Diagnostic Approach to the Patient with Jaundice

How to approach jaundice in the MRCP PACES exam

For every medical trainee, the Membership of the Royal College of Physicians' Practical Assessment of Clinical Examination Skills (PACES) exam is one of the most difficult exams they must face in their career. It is designed to assess the clinical knowledge and skills of the trainee doctors who are entering higher specialist training. It sets rigorous standards to ensure the competence of the candidates across a range of skills. This article discusses a systematic approach to a patient with jaundice, which is a commonly encountered station in the exam, so that candidates will become more familiar with common causes and how to differentiate between these, as well as important bedside examination skills.

R-JaunLab: Automatic Multi-Class Recognition of Jaundice on Photos of Subjects with Region Annotation Networks

Jaundice occurs as a symptom of various diseases, such as hepatitis, the liver cancer, gallbladder or pancreas. Therefore, clinical measurement with special equipment is a common method that is used to identify the total serum bilirubin level in patients. Fully automated multi-class recognition of jaundice combines two key issues: (1) the critical difficulties in multi-class recognition of jaundice approaches contrasting with the binary class and (2) the subtle difficulties in multi-class recognition of jaundice represent extensive individuals variability of high-resolution photos of subjects, huge coherency between healthy controls and occult jaundice, as well as broadly inhomogeneous color distribution. We introduce a novel approach for multi-class recognition of jaundice to detect occult jaundice, obvious jaundice and healthy controls. First, region annotation network is developed and trained to propose eye candidates. Subsequently, an efficient jaundice recognizer is proposed to learn similarities, context, localization features and globalization characteristics on photos of subjects. Finally, both networks are unified by using shared convolutional layer. Evaluation of the structured model in a comparative study resulted in a significant performance boost (categorical accuracy for mean 91.38%) over the independent human observer. Our work was exceeded against the state-of-the-art convolutional neural network (96.85% and 90.06% for training and validation subset, respectively) and showed a remarkable categorical result for mean 95.33% on testing subset. The proposed network makes a performance better than physicians. This work demonstrates the strength of our proposal to help bringing an efficient tool for multi-class recognition of jaundice into clinical practice.

Effects of Yinzhihuang Granules on Serum Liver Enzymes in Jaundice Patients: A Real-World Study Based on HIS Data

OBJECTIVE

Our aim was to analyze the influence of Yinzhihuang granules on serum liver enzymes in jaundice patients and to provide real-world evidence for the efficacy evaluation of Yinzhihuang granules in treating jaundice.

METHODS

We constructed a data warehouse which integrates real-world electronic medical records from the hospital information system of multiple 3A hospitals in China and used a descriptive statistical method to analyze the changes in the serum liver enzymes of the jaundice patients treated with Yinzhihuang granules and then used Wilcoxon signed-rank to test the changes in the indicators caused by the treatment.

RESULTS

After being treated with Yinzhihuang granules, the jaundice patients had a decrease in the average serum levels of total bilirubin, indirect bilirubin, aspartate aminotransferase, glutamyl transpeptidase, and alkaline phosphatase, and the differences were statistically significant (P < 0.05) but had no significant changes in the average serum levels of direct bilirubin and alanine aminotransferase (P > 0.05).

CONCLUSION

The data analysis on the real-world electronic medical records demonstrate that Yinzhihuang granules help to reduce jaundice patients' serum levels of total bilirubin, indirect bilirubin, aspartate aminotransferase, glutamyl transpeptidase, and alkaline phosphatase, but there is no evidence that Yinzhihuang granules help to reduce the jaundice patients' serum levels of direct bilirubin and alanine aminotransferase.

ACR Appropriateness Criteria® Jaundice

Jaundice is the end result of myriad causes, which makes the role of imaging in this setting particularly challenging. In the United States, the most common causes of all types of jaundice fall into four categories including hepatitis, alcoholic liver disease, blockage of the common bile duct by a gallstone or tumor, and toxic reaction to a drug or medicinal herb. Clinically, differentiating between the various potential etiologies of jaundice requires a detailed history, targeted physical examination, and pertinent laboratory studies, the results of which allow the physician to categorize the type of jaundice into mechanical or nonmechanical causes. Imaging modalities used to evaluate the jaundiced patient (all etiologies) include abdominal ultrasound (US), CT, MR cholangiopancreatography, endoscopic retrograde cholangiopancreatography and endoscopic US. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The Role of Diabetes Mellitus in Diseases of the Gallbladder and Biliary Tract

BACKGROUND

The increasing prevalence of diabetes mellitus worldwide continues to pose a heavy burden. Though its gastrointestinal impact is appropriately recognized, the lesser known associations may be overlooked.

OBJECTIVE

We aim to review the negative implications of diabetes on the gallbladder and the biliary tract.

METHODS

A MEDLINE® database search of literature was conducted with emphasis on the previous five years, combining keywords such as "diabetes," "gallbladder," and "biliary".

RESULTS

The association of diabetes to the formation of gallstones, gallbladder cancer, and cancer of the biliary tract are discussed along with diagnosis and treatment.

CONCLUSION

Though we uncover the role of diabetic neuropathy in gallbladder and biliary complications, the specific individual diabetic risk factors behind these developments is unclear. Also, in addition to diabetes control and surgical gallbladder management, the treatment approach also requires further focus.

