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The causes of obvious jaundice in South West Wales: perceptions versus reality

Abstract

AIMS (1) A prospective analysis of clinically obvious jaundice (bilirubin >120 μmol/l) in South Wales to determine accuracy of diagnosis, referral pattern, treatment, and outcome. (2) To compare British gastroenterologists' and local general practitioners' perceptions of common causes of jaundice with our study findings.

METHODS Over a seven month period all patients with bilirubin >120 μmol/l (excluding neonates with physiological jaundice) were identified by a biochemistry laboratory serving three general hospitals and the community. Clinical data were recorded prospectively. Sixty nine consultant gastroenterologists and 67 local general practitioners (GPs) were asked to cite the commonest causes of bilirubin >120 μmol/l in their experience.

RESULTS A total of 121 patients were identified of whom 95 were admitted to hospital because of jaundice, 22 developed jaundice while in hospital, and four remained in the community. Causes of jaundice were: malignancy 42, sepsis/shock 27, cirrhosis 25, gall stones 16, drugs 7, autoimmune hepatitis 2, and viral hepatitis 2. One in five was wrongly diagnosed, often as viral hepatitis. Although 30% were under surgical care only 4% required surgery. Overall mortality was high (31%) and greatest in sepsis/shock (51%). Gastroenterologists and GPs both perceived malignancy and gall stones to be the commonest causes of marked jaundice followed by viral hepatitis and cirrhosis; sepsis/shock was hardly mentioned.

CONCLUSIONS There are important discrepancies between gastroenterologists' and GPs' perceptions of likely causes of jaundice and the actual causes we have shown. In particular, sepsis/shock is common in hospital practice but is overlooked whereas viral hepatitis is rare but perceived as common and overdiagnosed. Gall stones usually cause mild jaundice with bilirubin levels less than 120 μmol/l. Many patients are referred to surgical services for historical reasons yet rarely require surgery and are usually treated by physicians or endoscopists.

  • jaundice
  • bilirubin
  • sepsis
  • hepatitis
  • gall stones
  • questionnaire
  • Abbreviations used in this paper

    GP
    general practitioner
    BSG
    British Society of Gastroenterology
    AST
    aspartate aminotransferase
    ITU
    intensive therapy unit
    CBD
    common bile duct
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