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Snapshot diagnosis - why is this 70 year old moderate drinker jaundiced?

Dr Hercules Robinson describes a case where the yellow eyes of a 70-year-old made him first think of liver metastases

Dr Hercules Robinson describes a case where the yellow eyes of a 70-year-old made him first think of liver metastases

The patient

A 70-year-old man came to the surgery after noticing that his eyes were a yellow colour when shaving that morning. He was normally well. He had hypertension, which was well controlled. He smoked and drank 10 units of alcohol per week. He was taking simvastatin because of an elevated CVD risk as well as an ACE inhibitor for his hypertension.

First instinct

I'm always concerned when older patients are jaundiced. Liver metastases are high on my list of possible causes. But the patient looked reasonably well despite the jaundice so there remained many other possibilities.

Differential diagnosis

There are innumerable causes for jaundice in a man of this age but many are unusual or rare:

• haemolytic – auto-immune haemolytic anaemia, drug-induced haemolysis

• intra-hepatic – hepatitis, drugs, cirrhosis, metastatic carcinoma

• extra-hepatic – common bile duct stone, carcinoma of the head of pancreas, ampulla or bile duct.

Getting on the right track

I took a history. He felt reasonably well. He had no history of any change in his bowel habit that would suggest a GI malignancy. He had no history of blood transfusions – ruling out possible hepatitis B and C – and he hadn't travelled abroad recently. He had been married for nearly 50 years and had had no other sexual contacts since marriage. There was no history of IV drug misuse.

His alcohol intake was well within advised limits and always had been. He gave no history of upper abdominal pain, especially of colicky right upper quadrant pain – suggestive of biliary colic.

He did not feel fatigued and his exercise tolerance was good, suggesting haemolytic anaemia wasn't the problem. He took lisinopril and simvastatin.

He had noted that his urine had turned dark and his stools were slightly paler, which was suggestive of obstructive jaundice.

On examination, he appeared reasonably well nourished. His sclera were yellow. There were no spider naevi present. His abdomen was soft. There was no tenderness and his Murphy's test was negative. No masses were palpable.

The hidden clue

He had noticed slight weight loss over the past few weeks but had taken no real notice of it, and had some pain in the middle of his back.


I arranged some blood tests and referred him for an urgent abdominal ultrasound scan.

The blood tests revealed a normal FBC, which excluded haemolysis. His liver enzymes and bilirubin levels were elevated as well.

The abdominal ultrasound scan revealed slight dilatation of his common bile duct but the gallbladder appeared normal. The pancreas was not visualised due to bowel gases.

After discussion with a local surgeon, an urgent abdominal CT scan was arranged. This revealed pancreatic cancer, with some retroperitoneal involvement. Unfortunately curative surgery was not an option. He underwent a stent insertion to relieve the jaundice. He remained reasonably well for about four months and then rapidly declined and died four weeks afterwards.

Dr Hercules Robinson is a GP in Caithness

Why is this 70 year old moderate drinker jaundiced? Why is this 70 year old moderate drinker jaundiced?

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