Jaundice is only a symptom/sign, not a disease. The diagnosis of jaundice is not difficult, but the differential diagnosis is important. Whenever the serum bilirubin concentration is 17.1 to 34.2umol/L (1 to 2mg/dl), and the jaundice is not visible to the naked eye, it is called occult jaundice. If the serum bilirubin concentration is higher than 34.2umol/L (2mg/dl), yellow staining of the sclera, skin, mucous membranes, and other tissues and body fluids is called dominant jaundice.
It needs to be differentiated from pseudo-jaundice. Pseudo-jaundice is seen with excessive consumption of carrots, pumpkins, tomatoes, oranges and other foods containing carotenoids. Carotene only causes yellow staining of the skin and normal sclera; in elderly people, there is a slight yellow fat accumulation in the bulbar conjunctiva, uneven yellow staining of the sclera, more pronounced in the inner canthus, and no yellow staining of the skin. The blood bilirubin concentration is normal in pseudo-jaundice.
Clinical manifestations.
1.Basic symptoms
(1) Yellow staining of skin, sclera and other tissues. When jaundice deepens, urine, sputum, tears and sweat are also stained yellow, and saliva usually does not change color.
(2) Change in color of urine and feces.
(3) Gastrointestinal symptoms, often with abdominal distension, abdominal pain, loss of appetite, nausea, vomiting, diarrhea or constipation.
(4) manifestations of bile saltemia, the main symptoms are: itchy skin, bradycardia, abdominal distension, steatorrhea, night blindness, weakness, mental depression and headache, etc.
2.Concomitant symptoms
(1) Jaundice with fever is seen in acute cholangitis, liver abscess, leptospirosis, septicemia, lobar pneumonia. Viral hepatitis or acute hemolysis may be preceded by fever and followed by jaundice.
(2) Jaundice with severe pain in the upper abdomen can be seen in biliary stones, liver abscess or biliary ascariasis; severe pain in the right upper abdomen, chills and high fever and jaundice are the charcot triad, suggesting acute purulent cholangitis. Persistent dull pain or distension in the right upper abdomen can be seen in viral hepatitis, liver abscess or primary liver cancer.
(3) Jaundice with hepatomegaly, if mild to moderate enlargement with soft or moderate hardness and smooth surface, is seen in viral hepatitis with acute biliary tract infection or biliary tract obstruction. Obvious enlargement with hard texture and uneven surface with nodules is seen in primary or secondary hepatocellular carcinoma. Hepatomegaly with no obvious enlargement and hard edges with small nodules on the surface is seen in liver cirrhosis.
3.Abdominal signs
(1) Abdominal appearance Occupational liver lesions, giant spleen, retroperitoneal tumors and intrapelvic tumors all have local bulging in the corresponding areas, frog abdomen when there is a lot of ascites, umbilical protrusion, abdominal wall hernia and umbilical hernia may also occur. Varicose veins of the abdominal wall are seen in portal hypertension, portal vein or inferior vena cava obstruction.
(2) Liver condition Jaundice and hepatomegaly coexist in acute viral hepatitis or toxic hepatitis, with a soft liver and more pronounced pressure and percussion pain. In acute and subacute hepatic necrosis, jaundice deepens rapidly, while hepatomegaly does not appear or shrinks instead. In chronic hepatitis and cirrhosis, hepatomegaly is less pronounced than in acute hepatitis, and the texture increases, and there may be no tenderness; in cirrhosis, uneven margins and nodules of various sizes may also be found. In hepatocellular carcinoma, the enlarged liver may lose its normal shape and firm texture, and huge masses or small nodules may be found, and the pressure pain may not be significant. When liver abscess is close to the liver surface, there may be local inflammatory signs such as redness, swelling and pressure pain on the skin, and there may be cystic or fluctuating sensation in the liver area in cases of huge liver abscess, liver encapsulation disease, polycystic liver and hepatic cavernous hemangioma.
(3) Splenomegaly Jaundice with splenomegaly is usually seen in the decompensated stage of various types of cirrhosis, chronic active hepatitis, acute hepatitis, hemolytic jaundice, systemic infectious diseases and infiltrative diseases, and when cancer invades the portal vein and splenic vein, it can cause splenomegaly, and rare splenic infarction and splenic abscess also have similar splenomegaly with signs such as pressure pain.
