Surgical Jaundice

1. Sclera discoloured if bilirubin >50umol/l
2. Classification
   • Pre-hepatic
   • Hepatic
   • Post-hepatic
3. Investigations
   • Blood tests: FBC (haemolytic anaemia, RDW, associated infection)
   • U/Es: Associated hepato-renal syndrome
   • Liver function tests
     

     	Pre-hepatic	Hepatic	Post-hepatic
     Major causes	Haemolysis - post transfusion, SCC, Thal Hereditary - Gilbert's syndrome (failure of uptake)	Hepatitis Decompensated CLD Drugs (anaesthetics)	Gallstones Carcinoma of head of pancreas
     Bilirubin type	Unconjugated	Conjugated	Conjugated
     Bilirubin increase	++	++++	++
     ALT (alanine aminotransferase)	+	+++	+
     ALP (alkaline phosphatase)	+	++	+++

   • Clotting
   • USS: - underlying liver disease, dilation of CBD (>8mm is abnormal), gallstones, pancreatic mass
   • ERCP (endoscopic retrograde cholangiopancreatography)
   • CT scan

Approach

• Expose as for abdominal examination
• Start with the hands
• Look for signs of chronic liver disease
• Confirm presence of jaundice by looking at sclera
• Examine neck for Virchow's node

1. Inspect
   • Distension with ascities
   • Distended veins around umbilicus if portal hypertension (caput medusae)
2. Palpate
   • Feel for spleen / gallbladder
   • Palpate carefully in RUQ identifying tenderness or massess - Courvoisier's Law: "in presence of obstructive jaundice, a mass in the right upper quadrant is unlikelt to be due to gallstones"
3. Percuss
4. Auscultate

Completion

1. Check herniae orifices
2. Examine genitalia
3. Perform DRE
4. Check temperature
5. Dipstick urine