Patient details
- Name
- Mr Y.S.
- Age / sex
- 67-year-old man
- Occupation
- Retired teacher
- Marital status
- Married
- Admitted
- Surgical clinic, 10:00
- Clerked
- Surgical ward, 11:15
- Source
- Patient and his wife, reliable
- Referred by
- Family doctor
Presenting complaint
“My eyes have turned yellow over the last three weeks.”
History of presenting complaint
Mr Y.S. was well until three weeks before admission, when his wife noticed that the whites of his eyes had turned yellow. The yellow colour has deepened steadily since and has never faded. A few days before it appeared he noticed that his urine had become dark, like tea, and for the last two weeks his stools have been pale, bulky and difficult to flush. For two weeks he has had itching over the whole body, worse at night, which disturbs his sleep. He has had no abdominal pain, apart from a dull ache in the upper back over the past month that he put down to age. His appetite has been poor for two months and he feels full after small meals, and he has lost 8 kg in that time, from 82 to 74 kg, so that his clothes are loose. He was found to have diabetes four months ago. He has had no fever and no shivering attacks. He has never had attacks of pain after fatty food and has not been told he has gallstones. He has had no operation or endoscopic procedure on the bile ducts. He has had no blood transfusion, injections outside hospital or tattoos, no contact with anyone jaundiced, and no recent travel. He does not drink alcohol and has taken no new medicines or herbal remedies. He has not vomited, has passed no black stools and no blood. He has not noticed swelling of the abdomen or legs, and does not bruise or bleed easily.
Past medical history
Type 2 diabetes, diagnosed four months ago. Hypertension for ten years. No previous jaundice. No liver disease.
Past surgical history
No previous operations.
Drugs and allergies
Metformin 500 mg twice daily. Enalapril 10 mg once daily. No herbal or over-the-counter preparations.
No known drug allergies.
Family history
No family history of pancreatic, bowel or breast cancer, and none of jaundice or blood disorders.
Social history
Smoked 20 cigarettes a day for 40 years (40 pack-years), still smoking. Has never drunk alcohol. Lives with his wife, independent.
Last ate at 07:00 today.
Systems review
Tired for two months. No cough, breathlessness, bone pain or headache.
General examination
A thin man, comfortable at rest. Alert and orientated. Deeply jaundiced, seen in the sclerae and skin. Scratch marks on the arms and trunk. Not pale. Weight 74 kg, height 172 cm, body mass index 25.
Hands: no clubbing, no red palms, no flapping tremor. No spider naevi on the chest and no breast enlargement. No enlarged lymph node in the left supraclavicular fossa. No ankle swelling.
Abdominal examination
Inspection
Abdomen not distended. No scars. No dilated veins. Umbilicus normal.
Palpation
Soft and not tender. A smooth, rounded, non-tender mass is felt below the right costal margin at the tip of the ninth costal cartilage. It moves down with inspiration and its upper border cannot be reached: a palpable gallbladder. Liver edge felt 3 cm below the costal margin, smooth, firm and not tender. No epigastric mass. Spleen not palpable.
Percussion
Liver span 15 cm in the mid-clavicular line. No shifting dullness.
Auscultation
Bowel sounds normal.
Rectal examination
Performed with consent and a chaperone. Pale, clay-coloured stool on the glove. No mass and no blood.
Other systems
Chest: clear, no pleural effusion.
Heart: first and second heart sounds normal.
Legs: no swelling, no tender cords along the veins.
Summary
Provisional diagnosis
Obstructive jaundice from a malignant obstruction of the lower bile duct, most likely cancer of the head of the pancreas.
Initial plan
- Bloods: total and direct bilirubin, alkaline phosphatase, GGT, ALT and AST, albumin, clotting (INR), full blood count, urea and creatinine, glucose, CA 19-9.
- Ultrasound of the abdomen first, then CT of the pancreas with contrast.
- Vitamin K if the INR is prolonged. Keep him well hydrated.
- Discuss at the multidisciplinary meeting before any drainage procedure.
- Explain the findings to the patient and his wife with the senior doctor.
