GP Dr Oliver Starr describes how this patient's yellow eyes led him to the right diagnosis
The patient
This 46-year-old man looked entirely well as he said: ‘I'm feeling itchy all over, doctor. It started on my hands but now it's driving me crazy.' Aside from this he was fine. He had seen our nurse about a year ago after a big toenail avulsion, but that was it.
When I examined him there was no rash to see anywhere.
I was about to say my usual ‘it'll settle, try Eurax' when I wondered if his eyes looked a touch yellow. He hadn't noticed, but I asked him to humour me with a blood test. It could have just been how his eyes normally looked; I wouldn't know as I had never met him before.
Differential diagnoses
• Haemolytic anaemia
• Choledocholithiasis
• A pancreatic lesion
• Systemic causes of pruritus.
Haemolytic anaemia can cause itchiness with a raised bilirubin and a drop in haemoglobin with a macrocytosis. If this had shown up I would have proceeded to a Coombs test and referred him to haematology.
Stones in the common bile duct escaping from the gallbladder were a distinct possibility. They do not always cause pain and usually show up on ultrasound. The jaundice and itching would fit with this.
A head of pancreas tumour was a differential, although he looked too well to have cancer. There was no weight or appetite loss, although I've just seen a man with advanced colon cancer who hadn't lost any weight.
We are always told in dermatology talks to investigate thyroid, renal and liver function in any itching, so I duly ticked all the boxes on the blood form.
Getting on the right track
His bloods showed a normal FBC, but a very high bilirubin and ALP. All other bloods were normal. I organised an urgent ultrasound, which showed a dilated common bile duct.
I referred him to gastroenterologists via the two-week wait rule.
They performed an ERCP, which identified a distal common bile-duct stricture.
A stent allowed bile to flow freely and his jaundice settled. We were none the wiser because brushings taken did not reveal malignant cells. A CT scan confirmed the ERCP findings and showed a lytic lesion in a rib with a soft-tissue mass around it. A myeloma screen and epithelial tumour markers were normal.
The consultants referred him to a tertiary centre where, a full three months after my original referral, a second ERCP allowed biopsies to be taken. They showed B-cell lymphoma of the germinal centre type. Having been offered sperm banking, he has now started chemotherapy under the care of our haematologists.
When I saw him last week he looked well, hadn't lost any weight and wasn't particularly jaundiced. I was glad I acted on a mere passing thought.
Dr Oliver Starr is a GP in Stevenage, Hertfordshire
Yellowed eyes Yellowed eyes
