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.
- 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