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.