Special Operations Forces Medical Handbook

3-57

Follow-up Actions
Return evaluation: Reevaluate to assess effectiveness of treatment. Some patients may be depressed,
and pain may be a manifestation of their depression. Treating the depression is the best treatment of the
headache. Be careful not to cause a bigger problem by getting the patient hooked on narcotics.
Evaluation/Consultation Criteria: Evacuate if rst or worst headache. Evacuate in other situations if service
member unable to perform mission due to pain. Refer if patient fails adequate trials of standard prophylactic
medications.

Symptom: Jaundice

COL (Ret) Peter McNally, MC, USA

Introduction: Jaundice is the condition characterized by yellow discoloration of the skin, sclera of the eyes
and mucous membranes. It results from systemic accumulation of bilirubin due to signicant dysfunction of the
liver &/or biliary tract. Under normal conditions, the heme protein from old red blood cells (RBCs) is broken
down in the reticuloendothelial system (macrophages and other phagocytic cells) into unconjugated bilirubin,
which is transported by the blood to the liver. There the liver cells (hepatocytes) conjugate the bilirubin and
excrete it into the bile, where it is eventually eliminated from the body in the stool. Bilirubin is an end-product
of heme degradation.
Normal Bilirubin Metabolism:
Reticuloendothelial System Liver Hepatocyte/canniculi
RBCèhemeèunconjugated bilirubinèconjugation of bilirubinèexcretion into bileèpassage into stool
(makes stool brown) (Normally there is little or no renal excretion of bilirubin)

Renal bilirubin excretion occurs when the liver fails
(makes dark urine)
Abnormal Bilirubin Metabolism:

1. Hemolysis: RBC destruction and unconjugated bilirubin production exceeds the ability of the liver to
   conjugate and excrete the bilirubin.
   Result: Serum: - unconjugated hyperbilirubinemia


2. Hepatitis: Normal RBC destruction with normal levels of unconjugated bilirubin cannot be sufciently
   conjugated and excreted by the acutely or chronically damaged liver.
   Result: Serum: - unconjugated and conjugated hyperbilirubinemia
   Urine: - conjugated bilirubin (dark urine)
   Stool: - bilirubin (clay-colored stool)


3. Biliary Obstruction: Normal RBC destruction leading to normal amounts of unconjugated bilirubin, which
   is conjugated by the liver, but obstruction of the biliary tree prevents bile excretion into the stool.
   Result: Serum: - conjugated hyperbilirubinemia
   Urine: - conjugated bilirubin (dark urine)
   Stool: - bilirubin (clay colored stool)

Subjective: Symptoms
Itching, confusion, abdominal pain, fever, weight loss, fatigue

Objective: Signs
Using Basic Tools: Inspection: Frank jaundice of skin and scleral icterus (icterus of one eye only may
indicate other eye is glass); fatigue, confusion and suppressed sensorium in fulminant hepatitis; spider
angiomata over the blush area of the upper thorax and gynecomastia in chronic liver disease.
Auscultation: Usually normal
Palpation: Enlarged and tender liver due to inammation; spleen may also be enlarged. Ascites is uncommon