case of obstructive jaundice
TRANSCRIPT
CASE PRESENTATION
Obstructive Jaundice
. I.D:The patient is a 58 years old male, married with 3 kids, from Mangalore, working as a carpenter .
The patient had emergency admission at Wenlock Hospital on May 12.
Chief complain:Pain in the Rt. Upper part of his abdomen for 6 months, with yellowish discoloration of his eyes for 10 days.
History of Present Illness:The patient was apparently asymptomatic six months prior to his presentation when he started to have abdominal pain in the right hypochondrial and epigastric area that gradually increases in severity. The pain was continues, colicky in nature, aggravated by food especially fatty food, and relieved by medications.
And it was severe enough to prevent him from doing his job2 months back, he developed sudden, severe back pain, compressing in nature associated with nausea, vomiting and heart burn.
He has history of jaundice 10 days back, change urine color "tea like color" and soft white stool.
He has history of DM diagnosed while he as at the hospital since 8 days not on medication , no history of HTN.
Pt has history of anorexia and significant loss of weight about 30 Kg in 2 months.
No history of fever , no history of itching. He did not experience any attacks of similar pain in the past.
Regarding genitourinary system, apart from dark urine its symptomatically free.
Regarding CVS , RS , NS and MSS all are symp-tomatically free.
Past History:No past medical illnesses or surgeries.No history of blood transfusion.No known allergies. No Drug History. Family History:Married with 3 healthy kids.No chronic illness, no history of jaundice, no similar problem to his one in the family.
Personal History:Patient consumes mixed diet. Bowel and bladder habits are regu-lar. Sleep is unaltered. No addictions
Differential Diagnosis: Ca of the head of pancreas. HCC Cholagiocarcinoma Pre-ampulary carcinoma CBD stone. Hepatitis. Billary stricture.
Physical Examination: General examination:The patient was jaundiced.And looking well, conscious, lying comfortably in bed, not in pain or respiratory distress, average body built and connected to IV canula.
Vital Signs:Temperature: 37.2 CPulse rate: 66 beat per minute, regular , normal volume and char-acter with normal vessel wall.
Respiratory Rate: 15/minute.Blood pressure: 173/95
Head and neck: Eyes were moderately jaundiced, no pallor.Mouth was mildly jaundiced, no oral ulcers or pigmenta-tion with good oral hygiene.
No lymph nodes or any swelling in the neck is palpable.Left supraclavicular L.N. were not palpable. No increase in JVP. Hands:jaundiced, no palmar erythema, no muscle wasting, no Duputryn's contracture, no fingers clubbing.
Lower Limbs: All pulses are present.No peripheral edema.
Abdomen: Inspection:The abdomen was jaundiced.And symmetrical, move freely with abdominothoracic respi-ration, not distended but the flanks are full. inverted Umbilicus. No visible peristalsis or pulsation. No scars. Normal hair distribution. Hernial orifices are normal.
Palpation:Soft and lax abdomen.Tenderness in epigastric and RHC area.Palpable GB and enlarged liver , spleen not palpable. Normal temperature, no deep mass, no guarding and rigid-ity.
Both the kidneys were not palpable.
Percussion:Liver span is 16 cm. "hepatomegaly"The abdomen is resonant, no shifting dullness, normal spleen percussion.
Auscultation:normal bowel sounds.No renal artery or abdominal aorta bruite, hepatic rub was not audible.
PR and genitalia Examination: not done
RS:Normal bilateral air entry. Breath sounds are vesicular, no added sounds. Tactile vocal fremitus and vocal res-onance are normal.
CVS:Apex beat is palpable in the fifth intercostals space mid clavicular line.
Normal S1 and S2, no added sounds and no murmurs.
Investigations: Laboratory:CBC: leukocyte, neutrophil and lymphocytes counts are in the normal level RBC count and hematocrit shows a normal level.Blood glucose level: hi about 7.1 mmol/l.
Biochemistry:
SGOT Hi 127 u/l
SGPT Hi 180 u/l
Lipase NA
amylase 28
Gama G.T Hi 772 u/l
ALP Hi 228 u/l
T.Bilirubin Hi 208 umol/L
D.Bilirubin Hi 148 umol/L
albumin Slightly low 33 g/l
Imaging studies:X-Ray Chest and vertebrae X-rays are normal.CT: mass at the head of pancreas.U/S: the result was unavailable.
Final Clinical Diagnosis:Obstructive jaundice , due to mass at the head of pancreas.! Medications received during his admition: Vit. K , IV , 10 mg ,once a day. Zentack , IV , 50 mg , once a day. Flagyl , IM , 10 mg , once a day.
Plane:Medical report on Pt. request.Cont. same medicationsGet CT abdomen reportPossible discharge on 17 may. 2008 Follow up:Pt referred to King Faisal Specialist Hospital.
DISSCUSION
Obstructive Jaundice Pathogenesis it is due to intra- and extra hepatic obstruction of
bile ducts intrahepatic Jaundice: Hepatitis, PBC, Drugs Extra Hepatic Biliary Obstruction: Stones, Stricture,
Inflammation, Tumors, (Ampulla of Vater)
Etiology of Obstructive JaundiceIntrahepatic-Liver cell Damage/Blockage of Bile Canali-
culiDrugs or chemical toxinsDubin-Johnson syndrome Estrogens or PregnancyHepatitis-viral,chemical Infiltrative tumors Intrahepatic biliary hypoplasia or atresia Primary biliary cirrhosis
Etiology of Obstructive Jaundice
Extrahepatic-Obstructive of bile DuctsCompression obstruction from tumorsCongenital choledochal cystExtrahepatic biliary atresiaIntraluminal gallstonesStenosis-postoperative or inflammary
cholestasisclinical features
pain, due to gallbladder disease, ma-lignancy, or stretching of the liver capsule
fever, due to ascending cholangitis palpable and / or tender gallbladder enlarged liver, usually smooth
General signs of cholestasis
xanthomas: palmar creases, below the breast, on the neck. They indicate raised serum cholesterol of several months. Xanthomas on the tendon sheaths are uncommonly associated with cholestasis.
xanthelasma on the eyelids scratch marks: excoriation finger clubbing loose, pale, bulky, offensive stools dark orange urine
Obstructive Jaundice Lab Findings Serum Bilirubin Feceal urobilinogen (incomplete obstruction) Feceal urobilinogen absence (complete obstruc-
tion) urobilinogenuria is absent in complete obstruc-
tive jaundice bilirubinuria ALP cholesterol
Obstructive Jaundiceextrahepatic
serum / blood bilirubin (micromoles/l) 100-500; normal
range 3-17 AST I.U. 35-400; normal range <35 ALP I.U. >500; normal range <250 gamma GT I.U. 30-50; normal range 15-
40 albumin g/l 30-50; normal range 40-50 reticulocytes(%) <1; normal range <1 prothrombin time (secs) 15-45; normal
range 13-15 ( " + parenteral vitamin K) falls
Obstructive Jaundiceextrahepatic
urinary changes bilirubin: increased urobilinogen: reduced or absent faecal changes stercobilinogen: reduced or absent