Where is the best location to find jaundice?

  • Conjunctiva (scleral icterus is a misnomer because sclera is avascular)
  • Traditional teaching is that jaundice becomes evidence once bilirubin > 3 mg/dL (or >50 mmol/L), but the sens is only 70-80%. The sens increases when the bilirubin level increases.
    – JAUNDICE may not be apparent in palms or soles. Look at the conjunctiva.

Mimics of jaundice

  • Yellowish subconjunctival fat –> spares the area near cornea (limbus)
  • Carotenemia –> conjunctiva is spared despite yellowish palm and sole

Hepatocellular vs obstructive jaundice

  • Favour hepatocellular jaundice
    – Palmar erythema, spider angiomata, dilated abdominal veins (most significant LR +17.5), ascites (stigmata of liver disease)
  • Favour obstructive jaundice
    Palpable GB
  • Palpable liver and liver tenderness have NS positive and negative LR.

Predicting cirrhosis

  • Stigmata of liver disease and hepatic encephalopathy
  • ABSENCE of palpable liver in epigastrium argues against the diagnosis of cirrhosis (LR 0.2 = -30%)

Reference: Evidence-based physical diagnosis, Steven McGee – 2nd ed


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