Jaundice Case Study

Case study:

You’re in the middle of a busy Monday afternoon shift. The next chart simply states “other complaint,” but one look at the patient tells you why he is here. The patient is a middle-aged male with no prior medical history who states that his family has been telling him his eyes are yellow for the last two to three weeks. He initially thought nothing of it but became concerned when the discoloration spread to his face. He also admits to occasional nausea, vomiting, poor appetite, weight loss, and diffuse itching. There is no history of fever, abdominal pain, heavy alcohol use, or recent acetaminophen ingestion. The physical exam is remarkable for icteric sclerae, jaundice of his face and upper chest, and mild non-tender hepatomegaly. Your history and physical have helped to develop the differential diagnosis related to the patient’s presentation your challenge is directing the ED work-up so that the appropriate initial interventions can be made before disposition

Conclustion of the above case study…
Your patient’s lab profile was significant for elevated direct bilirubin and alkaline phosphatase as well as mildly elevated transaminases, consistent with biliary obstruction. Based on the history and physical, you were more concerned about a malignant obstruction, so you ordered a CT of the abdomen and pelvis with contrast. This study showed a distended gallbladder with no cholelithiasis, a dilated common bile duct, and a mass at the head of the pancreas. Surgery was called and you made arrangements to admit the patient for ERCP and biliary decompression. You informed the patient of the CT results and let him know that he would be admitted for further work-up of the mass.

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Risk Management Pitfalls

1. “The patient denied taking any acetaminophen.” Patients, especially suicidal ones, may not be truthful about the amount of acetaminophen they ingested. Additionally, patients who have been treating chronic pain with acetaminophen around the clock may have chronic toxicity. Because acetaminophen-induced liver toxicity is one of the few treatable forms, an acetaminophen level should be checked for any undifferentiated cause of hepatocellular injury. 

2. “The kid didn’t appear that jaundiced, so I just told his mom to have him seen by his pediatrician.” The physical examination alone is a poor predictor of serum bilirubin levels, especially in the low light of an emergency department. Even well appearing neonates should have a total and direct serum bilirubin checked. 

3. “She appeared so comfortable; I wouldn’t have thought she had a pancreatic head mass.” Painless jaundice can often indicate biliary obstruction. The chemistry panel can also help narrow the differential and determine which patients should be imaged in the ED. 

4. “The patient wasn’t encephalopathic the other day when I saw her; now she is back and obtunded.” The initial stages of hepatic encephalopathy can be subtle starting with agitation and poor memory. Patients may also be good at hiding their difficulties in public. Questioning the family about a patient’s behavior might help to detect signs of early hepatic encephalopathy. A mini mental status examination may aid in documenting a patient’s cognitive impairment. All patients with jaundice and hepatic encephalopathy should be admitted. 

5. “The patient had no abdominal tenderness, so I didn’t consider cholangitis as a possibility.” Only 50-75% of patients with acute cholangitis manifest Charcot’s triad (fever, jaundice, and right upper quandrant tenderness). These signs can be absent, especially in the elderly and immunocompromised. A high index of suspicion should be maintained in patients with fever and jaundice, especially if they have a history of gallstones or prior biliary instrumentation

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