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Am Fam Physician. 2005;71(3):425-426

to the editor: I read with great interest the review on “Jaundice in the Adult Patient,”1 by Drs. Roche and Kobos in the January 15, 2004, issue of American Family Physician. I think it is an easy to read and well-organized review; however, it contained certain inaccuracies.

The authors state, “Abdominal pain is the most common presenting symptom in patients with pancreatic or biliary tract cancers.”1 In fact, the most common presentation in patients with pancreatic cancer is jaundice (72 percent of patients versus 36 percent of patients with abdominal pain).2 Furthermore, by the time patients present with abdominal pain, they usually have unresectable tumors.3

In the paragraph discussing posthepatic causes of jaundice, the authors estimate that cholangiocarcinoma “is associated with an approximately 50 percent survival rate.”1 This survival rate is too optimistic, because it is well known that cholangiocarcinoma is usually associated with a very poor prognosis. Cholangiocarcinoma is almost always a fatal malignancy, primarily because it usually is diagnosed at a late stage (similar to pancreatic cancer).4

Finally, in their discussion of serum testing, the authors report that hemolysis “is indicated by the presence of fractured red blood cells (schistocytes) and increased reticulocytes on the smear.” I would like to clarify that schistocytes are seen only in microangiopathic hemolysis (disseminated intravascular coagulopathy, thrombocytopenic purpura), which is a subset of the hemolytic anemia family, but not present in all forms of hemolytic anemia, and with intravascular prostheses.

editor's note: This letter was sent to the authors of “Jaundice in the Adult Patient,” who declined to reply.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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