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One jaundice case in four is cancer

Over a quarter of patients aged over 45 presenting with jaundice to their GP have cancer identified as the underlying cause, concludes the first primary care study to look at the causes of jaundice.

The researchers said they were surprised at the high incidence of cancer in patients with jaundice and that the finding made the case for extending NICE guidelines to ensure all such patients over 45 were urgently referred for tests and assessment.

The study, conducted by researchers in Bristol and Exeter, analysed 187,000 records from patients aged over 45 who had a clinical event recorded from 2005-07 in the UK General Practice Research Database.

Of these, 277 patients (0.15%) had a diagnosis of jaundice recorded in their records, and 33% of these had obstructive jaundice. Cancer was the second most common cause of jaundice in the over-45s after gallstones, and more common than alcoholic liver disease.

Among patients with jaundice, 27% had a cancer diagnosis, 9% had alcoholic liver disease and 9% had other diagnoses. A further 22% had no diagnosis related to jaundice recorded.
The researchers concluded that GPs should conduct immediate blood tests to rule out
hepatic sources, and also refer urgently for transabdominal ultrasonography.

The researchers said NICE guidelines – which recommend a patient with obstructive jaundice be urgently referred for suspected cancer ‘depending on clinical state' and that urgent ultrasound may be considered ‘if available' – were too narrow.

They said these guidelines should be extended to encourage GPs to refer all patients aged over 45 with jaundice for an urgent blood test and imaging, no matter the suspected cause.
Study author Professor Willie Hamilton, professor of primary care diagnostics at Peninsula College of Medicine and Dentistry and a GP in Exeter, said: ‘It surprised us, the high proportion of cancer diagnoses. We double- and triple-checked.'

'That's why we are keen to see jaundice investigated urgently by GPs. Of course, some of the three-quarters with jaundice will be fairly obvious – with alcohol excess or gallstones – and if the GP can confidently diagnose them, great.'

Professor Greg Rubin, professor of general practice and primary care at Durham University, said the study showed the importance of urgent assessment: ‘There is no room for complacency when patients over 45 present with jaundice.'

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