# Upper abdominal pain and yellow eyes in a 58-year-old: a jaundice case to work up

> A gastroenterology case for medical students: a 58-year-old with months of upper abdominal pain, now with yellow eyes, dark urine and pale stools. What to ask, red flags, first tests and the differential.

- Gastroenterology · Intermediate · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/58-year-old-woman-with-upper-abdominal-pain-and-yellow-eyes
- Work up this patient: https://www.medikarya.in/case-studies/58-year-old-woman-with-upper-abdominal-pain-and-yellow-eyes

## How the patient presents

A 58-year-old teacher with three months of upper abdominal pain, now worse and going through to her back, has noticed yellow eyes, dark urine and pale stools. Her doctor referred her after a course of acid-reducing tablets did not help.

## Why jaundice with upper abdominal pain matters

Yellow eyes with dark urine and pale stools mean bile is not reaching the gut. The question is why: a stone, a narrowing or a growth. Ultrasound sorts out many, but the history and her weight tell you how worried to be.

## What to ask in the history

- When the yellowing started; itching
- The pain: where, where it goes, link with meals
- Weight loss, appetite
- Fever, shivering
- Alcohol
- Known gallstones or pancreatitis
- New diabetes
- Medicines, including herbal remedies
- Risks for viral hepatitis; family history

## Red flags

- Fever and shivering with jaundice
- Weight loss
- Jaundice that keeps deepening
- A palpable gallbladder
- Confusion or bleeding

## What to examine

- Jaundice, scratch marks
- Lymph nodes, including above the left collarbone
- Abdomen: tenderness, liver, gallbladder, masses, fluid
- Weight

## First investigations

- Liver function, to see the pattern
- Full blood count, clotting
- Kidney function
- Amylase or lipase
- Ultrasound of the abdomen
- CT or MRCP to define the cause
- Endoscopic tests as needed

## Differential diagnosis of jaundice with upper abdominal pain

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Liver

- Hepatitis
- Drug-induced liver injury

### In the bile duct

- Gallstones
- Cholangitis
- Benign narrowing

### Pancreas

- Chronic pancreatitis

### Growths

- Cancer of the head of the pancreas
- Bile duct cancer
- Ampullary tumour

## Common mistakes

- Repeating acid-reducing tablets without examining her.
- Going straight to a procedure before imaging.
- Forgetting to check and correct the clotting before a procedure.

---

A study guide for medical students, not medical advice. Follow your institution's protocols in practice.