21. Differential diagnosis of jaundice, Rectal cancer & Traumatic duodenum and pancreas injury

What is the definition of JAUNDICE?

Jaundice is the yellow discolouration of the skin, mucous membrane and sclera due to increased levels of bilirubin in the blood.

What is the classification of JAUNDICE?

Jaundice is classified as prehepatic, hepatocellular, and posthepatic.

What is the clinical presentation of JAUNDICE?

It presents as yellow discolouration of the skin, mucous membrane and sclera.

What are the signs of JAUNDICE?

A sign is yellow discolouration of the skin, mucous membrane and sclera.

What are the symptoms of JAUNDICE?

A symptom is yellow discolouration of the skin, mucous membrane and sclera.

What are the diagnostic methods of JAUNDICE?

Diagnostic methods include physical examination, ultrasound, liver biochemistry, CT scan and ERCP, and liver biopsy.

What are 3 main differential diagnoses of JAUNDICE and how do we differentiate?

The three main categories of causes are prehepatic, hepatocellular, and posthepatic jaundice. Prehepatic jaundice is due to unconjugated bilirubin not in urine. Hepatocellular jaundice shows altered liver enzymes like raised ALT/AST in hepatitis or raised ALP/GMT in cholestasis. Posthepatic jaundice shows raised ALP/GMT, bilirubin in urine, and often dilated bile ducts on ultrasound.

What is the definition of PREHEPATIC JAUNDICE?

Prehepatic jaundice is excessive extrahepatic formation of bilirubin due to increased break down of red blood cells.

What is the etiology of PREHEPATIC JAUNDICE?

Causes include hemolytic anemia, sickle cell anemia, hereditary spherocytosis, hematoma, immune hemolysis, thalassemia, and G6PD deficiency.

What is the pathophysiology of PREHEPATIC JAUNDICE?

Excessive extrahepatic formation of bilirubin leads to unconjugated bilirubin which is not water soluble and cannot be excreted in urine.

What is the clinical presentation of PREHEPATIC JAUNDICE?

It presents as mild jaundice and dark feces.

What are the signs of PREHEPATIC JAUNDICE?

A sign is mild jaundice and absence of bilirubin in urine.

What are the symptoms of PREHEPATIC JAUNDICE?

A symptom is dark feces because of unconjugated hyperbilirubinemia.

What is the definition of HEPATOCELLULAR JAUNDICE?

Hepatocellular jaundice arises from damaged hepatocytes.

What is the etiology of HEPATOCELLULAR JAUNDICE?

Causes include hemochromatosis, amyloidosis, Wilson's disease, viral hepatitis, drug-induced (rifampicin), cirrhosis, postoperative states, and total parenteral nutrition.

What are the signs of HEPATOCELLULAR JAUNDICE?

Signs of chronic liver disease like hepatomegaly, ascites, splenomegaly, spider nevi, and caput medusa may be present.

What are the diagnostic methods of HEPATOCELLULAR JAUNDICE?

Diagnostic methods include physical examination for signs of chronic liver disease, viral marker blood tests, ultrasound, liver biochemistry, and liver biopsy.

What are 3 main differential diagnoses of HEPATOCELLULAR JAUNDICE and how do we differentiate?

Three main causes are viral hepatitis, cirrhosis, and drug-induced damage. Viral hepatitis is diagnosed with blood tests, cirrhosis with liver biopsy, and drug history suggests drug-induced causes.

What is the definition of POSTHEPATIC JAUNDICE?

Posthepatic jaundice results from impaired bile flow due to large obstruction.

What is the etiology of POSTHEPATIC JAUNDICE?

Causes include common bile duct stones, biliary strictures, cholangitis, periampullary cancer, AID cholangiopathy, and parasites.

What is the clinical presentation of POSTHEPATIC JAUNDICE?

It presents as icterus of skin, darkened urine, and lightening of stools.

What are the signs of POSTHEPATIC JAUNDICE?

Signs are icterus of skin, darkened urine, lightening of stools, dilated bile ducts on ultrasound, and bilirubin positivity in urine.

What are the symptoms of POSTHEPATIC JAUNDICE?

Symptoms range from biliary colic to manifestations of obstructive jaundice, with jaundice being painful if due to stones and usually painless if due to tumor.

