Upper gastrointestinal
CASE 29:
PAINLESS JAUNDICE
History A 73-year-old man is admitted from surgical outpatients. You have been asked to clerk the patient and initiate his investigations. For the last 3 months, he has noticed a progressively deepening yellow discolouration of his skin. He has not had any abdominal pain. His appetite has reduced significantly and he has found that his clothes have become loose. He has also noticed that his urine has darkened and his stools have become pale and difficult to flush. He enjoys the occasional whisky at home in the evening and has smoked 10 cigarettes a day since he was a teenager. He is not on any regular medication. Examination The patient appears underweight and has a yellow discolouration of the skin and sclera. The heart sounds are normal with a blood pressure of 136/64 mmHg and a pulse of 86/min. He is afebrile and his chest is clear. The abdomen is soft with a smooth mass present in the right upper quadrant, which moves with respiration.
INVESTIGATIONS Haemoglobin Mean cell volume White cell count Platelets Sodium Potassium Urea Creatinine Amylase Alkaline phosphatase (ALP) Aspartate transaminase (AST) Gamma-glutamyl transferase (GGT) Albumin Bilirubin Glucose
13.0 g/dL 86 fL 12 ⫻ 109/L 260 ⫻ 109/L 137 mmol/L 4.3 mmol/L 5 mmol/L 65 µmol/L 32 IU/L 229 IU/L 96 IU/L 63 IU/L 46 g/L 82 mmol/L 5 mmol/L
Normal 11.5–16.0 g/dL 76–96 fL 4.0–11.0 ⫻ 109/L 150–400 ⫻ 109/L 135–145 mmol/L 3.5–5.0 mmol/L 2.5–6.7 mmmol/L 44–80 µmol/L 0–100 IU/dL 35–110 IU/L 5–35 IU/L 11–51 IU/L 35–50 g/L 3–17 mmol/L 3.5–5.5 mmol/L
Questions • Why are the stools pale? • What is Courvoisier’s law? • What additional investigations are required to make the diagnosis? • How should this patient be managed?
63