Learning guidelines for the clinical round of cholestasis

A. History taking:
I. Personal history: name, age, gender, order of birth, consanguinity,
residence, socioeconomic class.
II. Complaint:
1. jaundice.
2. Change the color of urine and stools.
3. Bleeding tendency
4. Developmental delay.
5. Convulsions.
III. History of present illness
Analysis of the presenting complaints in a chronological manner
jaundice: onset, course, duration, itching.
change of color of urine and stools: onset, course,
duration
bleeding tendency: onset, course, duration, amount

IV: Past history: hospital admission, previous surgery, blood transfusion,

previous NICU admission, any medications taken.

Vaccination history: obligatory vaccines and extra vaccines.

V. Family History: a similar condition in the family, previous deaths in siblings or
abortions.
B. Examination:
➢ General appearance: general condition, decubitus
➢ Vital signs: HR, RR, Temp, BP
➢ Complexion: pallor, jaundice, cyanosis
➢ Anthropometric measurements: Weight, length or height, OFC.
➢ Head and neck :
o Special facies.
o Eye examination.
o Lymph node examination.
o Thyroid swelling
o Congested neck vein.

➢ Upper limbs:
o Clubbing
o Bleeding in skin
o Itching marks.
 ➢ Lower limbs: edema, clubbing, itching marks, bleeding in the skin
➢ Cardiac examination:
➢ Congenital heart diseases.
➢ Neurological examination
➢ Chest examination:
➢ Abdominal examination: Inspection: abdominal contour, subcostal angle,
epigastric pulsations, divarication of recti, umbilical and inguinal hernial
orifices, scars of previous operations, itching marks, visible peristalsis,
pigmentation of the skin, bleeding in the skin
Palpation: superficial: for confidence, superficial masses, tenderness,
rigidity, temperature.
Deep: palpation of liver spleen and kidneys. Methods of palpation: single-
handed, double-handed, bimanual
Percussion: for the upper border of liver, for detection of ascites: knee-
elbow position for minimal ascites, shifting dullness for moderate ascites,
transmitted thrill for massive ascites
Auscultation: for intestinal sounds, venous hum.

C. Formulation of clinical diagnosis:

Disease: A case of cholestasis
Etiology: intrahepatic (metabolic, genetic),
extrahepatic(choledochal cyst, extrahepatic
biliary atresia)
Associations: associated with: congenital heart disease, renal affection, neurological
affection, chest affection
Complications: Complicated with portal hypertension, liver failure, renal affection

D. Selected investigations:
1. Liver enzymes (AST, ALT, GGT ALP).
2. Serum albumin.
3. Prothrombin time and INR.
4. Total and direct bilurubin.
5. CBC and ESR. CRP
6. Pelviabdominal ultrasound.
7. Viral markers, thyroid function, urine analysis
8. Liver biopsy
9. Upper GIT endoscopy
10.Diagnostic tapping of ascites if present.
E. Recommended lines of management:
1- Medications for jaundice and itching if present as ursodeoxycholic acid and
ADEK vitamins.
2- Specific treatment as surgery for extrahepatic causes, liver transplantation
for genetic causes as progressive familial intrahepatic cholestasis.
3- Regular follow up visits to assess liver condition and early detection
of complications.
4- Early diagnosis of complications (ascites, lower limb edema, portal
hypertension, hepatic encephalopathy, hepatorenal syndrome) and
treatment.
5- Beta blockers if portal hypertension is present with regular follow up by
endoscopy