(4) Enlarged gallbladder Jaundice with enlarged gallbladder are extrahepatic obstruction and should be considered.
(1) Cancerous jaundice is seen in cholangiocarcinoma, pancreatic head cancer, lack of special potbelly cancer and rare primary duodenal cancer. The gallbladder is smooth, non-pressurized and mobile, which is known as Cour-voisier gallbladder. In the case of gallbladder cancer, the gallbladder is firm and often has pressure pain.
②Once obstruction occurs in primary common bile duct stones, the gallbladder may be enlarged, mostly without pressure pain. In the case of gallbladder stones and chronic cholecystitis, the gallbladder is atrophied and cannot be retrieved.
③In chronic obstructive cholecystitis, due to the presence of stones in the gallbladder duct, the chance of enlargement of the gallbladder is greater than in acute cholecystitis, and the pressure pain is not obvious.
④In chronic pancreatitis, inflammatory fibrous tissue proliferation can compress the common bile duct and make the gallbladder enlarged, and the pressure pain is not significant.
⑤ Giant stones at the bottom of the gallbladder, congenital bile duct dilatation or biliary ascariasis can also cause enlargement of the gallbladder, and the pressure pain is not obvious. In intrahepatic cholestasis, the gallbladder is mostly atrophied, and whether the gallbladder is enlarged helps in the differential diagnosis of jaundice.
(5) Other conditions There are hepatitis, flutter tremor, hepatic encephalopathy and other neuropsychiatric abnormalities, sparse axillary hair, testicular atrophy, pestle and mortar fingers, hyperkeratosis of the skin, spatulate nails, multiple venous embolism and bradycardia. Patients with advanced cancer jaundice may also show signs related to metastasis of the cancer. Liver failure may manifest encephalopathy and intracranial hemorrhage. Hemoperitoneum, cholestatic peritonitis, cholestatic nephropathy and shock can also be seen in patients with cancerous jaundice.
Laboratory tests
In case of jaundice, total serum bilirubin and direct bilirubin should be checked to distinguish the type of bilirubin elevation, in addition to urinary bilirubin, urobilinogen and liver function are also essential.
(1) Jaundice dominated by elevated indirect bilirubin is mainly seen in various types of hemolytic diseases, neonatal jaundice and other diseases. The ratio of direct bilirubin to total bilirubin is less than 35%.
In addition to the above tests, some auxiliary tests related to hemolytic diseases should be performed, such as erythrocyte fragility test, acid hemolysis test, autohemolysis test, anti-human globulin test, blood routine, urinary occult blood, serum free hemoglobin, urinary iron-containing hemoglobin, serum lactate dehydrogenase, glucose-6-phosphate dehydrogenase, etc.
(2) Jaundice dominated by elevated direct bilirubin is seen in various types of intrahepatic and extrahepatic obstruction resulting in poor bile excretion and a direct bilirubin to total ratio greater than 55%.
In addition to some routine tests, further checks of alkaline phosphatase, γ-glutamyl transpeptidase, leucine aminopeptidase, 5-nucleotidase, total cholesterol, lipoprotein-X, etc. are required.
(3) Mixed jaundice with hepatocellular injury It is seen in all types of liver disease, manifested by elevated direct bilirubin and indirect bilirubin, with direct bilirubin to total bilirubin ratio of 35% to 55%, and abnormal results can be obtained by checking liver function.
Other tests
(1)Blood routine, urine routine.
(2)Jaundice index, quantitative serum bilirubin test.
(3)Urine bilirubin, urobilinogen, and urobilirubin examination.
(4)Serum enzymology test.
(5) Blood cholesterol and cholesterol ester determination.
(6)Immunological examination.
(7)X-ray examination.
(8) B-mode ultrasonography.
(9) Radionuclide examination.
(10) Liver biopsy.
(11) Laparoscopy.
Therefore, if you have yellow urine, yellow skin or yellow eyes, please consult a doctor in time to avoid delaying the diagnosis and treatment of the disease.