Jaundice (cont.)
How is the cause of jaundice diagnosed?
Many tests are available for determining the cause of jaundice, but the history
and physical examination are important as well.
History
The history can suggest possible reasons for the jaundice. For example, heavy
use of alcohol suggests alcoholic liver disease, whereas use of illegal,
injectable drugs suggests viral hepatitis. Recent initiation of a new drug
suggests drug-induced jaundice. Episodes of abdominal pain associated with
jaundice suggests blockage of the bile ducts usually by gallstones.
Physical examination
The most important part of the physical examination in a patient who is
jaundiced is examination of the abdomen. Masses (tumors) in the abdomen suggest
cancer infiltrating the liver (metastatic cancer) as the cause of the jaundice.
An enlarged, firm liver suggests cirrhosis. A rock-hard, nodular liver suggests
cancer within the liver.
Blood tests
Measurement of bilirubin can be helpful in determining the causes of jaundice.
Markedly greater elevations of unconjugated bilirubin relative to elevations of
conjugated bilirubin in the blood suggest hemolysis (destruction of red blood
cells). Marked elevations of liver tests (aspartate amino transferase or AST and
alanine amino transferase or ALT) suggest inflammation of the liver (such as
viral hepatitis). Elevations of other liver tests, e.g., alkaline phosphatase,
suggest diseases or obstruction of the bile ducts.
Ultrasonography
Ultrasonography is a simple, safe, and readily-available test that uses sound
waves to examine the organs within the abdomen. Ultrasound examination of the
abdomen may disclose gallstones, tumors in the liver or the pancreas, and
dilated bile ducts due to obstruction (by gallstones or tumor).
Computerized tomography (CT or CAT scans)
Computerized tomography or CT scans are scans that use x-rays to examine the
soft tissues of the abdomen. They are particularly good for identifying tumors
in the liver and the pancreas and dilated bile ducts, though they are not as
good as ultrasonography for identifying gallstones.
Magnetic resonance imaging
(MRI)
Magnetic Resonance Imaging scans are scans that utilize magnetization of the body to examine the soft
tissues of the abdomen. Like CT scans, they are good for identifying tumors and
studying bile ducts. MRI scans can be modified to visualize the bile ducts
better than CT scans (a procedure referred to as MR cholangiography), and,
therefore, are better than CT for identifying the cause and location of bile
duct obstruction.
Endoscopic retrograde
cholangiopancreatography (ERCP) and endoscopic ultrasound
Endoscopic retrograde cholangiopancreatography (ERCP) provides the best means
for examining the bile duct. For ERCP an endoscope is swallowed by the patient
after he or she has been sedated. The endoscope is a flexible, fiberoptic tube
approximately four feet in length with a light and camera on its tip. The tip of
the endoscope is passed down the esophagus, through the stomach, and into the
duodenum where the main bile duct enters the intestine. A thin tube then is
passed through the endoscope and into the bile duct, and the duct is filled with
x-ray contrast solution. An x-ray is taken that clearly demonstrates the
contrast-filled bile ducts. ERCP is particularly good at demonstrating the cause
and location of obstruction within the bile ducts. A major advantage of ERCP is
that diagnostic and therapeutic procedures can be done at the same time as the
x-rays. For example, if gallstones are found in the bile ducts, they can be
removed. Stents can be placed in the bile ducts to relieve the obstruction caused
by scarring or tumors. Biopsies of tumors can be obtained.
Ultrasonography can be combined with ERCP by using a
specialized endoscope capable of doing ultrasound scanning. Endoscopic ultrasound
is excellent for diagnosing small gallstones in the gallbladder and bile ducts that can be missed
by other diagnostic methods such as ultrasound, CT, and MRI. It also is the best
means of examining the pancreas for tumors and can facilitate biopsy through the
endoscope of tumors within the pancreas.
Liver biopsy
Biopsy of the liver provides a small piece of tissue from the liver for
examination under the microscope. The biopsy most commonly is done with a long
needle after local injection of the skin of the abdomen overlying the liver with
anesthetic. The needle passes through the skin and into the liver, cutting off a
small piece of liver tissue. When the needle is withdrawn, the piece of liver
comes with it. Liver biopsy is particularly good for diagnosing inflammation of
the liver and bile ducts, cirrhosis, cancer, and fatty liver.
How is jaundice treated?
With the exception of the treatments for specific causes of jaundice mentioned
previously, the treatment of jaundice usually requires a diagnosis of the
specific cause of the jaundice and treatment directed at the specific cause,
e.g., removal of a gallstone blocking the bile duct.
Last Editorial Review: 3/24/2005
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