Q&A: Diagnosis Of The Adult With Jaundice

Jaundice and asymptomatic hyperbilirubinemia are common clinical problems that can be caused by a variety of disorders, including bilirubin overproduction, impaired bilirubin conjugation, biliary obstruction, and hepatic inflammation. Liver test reference ranges will vary from laboratory to laboratory.

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This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Digestive Health article more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.

In this article:

Diagnostic approach to jaundice
MCQ: clinical scenario
MCQ: answer
MCQ: explanation

Diagnostic approach to jaundice

The diagnostic approach to the jaundiced patient begins with a careful history, physical examination, and initial laboratory studies. A differential diagnosis is formulated based on those results and additional testing is performed to narrow the diagnostic possibilities.

Although the evaluation is usually not urgent, jaundice can reflect a medical emergency in a few situations. These include massive hemolysis (eg, due to Clostridium perfringens sepsis or falciparum malaria), ascending cholangitis, and fulminant hepatic failure. Expedient diagnosis and appropriate therapy can be life-saving in these settings.

MCQ: clinical scenario

An 18 year old male works in a company where lunches are often catered. One day, the water at the company facility is not working, but they manage to have the lunch anyway. Two weeks later, he becomes sick. He develops anorexia, nausea, malaise and jaundice. During the course of the next four weeks, seven people who shared in the lunch become ill with similar symptoms. After a few weeks, each of the seven people completely recovers and they replace their caterer.

What is a likely diagnosis?

a) Primary biliary cirrhosis
b) Hepatitis B
c) Hepatocellular carcinoma
d) Laennec's cirrhosis
e) Hepatitis A

MCQ: answer

The correct answer is E

MCQ: explanation

With no water working, but a catered lunch proceeding anyway, there was probably rampant poor sanitation present.

Hepatitis A is transmitted by the faecal oral route and is readily transmitted by poor sanitation. Hepatitis A can occur in epidemics, as in this scenario. The incubation period is two to six weeks, which was the time frame the employees developed symptoms. The symptoms include anorexia, nausea, malaise and jaundice.

Primary biliary cirrhosis tends to occur in women aged 40-60 and does not occur in clusters of people over a brief time frame.

The incubation period for hepatitis A is much shorter than for hepatitis B. Hepatitis A has an incubation period of 2-6 weeks, as seen in this scenario. Hepatitis B has an incubation period of 4 weeks to 6 month, which is not the time frame presented in this scenario.

Hepatocellular carcinoma is associated with long-standing liver disease, such as cirrhosis or hepatitis B or C, which is not the case here.

Laennec's cirrhosis is associated with heavy alcohol use over many years.

Reference(s)
1). UpToDate: Diagnostic approach to the adult with jaundice or asymptomatic hyperbilirubinemia. Available online: https://www.uptodate.com/contents/diagnostic-approach-to-the-adult-with-jaundice-or-asymptomatic-hyperbilirubinemia