Jaundice

In this podcast, Dr Gavin Nimon interviews Dr Sandy Craig, Gastroenterologist, about his approach to assessing jaundice.

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Transcript

Gavin: Welcome to the Australian Medical Education Podcast, as I like to call it Aussie MedEd. This where I get interview different specialists in different areas of medicine and ask them about different conditions, including diagnoses, investigations, treatment options, et cetera.

Gavin: Really in these COVID times, it really replaces the actual general chit chat we used to have around the corridors or in the tea rooms or the hospitals. It actually gets, gives you an idea of a pragmatic approach to these different conditions and makes it more of a fun way to get a bit more information.

Gavin: Any questions that you might want to put to me can be put forward to, to me at gavin at med ed. com. au. And I'm [00:01:00] Gavin Nyman, the host of this podcast, which I'm hoping will be educational in a fun and relaxed fashion. Look forward to bringing you this information today and thank you for listening. Well, thanks again, once again, it's nice to have you on board in our first educational podcast, this time based on a gastroenterologist and talk, discussing the topic of jaundice.

Gavin: In this particular podcast, we interviewed Dr. Sandy Craig, who will talk to us about his approach to assessment of jaundice. We'll look forward to speaking to him later on. Hi, I'm Gavin Nyman, the host of this podcast, a North Peak Surgeon based in Adelaide in South Australia. The idea of the podcast is to provide information to you.

Gavin: After interviewing and speaking to consultants in the area of their specialties. Obviously this is not my main area of expertise and as such the information provided is of a general nature and really more of a chit chat sort of conversation to get an idea of how a real day person treats a condition.

Gavin: Please take on board that this information provided is of a general nature, not thought to be considered as general medical advice and nor [00:02:00] should it be the only way of treating a particular condition. Obviously the general practitioner or medical student listening to it should supplement their Acknowledge by this podcast, but also get refer to resources and consultants in the area around their specialty.

Gavin: I'd like to begin this podcast by acknowledging the traditional custodians of the land of which this podcast has been produced, the Kaurna people and pay my respects to the elders both past and present. It gives me great pleasure to introduce our first guest on Aussie Med Ed. He's a gastroenterologist who undertook his undergraduate teaching at Adelaide University from 1986 to 1991.

Gavin: Then completed his advanced physician training both at Royal Aid Hospital between 93 to 97. Obtaining a PhD at Flinders University and working on biliary motility from 98 to 2000. BMO at Flinders Medical Centre until 2017 and he now works in Adelaide. I'd like to introduce Dr. Sandy Craig, who is my special guest on Gash on Geology, who's going to talk to us about the assessment and [00:03:00] options of treatment for jaundice.

Sandy Craig: Sandy, how are you doing? 

Gavin: Good. Thanks very much for coming along and being our first guest on, Aussie med ed, Australian medical education podcast. It's great to have you on. I'm looking forward to it. Excellent. Excellent. Now you're a gastroenterologist. You obviously see a lot of, uh, uh, general, uh, complaints, but jaundice is one that's been raised by the medical students to me about how to assess it.

Gavin: Obviously, it encompasses a large group of conditions, and I just really wanted to know your approach to assessing a patient who might come in jaundiced and how you'd go about assessing them. And obviously, we're talking about the adult population. 

Sandy Craig: Look, I was, uh, grateful for your idea of the rule of threes, that you always try to break things down into ways of approaching it so that you can remember things. And you can try to look at jaundice as pre hepatic, hepatic and extra hepatic. But in simple terms, it [00:04:00] really is either in the liver or it's a blockage of the bile ducts out of the liver.

Sandy Craig: So the key from my point of view is obviously to take a full history. In particular, asking about, you know, the sense of whether or not there's been any infective event, the drug history, also about, non prescribed medications, there are some over the counter herbal remedies that can cause hepatitis, obviously alcohol, something you need to consider, um, and then whether or not people have pain, because painless jaundice versus someone with a history, perhaps a biliary colic, that could then suggest Common bile duct stones is, is an important part of the history, especially in the older person who could be at risk of even having cholangitis.

