Special Operations Forces Medical Handbook

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in acute hepatitis, but may occur if fulminant hepatic failure occurs. A small, hard and nodular liver is typical of
chronic hepatitis, cirrhosis and submassive necrosis.
Percussion: Shifting abdominal dullness and uid wave is suggestive of ascites.

Comparison of Common Causes of Jaundice
Symptom/Sign Acute Hepatitis Chronic Hepatitis Obstruction –stones Obstruction – cancer
Viral prodrome Yes No No No
Pain Tender liver No Yes No
Fever Low grade No Yes No
Hepatomegaly Yes, often tender Often shrunken, Normal Enlargement
may be enlarged suggests metastasis
and nodular
Weight loss Mild, anorexia Variable No Yes, >10%

Stigmata of Usually not Invariable, yes No Usually not
cirrhosis:
Spider angiomata,
gynecomastia, ascites.
Using Advanced Tools: Lab: CBC for anemia, infection; urinalysis for urobilinogen

Assessment:
Differential Diagnosis
Hemolysis or hemoglobinopathy (sickle cell, G6PD, thalassemia) (see Hematology Chapter)
Hepatic Causes (see ID: Hepatitis):
Acute or subacute hepatitis - usually no signs of cirrhosis
a. Hepatitis A - inuenza-like illness (fever, myalgia, nausea, vomiting, etc); tender hepatomegaly;
splenomegaly in 10%.
b. Hepatitis B - 2 week pre-icteric phase (fever, rash, arthritis); icteric phase (1 month); then resolution.
c. Liver cell toxicity - drugs (isoniazid, methyldopa, acetaminophen and chlorpromazine), Amanita mush
room poisoning, ETOH
Chronic Hepatocellular Disease - signs of cirrhosis (small, hard liver; ascites; esophageal varices; etc.)
Hepatitis B or C (never hepatitis A) - ethanol, autoimmune hepatitis, other rare diseases
Obstructive:
a. Stones in the gall bladder (cholecystitis), or stone in the bile duct - abdominal pain and/or fever
b. Primary Sclerosing Cholangitis (PSC) - 80% will have inammatory bowel disease (diarrhea)
c. Neoplasm - associated weight loss; usually painless.
d. Inammation - primary Biliary Cirrhosis usually seen in females 40-60 yrs, drugs (chlorpromazine,
erythromycin)
e. Inltrative - tuberculosis, sarcoidosis, lymphoma; evidence of invasion of other tissues

Plan:
Treatment

1. Prevent spread of infectious hepatitis by using body uid precautions, and managing all acute cases in
   an isolation area.


2. Encourage po uid and nutrition intake.


3. Discontinue medications that can cause hepatitis or jaundice. Avoid all Tylenol and alcohol.


4. For suicide attempt with acetaminophen overdose, give N-acetyl cysteine (NAC or Mucomyst) or
   evacuate immediately.


5. If clinical picture is consistent with obstructive jaundice with cholangitis (fever, RUQ abdominal pain), start
   IV antibiotics: ticarcillin or piperacillin 4 gm IV q 6 h and Flagyl 1 gm q 12 h; or imipenem 0.5 gm
   IV q 6 h.


6. Signs of hepatic decompensation (bleeding, encephalopathy, ascites) or infection should prompt
   evacuation.