The presence of jaundice (icterus) must alert the examiner that there is either liver parenchymal disease or an obstruction to bile flow. The presence of icterus, or jaundice, results from a decreased excretion of conjugated bilirubin into the bile. This can result from intrahepatic biliary obstruction, known as medical jaundice, or from extrahepatic biliary obstruction, known as surgical jaundice. In any patient with icterus, the examiner should search for clues by asking the following questions:

''How long have you been jaundiced?'' ''Did the jaundice develop rapidly?''

' 'Is the jaundice associated with abdominal pain? loss of appetite? nausea? vomiting? distaste for cigarettes?''

Is the jaundice associated with chills? fever? itching? weight loss?'' In the past year have you had any transfusions? tattooing? inoculations?'' Do you use any recreational drugs?'' If yes, Do you use any drugs intravenously?'' Do you eat raw shellfish? oysters?''

' 'Have you traveled abroad in the past year?'' If yes, ' 'Where? Were you aware that you may have consumed unclean water?''

''Have you been jaundiced before?''

''Has your urine changed color since you noticed that you were jaundiced?'' ''What is the color of your stools?''

''Do you have any friends or relations who are also jaundiced?'' ''What type of work do you do? What other types of work have you done?'' What are your hobbies?''

Viral hepatitis is associated with nausea, vomiting, a loss of appetite, and an aversion to smoking. Hepatitis A has a fecal-oral route of transmission and an incubation period of 2 to 6 weeks. It may be linked to ingestion of raw shellfish. Hepatitis B is blood-borne and has an incubation period of 1 to 6 months. Health professionals are at increased risk for hepatitis. Any contact with an individual with viral hepatitis places a person at a higher risk of contracting viral hepatitis. Hepatitis C virus (HCV) is the most common chronic blood-borne infection in the United States. The Centers for Disease Control and Prevention has estimated that during the 1980s, as many as 230,000 new infections have occurred in this country. It is estimated that as many as 3.9 million Americans have antibody to HCV and are currently asymptomatic. They are, however, at risk for chronic liver disease, the 10th leading cause of death in the United States. About 40% of chronic liver disease is HCV related and results in 8000 to 10,000 deaths a year. End-stage liver disease secondary to HCV infection is the most common indication for liver transplantation. Because most of these individuals are younger than 50 years, it is anticipated that by 2020, there will be a marked increase in the number of patients with chronic liver disease.

Slowly developing jaundice that is accompanied by pale stools and cola-colored urine is obstructive jaundice, either intrahepatic or extrahepatic. Jaundice accompanied by fever and chills is considered cholangitis until proved otherwise. Cholangitis may result from stasis of bile in the bile duct that results from a gallstone or from cancer of the head of the pancreas. Determine whether chemicals are used in a patient's occupation or hobbies, because they may be related to the cause of the jaundice. Many industrial chemicals and drugs have been associated with liver disease. These agents may be responsible for a viral hepatitis-like illness, cholestasis, or for granulomas or hepatic tumors. Occupational exposure to carbon tetrachloride and vinyl chloride is well known to cause liver disease. Ask questions related to alcohol abuse. These are described in Chapter 1, The Interviewer's Questions.

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