Approach to a patient
with jaundice
Dr Ali Tumi
Jaundice
• Yellow discoloration of skin & sclera due to
excess serum bilirubin. >40umol/l,
(3mg/dl)
• Conjugated & Unconjugated types
• Obstructive & Non Obstructive (clinical)
• Pre-Hepatic, Hepatic & Post Hepatic
types
• Jaundice - Not necessarily liver disease *
Bilirubin
Metabolism
•Blood
•Conjugated &
Unconjugated
•Urine – Urobilinogen
•Stool – Stercobilin
Common Causes of Jaundice
• Pre Hepatic (Acholuric) - Hemolytic
– Unconjugated/Indirect Bil, pale urine
• Hepatic – Viral, alcohol, toxins, drugs
– Liver damage - unconjugated
– Swelling, canalicular obstruction Conjugated
• Post Hepatic (Obstructive) – Stone,
tumor
– Conjugated/Direct Bil, High colored urine,
Critical Questions in the Evaluation
of the Jaundiced Patient
• Acute vs. Chronic Liver Disease
• Hepatocellular vs. Cholestatic
– Biliary Obstruction vs. Intrahepatic Cholestasis
• Fever
– Could the patient have ascending cholangitis?
• Encephalopathy
– Could the patient have fulminant hepatic failure?
Evaluation of the Jaundiced Patient
HISTORY
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Pain
Fever
Confusion
Weight loss
Sex, drugs, R&R
Alcohol
Medications
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pruritus
malaise, myalgias
dark urine
abdominal girth
edema
other autoimmune dz
HIV status
prior biliary surgery
family history liver dz
Evaluation of the Jaundiced Patient
PHYSICAL EXAM
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BP/HR/Temp
Mental status
Asterixis
Abd tenderness
Liver size
Splenomegaly
Ascites
Edema
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Spider angiomata
Hyperpigmentation
Kayser-Fleischer rings
Xanthomas
Gynecomastia
Left supraclavicular
adenopathy
(Virchow’s node)
Cirrhosis
Clinical
Features
Yes
Treat
Evaluation of the Jaundiced Patient
LAB EVALUATION
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AST-ALT-ALP
Bilirubin – total/indirect
Albumin
INR
Glucose
Na-K-PO4, acid-base
Acetaminophen level
CBC/plt
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Ammonia
Viral serologies
ANA-ASMA-AMA
Quantitative Ig
Ceruloplasmin
Iron profile
Blood cultures
Evaluation of the Jaundiced Patient
• Ultrasound:
– More sensitive than CT for gallbladder stones
– Equally sensitive for dilated ducts
– Portable, cheap, no radiation, no IV contrast
• CT:
– Better imaging of the pancreas and abdomen
• MRCP:
– Imaging of biliary tree comparable to ERCP
• ERCP:
– Therapeutic intervention for stones
– Brushing and biopsy for malignancy
New Onset Jaundice
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Viral hepatitis
Alcoholic liver disease
Autoimmune hepatitis
Medication-induced liver disease
Common bile duct stones
Pancreatic cancer
Primary Biliary Cirrhosis (PBC)
Primary Sclerosing Cholangitis (PSC)
Jaundiced Emergencies
• Acetaminophen Toxicity
• Fulminant Hepatic Failure
• Ascending Cholangitis
Jaundice Unrelated to
Intrinsic Liver Disease
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Hemolysis (usually T. bili < 4)
Massive Transfusion
Resorption of Hematoma
Ineffective Erythropoesis
Disorders of Conjugation
– Gilbert’s syndrome
• Intrahepatic Cholestasis
– Sepsis, TPN, Post-operation
HBV Serology
HBSAg HBcAb HBcAb HBSAb
IgM
IgG
Acute HBV
Resolved HBV
Chronic HBV
HBV vaccinated
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Jaundice
Jaundice
Yellow hands on top, red palms
underneath - a sign of liver damage
Ascitis in Cirrhosis
Ascitis in Cirrhosis
Gynaecomastia in cirrhosis