Jaundice

Differentials

Most Common Causes

• Choledocholithiasis (stones in the common bile duct)

• Hepatitis B/C (infectious)

• Alcoholic Hepatitis

Other Causes

• Malignancy: Pancreatic cancer, hepatocellular carcinoma (HCC), cholangiocarcinoma

• Autoimmune Cholangiopathies: Primary Biliary Cholangitis (PBC), Primary Sclerosing Cholangitis (PSC)

• Drugs/Toxins: e.g. paracetamol overdose, methotrexate, herbal supplements

• Non-Alcoholic Steatohepatitis (NASH)

• Haemochromatosis (iron overload)

• Gilbert’s Syndrome (benign unconjugated hyperbilirubinaemia)

• Haemolysis (increased bilirubin production)

History

Symptoms & Signs to Elicit

1. Colour of Stool & Urine

   • Pale (acholic) stools and dark urine typical of obstructive or cholestatic jaundice

2. Previous Abdominal Surgeries

   • Risk of bile duct strictures or altered anatomy

3. Possible Infectious Risks

   • IV drug use (Hepatitis B/C)

   • Travel to high-prevalence regions

   • Past immunisations for hepatitis B

4. Medications/Exposures

   • Herbal medications, recreational drugs

   • Hepatotoxic drugs (anti-TB meds, certain antibiotics, etc.)

5. Abdominal Pain

   • Right upper quadrant pain (cholelithiasis, choledocholithiasis)

   • Epigastric pain radiating to the back (pancreatitis or pancreatic malignancy)

6. Alcohol Intake

   • Chronic heavy use can cause alcoholic hepatitis/cirrhosis

7. Weight Loss

   • Potential malignancy (pancreatic, HCC, cholangiocarcinoma)

8. Haemolysis Signs

   • Pallor (anaemia), splenomegaly, personal/family history of haemolytic disorders

9. Fever/Chills

   • Suggests ascending cholangitis if obstructive symptoms

10. Skin Pigmentation Changes

11. Haemochromatosis (bronze diabetes), family history

12. Intermittent Mild Jaundice

13. Triggered by fasting/infections → Gilbert’s Syndrome (mild unconjugated bilirubin elevation)

Interpretation of Jaundice

• Pre-Hepatic: Haemolysis → unconjugated hyperbilirubinaemia

• Hepatic: Hepatitis (viral, alcoholic, autoimmune), NASH, drug-induced → conjugated/unconjugated mix

• Post-Hepatic: Obstruction (choledocholithiasis, malignancy, strictures) → predominantly conjugated hyperbilirubinaemia, dark urine, pale stool, pruritus

Key Investigations

• LFTs (bilirubin fractions, ALP, GGT, ALT, AST)

• Coagulation profile (INR) if severe liver impairment suspected

• Viral serologies (Hep A/B/C, EBV if indicated)

• Abdominal ultrasound (biliary tract dilation, gallstones, masses)

• CT/MRI or ERCP/MRCP if uncertain aetiology or suspected obstruction

• Iron studies (for haemochromatosis)

• Autoimmune markers (ANA, ASMA) if autoimmune hepatitis or PBC/PSC suspected

• Haemolysis markers (FBC, LDH, haptoglobin, reticulocyte count)

• Genetic testing (Gilbert’s, haemochromatosis) if indicated

Management

• Dependent on Aetiology

  • Choledocholithiasis: ERCP ± stone extraction

  • Hepatitis (B/C): Antiviral therapy guided by viral load, genotype, liver status

  • Alcoholic Hepatitis: Abstinence from alcohol, supportive care, consider corticosteroids if severe

  • Malignancy: Surgical resection if possible, chemotherapy, or palliative stenting for biliary obstruction

  • PBC/PSC: Ursodeoxycholic acid, potential transplant evaluation in advanced disease

  • Drug-Induced: Discontinue offending agent; supportive treatment

  • Haemolysis: Treat underlying cause, e.g. RBC transfusion if severe anaemia, manage triggers for haemolytic episodes

  • Gilbert’s Syndrome: Reassure, usually benign

General Measures

• Optimise nutrition, correct vitamin deficiencies (e.g., fat-soluble vitamins in cholestatic disease)

• Assess for pruritus → Cholestyramine or rifampicin can help if cholestatic

• Monitor for complications: varices in cirrhosis, coagulopathy, encephalopathy

• Lifestyle: Abstinence from alcohol if hepatic disease, healthy weight, adequate hydration

Notes

• Always exclude obstructive causes (choledocholithiasis, cholangiocarcinoma) if conjugated hyperbilirubinaemia.

• Chronic viral hepatitis needs specialist referral if advanced fibrosis, or for antiviral therapy.

• Screen for hepatocellular carcinoma (HCC) in cirrhotic patients via 6-monthly ultrasound ± alpha-fetoprotein.