What are the diagnostic methods of POSTHEPATIC JAUNDICE?

Diagnostic methods include abdominal ultrasound, liver biochemistry, positivity of bilirubin in urine, CT scan, and ERCP.

What are the complications of POSTHEPATIC JAUNDICE?

Complications include obstructive cholangitis, biliary pancreatitis, and acute liver failure.

What are 3 main differential diagnoses of POSTHEPATIC JAUNDICE and how do we differentiate?

Three main causes are common bile duct stones, biliary strictures, and periampullary cancer. Stones often cause painful jaundice, while tumor jaundice is usually painless. Imaging like ultrasound or CT can identify stones, strictures, or tumors.

What is the etiology of CHOLESTATIC JAUNDICE?

Causes include common bile duct stone, cholangitis, cholestatic hepatitis A, EBV/CMV hepatitis, primary biliary cirrhosis, sickle cell disease, periampullary cancer, AID cholangiopathy, parasites, and total parenteral nutrition.

What are the signs of CHOLESTATIC JAUNDICE?

Signs include raised ALP and GMT in liver biochemistry and positivity of bilirubin in urine.

What are the diagnostic methods of CHOLESTATIC JAUNDICE?

Diagnostic methods include liver biochemistry showing normal ALT & AST and raised ALP & GMT, positivity of bilirubin in urine, CT scan, and ERCP.

What are 3 main differential diagnoses of CHOLESTATIC JAUNDICE and how do we differentiate?

Three main causes include common bile duct stone, cholangitis, and periampullary cancer. Cholangitis presents with Charcot's triad (fever, pain, jaundice). Painful jaundice suggests stones, while painless jaundice may suggest tumor.

What is the etiology of ISOLATED JAUNDICE?

Causes include hereditary spherocytosis, hematoma, immune hemolysis, thalassemia, and G6PD deficiency.

What is the etiology of POSTOPERATIVE JAUNDICE?

The postoperative state.

What is the classification of CARCINOMA OF RECTUM?

Histologic types are evaluated according to the WHO classification, with most being usual adenocarcinoma or mucinous adenocarcinomas. Other tumor types like signet-ring cell or squamous cell carcinoma are rare.

What is the epidemiology of CARCINOMA OF RECTUM?

Rectal cancer is among the most frequent cancers in the world.

What is the etiology of CARCINOMA OF RECTUM?

Lifestyle factors such as high intake of fat and calories, as well as alcohol and tobacco, have been suggested.

What are the risk factors of CARCINOMA OF RECTUM?

Lifestyle factors like high fat/calorie intake, alcohol, and tobacco, and hereditary disorders such as HNPCC or FAP are suggested risk factors.

What is the pathophysiology of CARCINOMA OF RECTUM?

Adenomas can become dysplastic and progress to carcinomas.

What is the clinical presentation of CARCINOMA OF RECTUM?

It presents with symptoms like hematochesia, mucus discharge, tenesmus, and change in bowel habit, and the tumor may be palpable on digital exam if reachable.

What are the signs of CARCINOMA OF RECTUM?

The tumor can be inspected or felt by digital palpation if it is reached from the anus. Elevated serum CEA is helpful in detecting recurrence after curative surgical resection.

What are the symptoms of CARCINOMA OF RECTUM?

The most common symptom is hematochesia, with other symptoms including mucus discharge, tenesmus, and change in bowel habit.

What are the diagnostic methods of CARCINOMA OF RECTUM?

Diagnostic methods include digital palpation, rectoscopy or flexible endoscopy with biopsies, MRI, ERUS, CT scan, and PET scan.

What is the pharmacological treatment of CARCINOMA OF RECTUM?

Preoperative adjuvant treatment such as radiotherapy may be needed. For higher stage, a combination of irradiation and chemotherapy may be used.

What is the surgical treatment of CARCINOMA OF RECTUM?

Complete surgical removal with adequate margins is the preferred treatment for localized cancer. Low anterior resection is a type of surgery for the rectum, and Miles operation treats advanced lesions involving sphincters.

What is the prophylactic measures against CARCINOMA OF RECTUM?

Increased intake of fibre is associated with a decreased risk.

