1. Identify salient historical information that my have a bearing to this patient's chief complaint and indicate its significance.

• 2 weeks preceding onset of jaundice has tired, anorexic, nauseated

• Fever last night with "shaking chills"

• Pain and fullness in RUG

• Emesis

• 30 pound weight loss in 3 months

• Chronic alcoholic

• Psychiatric admission

• Affair with an IV drug user with history of hepatitis

• Uses Tylenol

• Travel to Mexico

2. What is your working diagnosis for her Jaundice based on the history.

• Alcoholic hepatitis

• Viral hepatitis

• Drug induced hepatitis

• Choledocholithiasis/ascending cholangitis

• Acute pancreatitis

3. Identify salient physical findings that my have a bearing to this patient's chief complaint and indicate its significance.

• Unkempt

• Scleral icterus

• Liver span 20 cm

• Tender Liver

• No rebound

• Skin icteric

• Spider nevi

• Fine tremors of hands

• Palmar erythema

4. What is your working diagnosis for her Jaundice based on the history and physical?

• Alcoholic hepatitis

• Viral hepatitis

• Drug induced hepatitis

• Choledocholithiasis/ascending cholangitis

• Acute pancreatitis

5. Identify salient Laboratory findings that my have a bearing to this patient's chief complaint and indicate its significance.

• Anemia

• Macrocytosis

• Leukocytosis

• Bilirubin

• Liver enzymes

• Alkaline phosphatase

• Worsening WBC count and bilirubin in 3 days

Transaminases are elevated but not very high. Probably mild hepatocellular injury. The total bilirubin is high. We are not given fractionation. Alkaline phosphatse is elvated suggesting  (with increase in conjugated bilirubin) a cholestatic process.

6. Cite the main clinical problem (not the diagnosis)

Jaundice

7. Cite other significant clinical problems (not diagnoses).

Nausea, vomiting, fever, chills, abdominal pain

8. We need a clear understanding of Bilirubin metabolism to solve clinical problems related to it Briefly review the formation of bilirubin. 

• Conjugated bilirubin is water soluble and is excreted in the bile.  

• Unconjugated bilirubin must be converted in the liver to the water soluble form.  

• Diseases such as hemolysis, Gilbert’s cause an unconjugated bilirubin.  Kernicterus in the newborn is the most serious disease expression of unconjugated bilirubin.  

• Most other disease such as viral hepatitis and obstructive liver disease will cause a conjugated hyperbilirubinemia as this function is usually the “last to go” in advanced liver disease. 

9. Discuss a differential diagnosis based on disease categories. A good way to discuss this question is to approach the jaundiced patient according to the fractionation of the bilirubin. 

Unconjugated hyperbilirubinemia

80-85 % of unconjugated bilirubin (indirect)  in unconjugated hyperbilirubinemia

• Increased bilrubin production
  • Hemolysis
• Decreased hepatic uptake/Decreased glucoronide conjugation
  • Gilbert's syndrome
  • Drugs
  • Physiologic jaundice of newborn

Conjugated hyperbilirubinemia

>50% direct reacting indicates conjugated hyperbilirubinemia

• Hereditary disorder
  • Dubin-Johnson Syndrome
• Hepatocelluar disease
  • Viral hepatitis
  • Alcoholic hepatitis/Cirrhosis
  • Ischemia/CHF
  • Autoimmune hepatitis
  • Metabolic: Rye syndrome, Wilson's disease
• Cholestatic jaundice
  • Intrahepatic
    • Granulomatous infection
    • Severe inflammation
    • Malignancy
    • Primary biliary cirrhosis
    • Drugs
  • Extrahepatic
    • Choledocholithiasis
    • Primary sclerosing cholangitis
    • Pancreatitis
    • Pancreatic carcinoma

10. Now after listing differential diagnosis, what are the important historical information you should gather from history and why?

Review this information from "Resource". "Jaundice" option. The information provided is exhaustive. Use it in your clinical years.

11. Now after listing differential diagnosis, what are the important physical findings you should gather from physical examination and why?

Review this information from "Resource". "Jaundice" option. The information provided is exhaustive. Use it in your clinical years.

12. What are the useful lab studies in evaluation of a patient with jaundice and their utility?

Review this information from "Resource". "Jaundice" option. The information provided is exhaustive. Use it in your clinical years.

13. What patho-physiologic process does the laboratory data suggest?

• The liver transferases are slightly elevated  along with bilirubin.  (presumably it is conjugated)

• This indicated mild hepatocellular injury with marked cholestasis.  

• The alkaline phosphatase level also gives evidence of the severe cholestasis (with increase in conjugatedbilirubin).  (You need to order a gamma glutamy/transpeptidase to be specific about the organ of origin of alkaline phophatase)

• Note that the AST level is greater than the ALT level which is classic for the disease process (alcoholic hepatitis) that is present in this patient.

14. What is the diagnosis in this patient

Alcoholic hepatitis. 

Infection must be ruled out in view of the fever, chills, and leukocytosis.

15. Cite data from the history, physical exam and laboratory to support this diagnosis.

• Recent and past history of alcoholism. 

• Nausea, vomiting and RUQ pain.  

• Hepatomegaly, spider nevi, palmar erythema. 

• Cholestatic picture.  AST greater than ALT. AST/ALT ratio >1

• Leukocytosis.  

• Worsening clinical picture after hospitalization.

5.     

16. Why is it not Viral hepatitis?

• Viral hepatitis is unlikely, especially if we assume patient is not an IV drug user. Sexual transmission is possible but inefficient mode.

• AST is greater tha ALT. 

• Transaminases are low for hepatitis. 

• Increased wbc is not typical for viral hepatitis, especially level of 42,000/mm3.

17. What disease or group of diseases would account for the patient's fever, chills and elevated WBC's?

• Infection

• Alcoholic hepatitis

• Neoplasm

18. What other laboratory/radiologic examinations might be done to exclude other causes of jaundice? 

• Serum amylase/lipase to exclude pancreatitis.  

• Hepatitis serologies (unlikely diagnosis). 

• Flat plat of abdomen  - pancreatic calcification 

• Ultrasound exam of RUQ to exclude gallstone, common duct disease.

19. Assuming that she has alcoholic hepatitis what would a liver biopsy show in this patient?

• Scattered, small foci of liver cell necrosis.  

• Mallory bodies (intracellular accumulation of cytokeratin).

• Scattered foci of neutrophils

• Steatosis.  

• Cholestasis.  

• Possible fibrosis since alcoholism has been chronic. 

20. What advice would you give the patient regarding the use of Tylenol.

• Acetaminophen (Tylenol) in therapeutic doses can be and is reported to be toxic in patients with liver disease due to increased P-450 enzyme activity.  

• Tylenol should be used cautiously or probably not at all in these patients and they should be properly instructed about the potential toxicity of therapeutic doses of Tylenol.