Differential diagnosis of jaundice
Sort jaundice into three groups: before the liver, in the liver and after the liver. Then, for obstructive jaundice, benign or malignant.
| Diagnosis | Points to it in the history | Points to it on examination | In this patient |
|---|---|---|---|
| After the liver: malignant obstruction | |||
| Cancer of the head of the pancreas | Painless progressive jaundice, weight loss, back ache, new diabetes | Deep jaundice, palpable gallbladder | Most likely |
| Periampullary cancer | Jaundice that goes up and down, black or silvery stools, anaemia | Pallor with jaundice, palpable gallbladder | Jaundice has never faded |
| Bile duct cancer | Painless jaundice, weight loss | Gallbladder not palpable if the block is above the cystic duct | Possible; imaging decides |
| Gallbladder cancer or nodes at the liver hilum | Long history of gallstones, or a known cancer elsewhere | Hard mass in the right upper quadrant | No such history |
| After the liver: benign obstruction | |||
| Bile duct stones | Attacks of pain, jaundice that fluctuates, fever and rigors | Tender right upper quadrant, gallbladder not palpable | No pain, no fluctuation |
| Benign stricture | Previous gallbladder or bile duct surgery | Operation scar | No surgery |
| Chronic pancreatitis | Years of alcohol, recurrent epigastric pain, fatty stools | Epigastric tenderness | Never drank alcohol |
| Hydatid cyst opening into the ducts | Contact with dogs and sheep, attacks of colic and jaundice | Enlarged liver | No such attacks |
| In the liver | |||
| Viral hepatitis | Malaise and nausea before jaundice; contacts, transfusion, travel | Tender liver, no palpable gallbladder | No risk factors, stools pale |
| Drug-induced or alcoholic hepatitis | New drugs, herbal remedies, heavy drinking | Tender liver | Neither |
| Cirrhosis | Long-standing liver disease, swelling of abdomen and legs | Spider naevi, red palms, ascites, small liver | No such signs |
| Before the liver | |||
| Haemolysis | Mild lemon-yellow tinge, normal urine and stool colour, family history | Pallor, enlarged spleen | Urine dark, stools pale |
Clinical signs related to this case
The signs you should look for in any jaundiced patient. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Signs of jaundice and its type | ||
| Yellow sclerae | Look at the white of the eye in daylight with the patient looking down | Jaundice; visible when bilirubin is roughly above 2.5 to 3 mg/dL |
| Scratch marks | Linear marks on the limbs and back | Itching from bile salts: obstructive jaundice |
| Pale stool on the glove | Clay-coloured stool on rectal examination | No bile reaching the bowel |
| Pallor with a lemon tinge | Pale conjunctivae with mild jaundice | Haemolysis |
| Signs in the abdomen | ||
| Palpable gallbladder (Courvoisier's law) | Smooth, rounded, non-tender mass at the tip of the right ninth costal cartilage, moving with breathing | Obstruction below the cystic duct that is unlikely to be due to stones |
| Murphy's sign | Catch in the breath on palpation under the right costal margin | Acute cholecystitis |
| Enlarged liver | Smooth and firm in obstruction; hard and irregular with deposits; tender in hepatitis | Character of the edge gives the cause |
| Enlarged spleen | Felt below the left costal margin, moving towards the right iliac fossa | Portal hypertension or haemolysis |
| Shifting dullness | Flank dullness that moves when the patient turns | Ascites: cirrhosis or spread of cancer |
| Signs of chronic liver disease | ||
| Spider naevi | Small red spots on the chest and face that fill from the centre | Chronic liver disease when more than a few |
| Red palms and breast enlargement | Redness of the outer palm; breast tissue in a man | Chronic liver disease |
| Flapping tremor | Jerking of the outstretched hands with wrists bent back | Liver failure affecting the brain |
| Signs of spread | ||
| Virchow's node | Hard node in the left supraclavicular fossa | Spread from an abdominal cancer |
| Sister Mary Joseph nodule | Hard nodule at the umbilicus | Spread within the abdomen |
| Tender cords along superficial veins | Red, tender lines that appear in different places over weeks | Migrating vein clots, linked to pancreatic cancer |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.