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Jaundice

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  • Jaundice is defined as a serum bilirubin level above 19 µmol/L.

  • Clinical jaundice manifests only when the bilirubin exceeds 50 µmol/L.

  • Jaundice is difficult to detect visually below 85 µmol/L if lighting is poor.

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

  • Always take a full travel, drug and hepatitis contact history in any patient presenting with jaundice.

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Table J1

Jaundice (adults): diagnostic strategy model

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Table J1

Jaundice (adults): diagnostic strategy model

  • Q. Probability diagnosis

  • A. Hepatitis A, B, C

     Gallstones

     Alcoholic hepatitis/cirrhosis

     Drugs (e.g. flucloxacillin, sodium valproate)

  • Q. Serious disorders not to be missed

  • A. Malignancy

    • pancreas

    • biliary tract

    • hepatocellular (hepatoma)

    • metastases

     Severe infections

    • septicaemia

    • ascending cholangitis

    • fulminant hepatitis

    • HIV/AIDS

     Rarities

    • Wilson syndrome

    • Reye syndrome

    • acute fatty liver of pregnancy

  • Q. Pitfalls (often missed)

  • A. Gallstones

     Gilbert syndrome

     Cardiac failure

     Primary biliary cirrhosis

     Autoimmune chronic active hepatitis

     Haemochromatosis

     Viral infections (e.g. CMV, EBV)

     Chronic viral hepatitis
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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

++ 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.

++ 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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Table J2

Characteristic liver function tests

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Table J2

Characteristic liver function tests

Liver function tests (serological)Hepatocellular (viral) hepatitisHaemolytic jaundiceObstructionAlcoholic liver disease
Bilirubin ↑ to ↑↑↑ ↑ unconjugated ↑ to ↑↑↑ ↑ to N
Alkaline phosphatase ↑ to <2 N N ↑↑↑ >2 N ↑
Alanine transferase ↑↑↑ >5 N N N or ↑ ↑
Gamma gultamyl transferase N or ↑ N ↑↑ ↑↑↑
Albumin N or ↓ N N N to ↓↓
Globulin N or ↑ N N N to ↑

N: is within normal limits

The normal ALP is 30–120 µ/L: it is elevated with cholestasis, osteoblastic activity (e.g. Paget disease), hepatitis and bony metastases.

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Infective viral hepatitis
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Hepatitis

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  • Hepatitis A, B, C, common esp. B and C

  • A and E—faeco–oral transmission

  • B, C, D—from IV drugs and bodily fluids

  • Sexual transmission with B and C

  • Diagnosed by viral markers for A, ...

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