Diagnosis Of Jaundice Research Articles

Obstructive jaundice associated with polysplenia syndrome in an older child

Polysplenia syndrome includes malrotation and various forms of heterotaxy. Associated with this and malrotation are extrahepatic biliary anomalies. Actual obstruction, other than in associated biliary atresia, is extremely rare, and rarer still in older children. An 11-year-old girl presented with obstructive jaundice, malrotation, and heterotaxy, which were found in association with common bile duct anomalies and intermittent common bile duct obstruction. This case illustrates that the differential diagnosis of obstructive jaundice, even in older children, should include congenital anomalies, and that biliary anomalies should be considered in cases of malrotation and heterotaxy.

Importance of intraoperative ultrasonography in the diagnosis of obstructive jaundice of unclear etiology (In Spanish) : González Sańchez JA, Velasco M, Dominguez Sayans JF, et al. (C/Cristobál Bordiu, 40, E-28003 Madrid, Spain). Rev Esp Enferm Dig 1991;80:316–319

Importance of intraoperative ultrasonography in the diagnosis of obstructive jaundice of unclear etiology (In Spanish) : González Sańchez JA, Velasco M, Dominguez Sayans JF, et al. (C/Cristobál Bordiu, 40, E-28003 Madrid, Spain). Rev Esp Enferm Dig 1991;80:316–319

Complications of Primary Upper Gastrointestinal Lymphoma

This study reports the gastrointestinal complications of primary upper gastrointestinal lymphoma (PUGIL). of thirty-three patients with PUGIL, twenty-one (64%) had complications. These included upper gastrointestinal bleeding, narrowing of the lumen, malabsorption and obstructive jaundice in 11, 9, 5 and 4 patients, respectively. Perforation and fistula formation were encountered in one patient each. THe patients with complications were treated with chemotherapy alone (13), in combination with surgery (6), or combination with surgery and radiotherapy (2). Only in one of four patients was the mortality due to gastrointestinal complication in the form of severe upper gastrointestinal hemorrhage. The remaining three patients died of refractory septicemia. In conclusion, there was a high rate of gastrointestinal complications in patients with PUGIL in our population. Mortality was commonly unrelated to these gastrointestinal complications.

Test Selection in Jaundice: A Comparison between Physician Behavior and a Diagnostic Model

The results of an observational study aimed at a formal assessment of clinicians' test-selection behavior are presented. We first make a proposal for diagnostic test usage in the latter phases of jaundice diagnosis. Next we compute a probabilistic estimate of the patient diagnosis, based on the COMIK algorithm. From the proposal and the probabilistic estimate we can predict the "test-selection behavior" of clinicians. The assessment follows from a tabulation of the predicted behavior against the tests selected by clinicians. It is shown that for most tests, the predictions are consistent with the observed test-selection behavior at a statistically significant level. Discussions of discrepancies between prediction and observation, and reasons for deviations from general guidelines, provide new dimensions for medical education. The methodology applied is a useful tool to improve medical care for the jaundiced patient.

Percutaneous stenting for malignant biliary stenosis

Percutaneous stenting for malignant biliary stenosis is quite beneficial to patients with unresectable or recurrent disease, tremendously improving the quality of their lives. Percutaneous transhepatic biliary drainage (PTBD) was attempted in 92 patients with obstructive jaundice during the period between January 1986 and July 1989. Implantation of an endoprosthesis was performed in 14 cases (15.2%) and succeeded in 12 (85.7%). When a guide wire could not be passed distally across the stricture site, percutaneous transhepatic cholangioscopy (PTCS) through the dilated PTBD fistula was carried out to enable its passage. PTCS is also valuable in the preoperative diagnosis of obstructive jaundice. The patients who are not candidates for surgery are suitable for this procedure. A Miller double-mushroom stent is used as the endoprosthesis in the majority of cases. One patient with recurrent hepatoma has lived at home with this stent for greater than 3 years due to repeated transarterial embolization and chemotherapy and does not need to wash or change the stent.

Intestinal origin alkaline phosphatase activity in plasma for differential diagnosis of jaundice.

