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Why has this jaundiced young patient started vomiting?

This young patient normally looked pale and jaundiced due to a hereditary condition. But why has she suddenly started vomiting? Dr Mike Wyndham describes the case

 

The patient

This nine-year-old girl has the hereditary haemolytic disorder spherocytosis. She was normally pale and in fact had been perfectly well in recent months – her pallor being the result of the disease's tendency to cause anaemia along with a mild jaundice.

On the day before consulting, she developed a bout of prolonged vomiting associated with mild abdominal pain. On examination, she looked more jaundiced than normal and she had a mild diffuse tenderness in the upper abdomen.

Her spleen was palpable consistent with her haemolytic anaemia. There was no history of dietary change, having eaten suspicious food products or having travelled overseas.

First impression

I felt the most likely cause was vomiting from a viral origin such as norovirus or perhaps from a food-borne infection and suggested taking fluids to maintain rehydration.

Differential diagnosis

• Hepatitis infection

• Obstructive jaundice

• Drug-induced hepatitis

• Wilson's disease

Of the hepatitis infections, hepatitis A seemed the most likely possibility. In under-5s, the infection may not be noticeable but in the older child symptoms include vomiting, jaundice, pale stools and dark urine.

Obstructive jaundice may be the result of gall stones, which can develop in haemolytic anaemia. Certain drugs may cause hepatitis, such as isoniazid and erythromycin, but the patient was not on any medication. Wilson's disease may present similarly to hepatitis A.

Additionally, there may be neurological signs such as problems with walking and co-ordination.

Getting on the right track

The patient appeared to slowly improve and the vomiting ceased.

Her blood tests confirmed an obstructive jaundice and so an ultrasound was arranged. This showed gall stones and sludge in the common bile duct. In view of her continuing haemolysis, it was decided that she would have her gall bladder and spleen removed.

Dr Mike Wyndham is a GP in Edgware, north London

Jaundice and vomiting

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