Sandy Craig: So I suppose that, that the key is a good history on examination, trying to look for any signs of, or any signs of toxicity, but, um, also whether or not there are any signs of [00:05:00] chronic liver disease to try to work out if this is an acute or chronic situation. And then the, the, the crux of it will usually come down to.

Sandy Craig: Um, the liver function test and imaging to look at the bile ducts. And once you've got those things in play, you can usually then start to work it out as to whether or not it's a liver problem or a problem in the bile ducts. Yeah, 

Gavin: that's, that's a, that's a great point. I think you bring up the idea of the history really being the most important part of the And you've outlined a pretty good aspect of the history You mentioned though, medications that are bad, and can cause this, which ones particularly should we watch out for? 

Sandy Craig: Well I suppose just, any antibiotic can potentiate it. The classic, uh, uh, commencing of anti convulsant medication, and honestly if someone's, um, in a more acute situation, if they've had, uh, paracetamol.

Sandy Craig: poisoning or, or overdose. [00:06:00] Um, they're, they're really the main ones and there's some, some unusual things like anabolic steroids, some cardiac medications, but they're, they're the main ones. 

Gavin: So most of these medications probably wouldn't affect the average person, but there's some people who can have a hyper reaction to it or can take, accidentally take too large a dose and this can cause issues.

Gavin: What about the infections? Um, obviously I was brought up on Hep A, B and C. At the time when I was training, Hep C was a bad diagnosis, but now I believe it's curable. Are there any other type of new acute infections that we need to watch out for? 

Sandy Craig: I suppose we're always going to watch out for Hepatitis, you know, severe Hepatitis A, because it might then cause more infections with other people, but um, Uh, not, not, not really, Gav, I think most of that stuff's unusual, although it's fascinating the number of people that actually have antibodies to Hepatitis A, meaning that there are many people who develop Hepatitis A as some sort of viral illness, but never actually become significantly unwell or [00:07:00] jaundiced.

Sandy Craig: Glandular fever in its severe form can be associated with an acute Hepatitis and CMV, but it's pretty uncommon. I've, I've, I've only ever seen severe hepatitis, severe glandular fever causing jaundice on a handful of occasions. You're, you're 

Gavin: heading on to about the obstructive causes with, with biliary disease.

Gavin: You obviously, when I was training we saw a lot of cholecystitis, gallstones. Yet for some reason I haven't seen it come across it that often in, in practice. And if I don't know if I've ever met anyone, both privately through my friends or as any of my patients who have actually had it. How common is gallstones and cholecystitis in the community? Is it a common thing? Is  it, is that one of the major causes of jaundice? 

Sandy Craig: Well, 12% of autopsy studies in autopsy studies, 12% of people have asymptomatic gallstones, but pretty common gallstones being present in the, in society. But, um, it's those unlucky people where the gallstone can [00:08:00] get into the, into the bile ducts, obstruct situation.

Sandy Craig: Particularly junior doctors need to be aware of because an older person presenting with jaundice and fever, cholangitis can be lethal. So understanding that that is a really important situation to be aware of is, is critical. Most of these patients, I think they come, come through A& E departments, Gav, so you, that's probably why you don't.

Sandy Craig: see it in your practice, but, um, cholangitis is a worrying diagnosis. So 

Gavin: of all those ones, which one's the most common thing that you'd see in your practice? 

Sandy Craig: Yeah, so, um, I suppose we worry always about pancreatic malignancy. In terms of, uh, pancreatic malignancy, it's more about painless, jaundice, because if you do get a pancreatic cancer that's obstructing the bile duct, it tends to be quite early and not associated with pain.

Sandy Craig: And it's a [00:09:00] classic, um, clinical sign of a of a palpable gall bladder

Gavin: So, pancreatic tumors, are they, are they very common Sandy? 

Sandy Craig: The early pancreatic cancer involving the bile duct is one of those rare situations where you can actually have a successful outcome in pancreatic cancer treatment because the jaundice is an early event, classically associated with a palpable gallbladder.