Intestinal origin alkaline phosphatase activity (ALP) in plasma was measured by a sensitive immunocapture assay in 104 jaundiced patients--84 with intrahepatic and 20 with post-hepatic jaundice. Increased enzyme activities were observed in those with intrahepatic disease and subnormal values in those with post-hepatic disease. At a discriminant level intestinal origin ALP showed a diagnostic sensitivity of 77% for intrahepatic cholestasis, with a diagnostic accuracy of 75% for its differentiation from post-hepatic jaundice. This diagnostic accuracy is not as good as that derived with other techniques--for example, imaging--and the technique is therefore not recommended as a supplement or replacement.

Jaundice and cholestasis

Jaundiced patients may not always be as sick as they look, and cholestatic patients may be quite ill but not yet jaundiced. There is variability in presentation of cholestasis, and jaundice may be intrahepatic or extrahepatic and acute or chronic. Even though the diagnosis of jaundice can be elusive, an unnecessarily exhaustive search for a cause should be avoided, because some tests are not without dangers. Dr Gordon describes many possible causes, some of which are rare but are still worth consideration.

‘Soluble’: Decision-making in the diagnosis of Jaundice

We have designed a computer program ‘Solubile’ to aid clinicians in the diagnosis of jaundice. Based on Bayes' theorem, ‘Solubile’ uses up to 47 items of information about the patient to produce the most probable diagnosis from 22 possible diseases. In a prospective analysis of 50 patients, 74% were correctly diagnosed in first place and 94% within the first three choices. The possibility of using ‘Solubile’ at differing locations was tested by prospectively diagnosing 100 cases at a second centre having a significantly different patient population. 75% of these patients were correctly diagnosed in first place and 89% within the first three choices. The diagnostic ability of ‘Solubile’ was compared with that of 20 clinicians of various grades. The clinicians correctly diagnosed 49.5% of cases (Solubile 74%) and placed 68.5% (Solubile 94%) within the first three choices. ‘Solubile’ will be of use to aid clinicians in aspects of the diagnosis and management of jaundice.

A CASE OF TUMOR-FORMING TYPE OF CHRONIC PANCREATITIS

We experienced a case of tumor-forming chronic pancreatitis with difficult defferential diagnosis from pancreatic cancer. A 73-year-old man was admitted to our hospital with a diagnosis of obstructive jaundice and performed transhepatic percutaneous drainage. Ultrasonography, computed tomography and transendoscopic ultrasonography revealed a tumor at the pancreatic head, but it could not be differed from malignant neoplasms. Aiming at complete biopsy, partial resection of the head of pancreas with resection of tissues including the tumor were performed. Intraoperative frozen section diagnosis and pathological diagnosis resulted in chronic pancreatitis, which showed a high degree of fibrosis in the pancreas.With a recent progression in graphic modalities, pancreatic cancer can be easily differentiated from chronic pancreatitis in most cases. However, we have often difficulties in differentiating tumor-forming pancreatitis from malignancies. Partial resection of the head of pancreas is useful for complete biopsy in such cases well as other cases presenting with stricture of the pancreatic duct or choledocheal duct.In this paper, we descrive the usefulness of this partial resection of the head of pancreas, protocol of diagnosis, and therapeutic guideline tumor-forming chronic pancreatitis.

The Measurement of Bilirubin Fractions in Serum

Bilirubin fractions are measured by (1) the direct diazo reaction, (2) high-performance liquid chromatography (HPLC), (3) direct spectrophotometry, and (4) enzymatic methods. HPLC, which effects separation and quantitation of the four bilirubin fractions, is the method of choice, but impractical for routine use. A special application of direct spectrophotometry allows the measurement of unconjugated bilirubin and the sum of bilirubin conjugates. This approach, which provides essentially the same information as HPLC, unfortunately is available only in one clinical analyzer. The direct diazo reaction measures bilirubin conjugates plus delta-bilirubin, albeit not very accurately. Direct diazo methods that measure unconjugated bilirubin as direct could obscure the clinical diagnosis. At acid pH, enzymatic methods measure all direct reacting bilirubins, while at pH 10 only conjugated bilirubins are measured. Because the measurement of conjugated bilirubins is clearly more helpful than that of direct bilirubin in the differential diagnosis of jaundice, direct diazo methods should be replaced by methods specific for bilirubin conjugates.

Measurement of hepatocellular function with deconvolutional analysis: application in the differential diagnosis of acute jaundice.

