Case 24: Ex-Nurse With Jaundice
Monday, July 11th, 2011Author: Dr Ian Stell
A 53 year old female ex-nurse presented feeling unwell for 10 days, associated with the development of jaundice.
She also had mild upper abdominal pain.
Her stool colour was normal, and urine dark.
She had lost about 10 Kg of weight over 2/12.
Her father was Vietnamese, although she was brought up in the UK. She had worked extensively in the middle-East, but this was 20 years ago. She had been a fairly heavy drinker, but less in recent years. She had carcinoma of the cervix treated successfully 20 years ago.
On physical examination she was markedly jaundiced (see photo), with no stigmata of chronic liver disease. Her liver was not palpable and she had no ascites.
Her bilirubin was 301 μM/L, AST 225 U/L, Alk P 1662 U/L, albumin 32 g/L.
1. What type of jaundice is this?
Click to see the answerShe has a severe jaundice. The high Alk P indicates an obstructive pattern. The clinical features and well maintained albumin suggest an acute liver disease.
2. Could the Vietnamese connection be significant?
Click to see the answerHepatitis B is common in South East Asia, and both vertical transmission and transmission in childhood are common. When Hep B is acquired in childhood chronic carriage is much more likely. This in turn increases the likelihood of the development of hepatoma many years later. So had her mother been Vietnamese, or her childhood been in Vietnam, hepatitis B related hepatoma would have been a possibility.
3. Could this be alcohol related?
Click to see the answerThis is relatively unlikely, jaundice in alcoholics generally occurs in the context of chronic liver disease; so clinical features would usually be present. In acute alcoholic hepatitis there might not be much clinical evidence of pre-existing liver disease, but the biochemical findings would be those of a hepatitis.
4. What is the likely diagnosis?
Click to see the answerA malignant cause is likely with extensive hepatic metastases. Although carcinoma of the head of the pancreas can cause a painless severe jaundice, this is unlikely given the absence of pale stools – suggesting biliary drainage was not obstructed.
A CT scan (shown below) indicated extensive metastases. The primary was thought to be a cholangiocarcinoma. The patient died within weeks of presentation.