Epidemiological profile, referral routes and diagnostic accuracy of cases of acute cholangitis among individuals with obstructive jaundice admitted to a tertiary-level university hospital: a cross-sectional study

BACKGROUND

Obstructive jaundice may lead to ominous complications and requires complex diagnostic evaluations and therapies that are not widely available.

OBJECTIVE

To analyze the epidemiological profile, referral routes and diagnostic accuracy at admittance of cases of acute cholangitis among patients with obstructive jaundice treated at a referral unit.

DESIGN AND SETTING

Cross-sectional study at a tertiary-level university hospital.

METHODS

Patients with obstructive jaundice who were treated by means of endoscopic retrograde cholangiopancreatography, resection and/or surgical biliary drainage were evaluated. The main variables analyzed were epidemiological data, referral route, bilirubin levels and time elapsed between symptom onset and admittance and diagnosing of acute cholangitis at the referral unit. The accuracy of the clinical diagnosis of acute cholangitis was compared with a retrospective analysis on the medical records in accordance with the Tokyo criteria.

RESULTS

Female patients predominated (58%), with an average age of 56 years. Acute cholangitis was detected in 9.9% of the individuals; application of the Tokyo criteria showed that the real prevalence was approximately 43%. The main referral route was direct contact (31.8%) and emergency care (29.7%); routing via official referral through the public healthcare system accounted for 17.6%, and internal referral from other specialties, 20%. The direct route with unofficial referral was the most important route for cases of neoplastic etiology (P < 0.01) and was the fastest route (P < 0.01).

CONCLUSIONS

There is a deficiency in the official referral routes for patients with obstructive jaundice. The accuracy of the clinical diagnosis of acute cholangitis was poor. Wider dissemination of the Tokyo criteria is essential.

Green Teeth Related to Bilirubin Levels

Objective

To describe a form of tooth pigmentation caused by serum bilirubin deposition during dental calcification in a premature child. The bilirubin levels during the three months after birth are presented. In this period the crowns of the primary teeth are still forming. Such anomaly does not have symptoms, but has a displeasing effect and great anxiety within the family.

Case report

The case reported here highlights the relevance of past medical history, especially the diagnoses of prolonged conjugated hyperbilirubinemia, in this case, to confirm them and to comfort the family. In this case, no esthetic treatment had been undertaken because the child was still too young and not yet concerned. The dental treatment plan included regular checkups every 3 months for maintaining oral health to prevent caries.

Conclusion

As this is a rare condition that affects the teeth, parents will most likely look for a dentist for treatment. Therefore, dentists must be aware or such abnormalities and take a multidisciplinary approach, thus making it possible to establish a final diagnosis.

QM study of complexation between natural bilirubin and poly-terthiophene carboxylic acid–Mn(II) as a biosensor: Temperature and interferences effect

Bilirubin is an insoluble yellow pigment produced from heme catabolism and serves as a diagnostic marker of liver and blood disorders. Here, a systematic study of several interactions and arrangements between different forms of natural bilirubin and poly-5, 2[Formula: see text]-5[Formula: see text], 2[Formula: see text]-terthiophene-3-carboxylic acid/Mn(II)2complex, PTTCA–Mn(II)2, as a biosensor of bilirubin has been investigated extensively. The PTTCA–Mn(II)2biosensor detects natural bilirubin through the mediated electron transfer by the Mn[Formula: see text]. Initially, density functional theory (DFT) using B3LYP and different basis sets including 6-31G* and 6-311G** has been employed to calculate the details of electronic structure and electronic energies of natural biliverdin and [Formula: see text]-, [Formula: see text]- and [Formula: see text]-bilirubin. Next, the interaction of the PTTCA–Mn(II)2biosensor, being in three possible spin states, with [Formula: see text]-, [Formula: see text]- and [Formula: see text]-natural bilirubin with 1:1 and 1:2 stoichiometry using UB3LYP/6-31G* method has been investigated. Natural population analysis (NPA) calculations have been used to derive more suitable interaction sites of bilirubin with Mn[Formula: see text] ions in PTTCA–Mn(II)2biosensor. Investigation of different manganese complexes with bilirubin shows that the most stable complex is high spin state (total electron spin [Formula: see text]) rather than intermediate and low spin states with 1:2 stoichiometry. Also, the temperature effect and interferences from other biological compounds such as ascorbic acid, L-glutamic acid, uric acid, creatine, glucose and dopamine have been investigated. The nature of the interaction between manganese metal cations and natural bilirubin is also discussed employing NPA, molecular orbital (MO) analysis and Bader’s Atoms in Molecule (AIM) theory.

Assessment of jaundice in the hospitalized patient

Jaundice in the hospitalized patient is not an uncommon consultation for the general gastroenterologist. It is essential to explore the underlying cause of jaundice because management is largely aimed at addressing these causes rather than the jaundice itself. Although the diagnostic evaluation for jaundice can be broad, clinical judgment must be used to prioritize between various laboratory tests and imaging studies. Most importantly, clinicians must understand which conditions are emergent and/or require evaluation for liver transplantation. Further studies need to be performed to better understand the outcomes of hospitalized patients who develop jaundice.