A direct, noninvasive technique was developed to quantitate hepatocyte function with computer assessment of scintiscans obtained after administration of technetium-99m disofenin in 53 patients with acute jaundice: 32 patients with normal livers, 10 patients with acute biliary obstruction, and 11 patients with acute hepatocellular dysfunction. In all patients a final clinical diagnosis was obtained with follow-up for a minimum of 4 months and, in most patients with obstruction or dysfunction, with surgery, intraoperative cholangiography, ultrasound, and/or computed tomography. Heart (blood pool) and liver time-activity curves were generated for 32 minutes after intravenous injection of 5-15 mCi (185-555 MBq) of Tc-99m disofenin and were subjected to deconvolutional analysis to determine the first-pass hepatocyte extraction fraction (HEF) of the tracer. The difference in HEF between patients with obstruction and those with dysfunction was highly significant (P = 3.3 X 10(-19)). Deconvolutional analysis eliminates the effects of tracer recirculation, thus permitting direct measurement of hepatic disofenin extraction, and appears to provide functional information useful in evaluation of the patient with acute jaundice.

Application of artificial intelligence techniques to a well defined clinical problem: jaundice diagnosis

Jaundice is a very common medical condition, in which pathophysiological knowledge has been quite well assessed and clinical features are usually well known. However, incorrect conclusions are sometimes reached in medical practice which can lead to serious implications. Thus, jaundice diagnosis appears as one of the medical situations which might be substantially improved by computer assistance. The present study is aimed at describing and discussing in what way a computer program supporting medical decision making in jaundiced patients can be developed on the basis of advanced Artificial Intelligence methods. To this extent methodological problems concerned with the organization and the formalization of medical knowledge have been outlined with some detail. The resulting expert system is expected to become a well assessed and potentially useful tool for both medical decision making and medical education.

Cholestatic Jaundice in the Newborn

Neonatal cholestasis or direct hyperbilirubinemia in the first 3 months of life is nearly always more pathologic than physiologic. This article reviews the extensive differential diagnosis of cholestatic jaundice and the approach to diagnosis. A sense of urgency is underscored by the value of early recognition and intervention in metabolic, iatrogenic, and anatomic disorders. The long-term management goals are reviewed, including indications for hepatic transplantation.

Rapid method for distinguishing clonal from polyclonal B cell populations in surgical biopsy specimens.

The polymerase chain reaction (PCR) was used to detect clonal rearrangements of the immunological heavy chain gene in frozen samples of human lymphoid tissue. DNA sequences in rearranged genes were amplified using oligomeric primers predicted from conserved sequences in the variable (VH) and joining (JH) regions. On polyacrylamide gel electrophoresis, polyclonal B cell proliferations showed a "smear", probably due to the variable lengths of the diversity (DH) region genes and the N regions separating the VH and DH and JH regions. In contrast, DNA from B cell lymphomas showed a clear single band in eight out of 10 cases. PCR undertaken on germ line DNA from non-lymphoid tumours showed no detectable bands or smears. The method can be completed within one day of biopsy, compared with several days in the case of conventional DNA blot analysis. Furthermore, it is cheaper, simpler, avoids the need for radioactive materials and requires very small amounts of DNA (about 1 micrograms).

Cholescintigraphy in the Evaluation of Jaundice

<h3>To the Editor.—</h3> I read with interest the recent article on the clinical evaluation of jaundice by Dr Frank and members of the Patient Care Committee of the American Gastroenterological Association.¹The authors reviewed accurately the usefulness of noninvasive studies, including ultrasonography and computed tomographic scan, in the assessment of jaundice. However, the value of cholescintigraphy as an adjunct noninvasive study and in selected cases as the modality of choice in screening patients was overlooked. Ultrasound is poor at detecting common bile duct stones; not all obstructed ducts are dilated and not all dilated ducts are functionally obstructed, especially after cholecystectomy,^2,3and therefore cholescintigraphy can play a major role in the diagnosis of obstructed jaundice. Its overall accuracy is reported to be about 96% to 97%.⁴Cholescintigraphy has a distinct advantage in patients in whom choledocholithiasis is considered to be the most likely cause (eg, acute