Sandy Craig: And the, the, i, I assume it was a Frenchman called Vao who described that sign. And the, the, the important aspect of that sign is that if people have had a history of gallstones, the gallbladder tends to be small and contracted and dilate. So that, that, and that's often a bit of a classic exam question. Um, then no pan pancreatic cancer, and then the, the rarities in terms of Bile duct tumors, such as cholangiocarcinoma, which is not, not very common in more.[00:10:00] 

Sandy Craig: In, in terms of malignancy, metastatic cancer in the liver causes a bit of a mixed picture of cancer. Um, sometimes with nodes around the bile duct getting compressing the bile duct, but also if the liver becomes extensively involved in the test disease, it develops its own form of what, what you'd call intra hepatic cholestasis.

Sandy Craig: Okay, so now they're, they're probably the most common. And then, then the classic being the the cirrhotic person who then, Decompensate to me comes, John, because that's a very common cause. If you just come back to your earlier question of how you define it, you're really trying to work out if it's an intra hepatic or extra hepatic problem.

Sandy Craig: And I would initially do blood tests looking at the liver function test, and if it was a transaminitis with an ultrasound not showing bile duct dilation, then you'd head down the pathway of investigating liver causes. If the bile ducts were dilated, you immediately look at, and the liver tests were suggestive of [00:11:00] cholestasis with a raised ALP and AL and GGT. You then down, head down the pathway with more careful examination of the bollarducts usually with an MRI of the biliary ducts or MRCP. Right. 

Gavin: MRCP is an MRI ? 

Sandy Craig: It turns out that biliary secretions can be imaged by the MRI machine to give you lovely pictures of, of a, of a cholangiogram.

Gavin: Okay. So, so ERCP is only really now an interventional procedure to either put a stent in or to remove stones. Gee, that needs to be so common. Yes, no, well that, so, so MRCP really has taken, has taken over that space.

Gavin: how often, how often do you need to do intervention to remove stones or? Uh, how often a cholecystectomy is required of all the people who get [00:12:00] some jaundice? Will most of them require something like that in that scenario or? 

Sandy Craig: I think these days if, um, the surgeons are far more skilled at trying to handle both removing the gallbladder and trying to remove common bile duct stones at the same time.

Sandy Craig: Although, it can be a tricky situation because if you operate on the gallbladder and you don't decompress the bile duct, you run the risk of the surgical, clips not holding. So, more often than not, people will do an ERCP prior to cholecystectomy to ensure that you've got good drainage of the bile ducts.

Sandy Craig: But how common is this stuff? It's happened that there'd be several lists a week of ERCP at most tertiary centres. Um, for, you know, bowel duct stone removal, or mainly to put stents in malignant strictures as a way of decompressing the system and, and relieving jaundice. 

Gavin: Okay. We talked about examination before, and I, what parts do you really want to look at when you're examining a patient?

Sandy Craig: I [00:13:00] suppose you're, you're obviously trying to examine the, just get a feel for how big the liver is, tender, which is more common in acute hepatitis. In particular looking for signs of chronic liver disease, and all those classical things. Starting with the hands and working out the arms to the, to the, to the head.

Sandy Craig: Um, looking for palmar erythema, clubbing, dupuytren’s, bruising, suggesting coagulopathy, spider nevi in the chest and cheeks, you know, gynecomastia for a sign of cirrhosis. Um, assessing for splenomegaly, which could be either tied up with an infective event or a sign of chronic liver disease with total hypertension.

Sandy Craig: So you're really trying to assess all of those issues.

Gavin: Okay. What about, what about something like Gilbert's syndrome, I'm not sure how it's pronounced nowadays, but um, is that, I believe that's quite common. 

Sandy Craig: Did you think you had a bit of French sound about it? 

