Jaundice is not a particularly common presentation in general practice (56 in 100,000). However it often indicates a serious underlying condition (35% malignancy) which requires urgent investigation via a 2 week wait referral.1 Various methods have been tried to expedite these referrals including a rapid access hotline.2 and clinics. The experience and impact of an acute jaundice clinic providing prompt clinical, biochemical and radiological assessment is evaluated at a tertiary referral centre.Methods
The acute jaundice clinic provides open access bi-weekly clinics, following primary care referral, for clinical assessment, same day access to radiological investigations and prompt referral for hepato-pancreato-biliary (HPB) MDT discussion and, if required, biliary decompression. The primary goal is to ensure patients found to have HPB cancers are assessed quickly; the secondary aim is to avoid unnecessary admissions. This review will analyse appropriateness of referral, timing of investigations, diagnoses made and subsequent patient outcomes. Data was collected contemporaneously and supplemented with online patient records. This included patient age, bilirubin level, referral date and date of clinic appointment, timeliness of radiological investigations, final diagnosis, date of discussion at HPB MDT and malignant patient outcomes.Results
Data analysis was completed for all patients seen in the jaundice clinic over a 3 year period (2015–2017). In total, 291 patients were referred with a median age of 68 years (range 18–96 years). 245 (84.2%) of these were deemed appropriate to be seen with 172 (70%) clinically jaundiced at the time of review. Median time from GP referral to jaundice clinic review was 5 days (range 1–33 days). 209 (85.3%) of the patients were managed in the outpatient setting. The main diagnoses made following jaundice clinic are shown in figure 1.Results
For suspected malignant diagnoses, 90.4% had a CT on the day of clinic and were discussed at MDT, on average, 10 days (range 1–50 days) later. Outcome data was only available for 2016 and 2017 but in patients diagnosed with malignant biliary obstruction, 17/19 (89.5%) had prompt biliary decompression with one of the remaining patients declining intervention. Only 4/19 (17.3%) were eligible for potentially curative surgery and 5/19 (26.3%) received palliative chemotherapy. One year survival was 50% (9/18).Conclusions
The introduction of a jaundice clinic in a tertiary centre has been successful in providing timely review of jaundiced patients with high patient satisfaction. It has also allowed for prompt radiological assessment of potential malignant cases within 24 hours in more than 90% of cases with patients on average discussed in the HPB MDT within 10 days of jaundice clinic. The service has also proved extremely beneficial in avoiding admission in over 85% of patients. The remaining number admitted denotes the acute requirement for biliary decompression in a group of patients who often have significant co-morbidities. Disappointingly curative resection rates remain low in this cohort of patients, although this likely reflects the late stage of disease when jaundice is present and highlights the need for research into other predictors.References
1. Whitehead, MW, Hainsworth, I, Kingham, J. G. C. (2001). The causes of obvious jaundice in South West Wales: perceptions versus reality. Gut, 48(3),409–413.References
2. Mitchell, J., Hussaini, H., McGovern, D., Farrow, R., Maskell, G., Dalton, H. (2002). Quality improvement report: The ‘jaundice hotline’ for the rapid assessment of patients with jaundice. BMJ: British Medical Journal, 325(7357),213.