Use of computers in diagnosis of jaundice

The development of computer-assisted diagnostic systems for the differential diagnosis of jaundice has been attempted in several studies during the last 25–30 years. All working systems have depended on numerical methods whereas expert systems have not yet become operational. The first step in the construction of a system is the collection of a data base from a series of jaundiced patients of clinical information (indicants) i.e. symptoms, signs, and the results from laboratory tests. The best discriminating indicants are selected and processed into a mathematical rule. The performance of this rule must be tested on an independent test sample of relevant patients. The performance may also be compared to that of clinicians. So far the computerized diagnoses have not been more accurate than those of clinicians. However, computer-assisted diagnostics may form an important first step in clinical decision making regarding the selection of a confirmatory diagnostic test (direct cholangiography, ultrasonography, liver biopsy, etc.) in the evaluation of the jaundiced patient.

Clinical and biochemical diagnosis of jaundice

Clinical and biochemical diagnosis of jaundice

The utility of ancillary tests in the diagnosis of jaundice.

The helpfulness of technological tests in the diagnosis of diseases presenting as jaundice was examined using a measure of expected utility derived from decision theory. Data from 243 patients admitted with jaundice yielded a total of 2260 test-results from twenty seven tests used. The results were partitioned into a total of 123 bands. Forty-three bands had a sufficient number of results to be considered for calculation. Eleven out of the 27 tests and 16 of 123 bands gave information recognized to be worthwhile. They contributed to the diagnosis of the 7 commonest diseases, and would permit the selection of the best combination of tests to be performed. The frequency of use of tests did not reflect their utility. A test-sequencing proforma might be a useful aid in the work-up of patients.

FACTORS AFFECTING THE INTELLECTUAL PROGNOSIS IN CONGENITAL HYPOTHYROIDISM (C.H.)

40 girls and 12 boys with CH. (8 athyreosis, 33 ectopics, 11 anatomically normal gland) whose treatment began at day : 29 ± 12 (mean ± SD) were followed for at least 4 years and in 13 cases for 7 years. The results of the Brunet-Lezine test at 0.5, 1, and 2 years; the Termann-Merill at 4 years and the WICSR test at 7 years, were all within the normal range but with a wide scatter : range 85-145 at 4 years, 95-133 at 7 years. The factors involved in this scatter were investigated. The following factors had no influence : clinical evidence of hypothyroidism at diagnosis, the presence and duration of neonatal jaundice, the initial levels of T4 and TSH, the etiology after 2 years, the date of starting treatment provided that this occured within the 2 first months of life. The following factors had a positive influence on the outcome : the presence of the 2 epiphysis of the knee (p <.025), socioeconomic level of parents (Graffar) : high medium vs medium (p <.05), vs low medium (p < .005) and good hormonal control during the first year (p <.025) and the following years (p<.05). The presence of psychological problems were predictive of a comparatively poor outcome : mild problems (p<.005) and severe problems (p <.0005) mild vs severe (p <.05). The development of psychological problems are associated with an initial hospitalization (p < .001) and the duration of it (p < .025). Postnatal factors are predominant which emphasises the need for good medical and familial care.

A CASE OF DOUBLE CARCINOMA OF THE BILIARY TRACT RESECTED 14 YEARS AFTER EXTENDED RADICAL MASTECTOMY

The present paper reports a case of double cancer of the biliary tract, i.e., the gallbladder and the lower portion of the common bile duct, developing 14 years after extended radical mastectomy for left breast cancer. A 79-year-old woman with the chief complaints of jaundice and epigastric pain was admitted to the department of surgery of our hospital under the diagnosis of obstructive jaundice. After a detailed examination, the patient underwent surgery for suspected cancer in the lower portion of the common bile duct and the gallbladder. Histopathologically the tumor in the gallbladder was tubular adenocarcinoma while that in the lower portion of the common bile duct was poorly differentiated cacinoma. As no continuity was noted between the two tumors, and lymph node metastasis was negative, the case was diagnosed as double cancer of the biliary tract. The breast cancer was scirrhous carcinoma located in the AC region with negative lymph node metastasis. Thus, this was a case of asynchronous triple cancer of the breast, gallbladder and common bile duct. Double cancer of the biliary tract is comparatively rare, and an association with carcinoma of other organs has been reported in only one case with concurrent gastric cancer. The authors report the extremely rare case of triple cancer involving the breast, and present a reveiw of the literature on cancer developing in other organs after surgery for breast cancer.