I've always called it Gilbert's, [00:14:00] but um, look, it's thought to affect maybe 5 -10% of the population. Typically, these people, this is now getting into the concept of the isolated. elevated bilirubin. So all the liver enzymes are normal, but you've got this, this bilirubin that's typically about 30 to 40. And if you fractionate it, you can work out if it's got, if it's unconjugated or conjugated.

Sandy Craig: And if it's predominantly unconjugated, that's classic for Gilbert's. Although it's important to always have a look at the blood picture to make sure there's no signs of hemolysis. Obviously, you know, hemolytic conditions will cause an unconjugated heart failure of the knee, but Gilbert's is undoubtedly the most common cause of an isolated elevated bilirubin 

Gavin: and Will they cause jaundice in that scenario?

Sandy Craig: Yes but not commonly. And what will typically happen is sometimes someone with Gilbert's will be given a medication or just get a viral illness or just Have, have, [00:15:00] you know, maybe a few too many drinks. And they might run a bilirubin of up to, say, 70 and be mildly jaundiced. And there's the rare cases where people will become obviously jaundiced.

Sandy Craig: I've got a general rule of thumb that the, the, the, the icteric or, you know, um, sclera becoming jaundice, you've got to have a bilirubin of about 50 to 70. And then once you, once you get a bilirubin of more than that, it might start to become apparent in the skin. Um, but they, they rarely get bilirubins of more than a hundred.

Sandy Craig: But Gilbert's is thought to affect five to ten percent of the population, so it's pretty 

Gavin: common. Interesting thing with this is, uh, once your patient does present with jaundice, how is it, how is it treated, apart from treating the underlying condition which caused it? Is there any way of actually improving the, uh, bilirubin, or reducing the bilirubin in the system?

Gavin: And, uh, excreting it? It's mainly in 

Sandy Craig: people with extrahepatic obstruction, and that's what I was talking about with the ERTP and the interventions you can... Look out with stenting [00:16:00] to, to drain, to get drainage out of the boulder, and that's really important because people can become very, very, um, distressed with itch when jaundice is persistent, and particularly people with malignant causes of jaundice, trying to make sure that they get drainage is critical.

Sandy Craig: And it also, once you've got drainage, it means the risk of colangitis decreases enormously. 

Gavin: Any other tests apart from, MRCP? blood tests that students need to be aware of? 

Sandy Craig: Obviously always assessing people's liver function, their synthetic function by looking at their INR, their albumin, looking for any signs of liver failure with hepatic flap, signs of ascites.

Sandy Craig: That's always important to have a sense of. People's, what's called the child's score is really an [00:17:00] assessment of how the liver is compensated or uncompensated. 

Gavin: Well thanks Sandy. I think that's been a fantastic rundown of how a real world physician treats jaundice. Really appreciate your advice and I hope the audience has found it very useful.

Gavin: Once again, it's been great having you on the show and for those listening, Dr. Sandy Craig, I really appreciate his advice. He's one of the nicest guys in medicine. And, uh, very pragmatic approach to how a broad jaundice can be assessed and treated. Once again, thank you very much, Sandy. It's been great having you.

Sandy Craig: You're very kind, Gav. Anytime. Thank you very much. 

Gavin: See ya. Once again, I'd like to remind you that the information provided in this podcast is really a supplement to other sources of information. So it's from research and from other consultants in the area. And the information provided today is of a general nature and not specific to a specific condition or specific [00:18:00] patient. A person listening to try to find out more information about their particular condition should always consult their general practitioner or seek specialist advice. Realise that the information provided is in general manner. And it's not considered as a part of a general medical consultation and any further information provided should be treated in general and in no way provide individual clinical advice.

Gavin: Well thank you very much for listening to our podcast Australian Medical Education or Aussie Med Ed. It's been a pleasure giving you this information and I'd like any further feedback or questions directed towards me put towards Gavin at med ed. com. au. Any questions on a particular area of medicine will be directed towards a specialist in the area.

Gavin: We'll make it as a part of our podcast for the next time. Look forward to hearing from you. And once again, we'll look forward to the next time you might listen. Thank you once again.[00:19:00]