difficult to Diagnose Preoperatively. 2009. Society for Surgery of the Alimentary Tract. Available from: [LINK].

3. Greg McLatchie, Neil Borley, Joanna Chikwe (2013). Oxford Handbook Of Clinical Surgery. 4th ed. Oxford, UK: Oxford University Press. P311-321.

4. J Hepatobiliary Pancreat Sci. 2013 Jan;20(1):1-7. DOI: 10.1007/s00534-012-0566-y. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. Takada T1, Strasberg SM, et al.

5. Alasdair K.B. Ruthven (2010). Essential Examination. 2nd ed. Oxfordshire, UK: Scion Publishing Limited. p14-17.

6. Ralls PW et al. Gastroenterol Clin N Am 2002. Ultrasound showing cholecystitis.


 

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