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++

Probability diagnosis

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Hepatitis A, B, C (mainly B, C)

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Gallstones

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Alcoholic hepatitis/cirrhosis

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Serious disorders not to be missed

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Malignancy:

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  • pancreas

  • biliary tract

  • hepatocellular (hepatoma)

  • metastases

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Infection:

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  • septicaemia

  • ascending cholangitis

  • fulminant hepatitis

  • HIV/AIDS

  • leptospirosis

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Paracetamol overdose

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Rarities:

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  • Wilson syndrome

  • Reye syndrome

  • acute fatty liver of pregnancy

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Pitfalls (often missed)

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Gallstones in common bile duct

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Genetic disorders: Gilbert syndrome, Wilson syndrome, galactosaemia, others

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Cardiac failure

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Primary biliary cirrhosis

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Autoimmune chronic active hepatitis

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Primary sclerosing cholangitis

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Chronic viral hepatitis

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Amyloidosis

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Haemochromatosis

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Viral infections (e.g. CMV, EBV)

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Masquerades checklist

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Drugs (several, see list)

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Anaemia (haemolytic)

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Is the patient trying to tell me something?

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Not usually applicable.

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Key history

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Associated symptoms (e.g. rash, pruritus, fever, arthralgia, weight loss). Medical history. Contact with people with hepatitis or jaundice. Overseas travel, family history, drug history, IV drug use, sexual history, occupational history.

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Key examination

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  • General inspection including skin for signs of excoriation

  • The abdominal examination is important with a focus on the liver and spleen

  • Look for signs of chronic liver disease

  • Test for hepatitis flap (asterixis) and fetor, which indicate liver failure

  • Include dipstick urine testing for bilirubin and urobilinogen

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Key investigations

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  • The main ones are the standard LFTs and viral serology for infective causes (hepatitis A, B, C and possibly EBV)

  • Consider hepatobiliary imaging, autoantibodies for autoimmune chronic active hepatitis and primary biliary cirrhosis, tumour markers and iron studies

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Diagnostic tips

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  • All drugs should be suspected as potential hepatotoxins.

  • All patients with jaundice should be tested for hepatitis B surface antigen (HBsAg).

  • Clinical jaundice manifests only when the bilirubin level exceeds 50 → mol/L.

  • The most common causes of jaundice recorded in a general practice population are (in order): viral hepatitis, gallstones, pancreatic cancer, cirrhosis, pancreatitis and drugs.

  • Haemolytic anaemia leading to jaundice has multiple causes (e.g. autoimmune, malaria, drugs, hereditary disorders, metabolic defects).

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