What are the complications of CARCINOMA OF RECTUM?

Complications can include obstruction, bleeding, metastasis, and local recurrence based on how the cancer spreads.

What are 3 main differential diagnoses of CARCINOMA OF RECTUM and how do we differentiate?

Hemorrhoids often cause similar bleeding but are differentiated by digital exam and endoscopy. Anal fissure or fistula can cause rectal bleeding and are identified by inspection and rectoscopy. Benign rectal tumors can mimic symptoms but their true nature is established by microscopic examination of biopsies.

What is the classification of ANAL CANAL NEOPLASM?

Tumors arising in the anal canal are usually squamous cell carcinoma, epidermoid carcinoma, basal cell carcinoma, or rare sarcomas.

What is the clinical presentation of ANAL CANAL NEOPLASM?

All of these tumors present as a mass, sometimes with bleeding or pruritus.

What are the signs of ANAL CANAL NEOPLASM?

The tumors present as a mass.

What are the symptoms of ANAL CANAL NEOPLASM?

Symptoms may include bleeding or pruritus.

What is the pharmacological treatment of ANAL CANAL NEOPLASM?

Patient with higher stage has combination of irradiation and chemotherapy.

What is the surgical treatment of ANAL CANAL NEOPLASM?

Treatment includes local excision if epithelial or subepithelial tissue is involved in tumor. Advanced lesions involving sphincters are treated by Miles operation.

What are 3 main differential diagnoses of ANAL CANAL NEOPLASM and how do we differentiate?

Hemorrhoids and anal fissure/fistula are differential diagnoses causing similar symptoms like bleeding. Differentiation relies on physical examination (inspection and palpation) and histological examination of biopsies.

What is the epidemiology of DUODENUM INJURY?

Duodenal injuries are relatively rare. Approximately three-quarters are blunt injuries and one-quarter are penetrating trauma in Middle Europe.

What is the etiology of DUODENUM INJURY?

Etiologies include penetrating trauma and blunt trauma from mechanisms like a steering wheel blow or bike frame compression. A heavy central abdominal impact can also cause injury.

What are the risk factors of DUODENUM INJURY?

Risk factors include being an unrestrained automobile driver or a child on a bike after compression. Heavy central abdominal impact is also a risk factor.

What is the pathophysiology of DUODENUM INJURY?

Blunt trauma can cause transection across vertebral bodies or retroperitoneal rupture. Duodenal hematoma or perforated small intestine can also occur.

What is the clinical presentation of DUODENUM INJURY?

Initial diagnosis after blunt trauma is difficult because clinical signs are poor. Delayed diagnosis of rupture beyond 24 hours leads to high mortality.

What are the signs of DUODENUM INJURY?

Clinical signs on the abdomen are often poor after blunt trauma. Patients with perforated small intestine may show signs like abdominal rigidity and guarding.

What are the diagnostic methods of DUODENUM INJURY?

Diagnosis of retroperitoneal rupture is best confirmed or excluded by Gastrografin upper GI series. Abdominal CT with oral and intravenous contrast is also used.

What is the surgical treatment of DUODENUM INJURY?

About 80 percent of duodenal wounds can be primarily repaired safely. Duodenal hematomas usually do not require operative intervention.

What is the epidemiology of PANCREATIC INJURY?

Pancreatic trauma is uncommon, representing less than 15 percent of all abdominal injuries. Mortality rates from large series are 10 to 25 percent.

What is the etiology of PANCREATIC INJURY?

Causes include heavy central abdominal impact leading to transection across vertebral bodies. High-speed motor vehicle accidents and gunshot wounds also contribute.

What are the risk factors of PANCREATIC INJURY?

High-speed motor vehicle accidents and gunshot wounds increase the incidence. Children falling across bike handlebars or a steering wheel are also at risk.

What is the pathophysiology of PANCREATIC INJURY?

Injury can involve transection of the pancreas across vertebral bodies due to impact.

What are the diagnostic methods of PANCREATIC INJURY?

CT can be helpful in diagnosing pancreatic injury.

What are the complications of PANCREATIC INJURY?

Major complications develop in 30 to 40 percent of patients surviving their initial injury. These complications include pseudocysts, abscesses, hemorrhage, and pancreatic fistulas.