History
A 76-year-old gentleman presents to the outpatient clinic with a 2-month history of jaundice associated with dark-coloured urine. He has no fever, abdominal pain or weight loss. He has a history of hypertension, hyperlipidaemia and chronic obstructive airway disease. He is taking nifedipine and simvastatin but there has been no recent change in dosage. He is a non-drinker and denies use of over-the-counter medications or herbs.
•Temperature 36.7°C, pulse 75 bpm, BP 135/80mmHg, SaO2 98-100% on RA.
•Hydration good, with jaundice.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual. No murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft, non-tender abdomen, with a vague palpable mass at the right upper quadrant.
•No signs of oedema.
Investigations
•CBC:
–WBC 8 x 109/L;
–haemoglobin 13.5g/dL;
–platelets 298 x 109/L.
•Total bilirubin 65μmol/L.
•ALP 412 IU/L.
•ALT 78 IU/L.
•Albumin 38g/L.
What is the differential diagnosis of jaundice?
Increased unconjugated bilirubin:
•Increased bilirubin production.
•Haemolytic anaemia.
•Ineffective haemopoiesis.
•Gilbert’s syndrome (less likely given the extent of hyperbilirubinaemia).
Increased conjugated bilirubin:
•Hepatocellular disease.
•Intrahepatic and extrahepatic biliary obstruction.
•Total parenteral nutrition.
What is the pattern of liver function abnormality?
An obstructive pattern (predominant increase in ALP).
Does this narrow down your differential diagnosis?
Biliary obstruction is more likely.
The causes of biliary obstruction include:
•Intraductal:
–biliary stones;
–biliary flukes;
–haemobilia.
•Ductal:
–cholangiocarcinoma;
–
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