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
Red flags for jaundice: unexplained weight loss, progressive jaundice (including painless jaundice), cerebral dysfunction, e.g. confusion, somnolence.
Table J1Jaundice (adults): diagnostic strategy model ||Download (.pdf) Table J1 Jaundice (adults): diagnostic strategy model
Hepatitis A, B, C
Gallstones in common bile duct
Drugs (e.g. flucloxacillin, sodium valproate)
Serious disorders not to be missed
Pitfalls (often missed)
Primary biliary cirrhosis
Autoimmune chronic active hepatitis
Viral infections (e.g. CMV, EBV)
Chronic viral hepatitis
Associated symptoms (e.g. rash, pruritus, fever, arthralgia, weight loss)
Contact with people with hepatitis or jaundice
Overseas travel, family history, drug history, IV drug use, sexual history, occupational history
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.
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.
Table J2Characteristic liver function tests ||Download (.pdf) Table J2 Characteristic liver function tests
|Liver function tests (serological) ||Hepatocellular (viral) hepatitis ||Haemolytic jaundice ||Obstruction ||Alcoholic 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 ↑ |
Infective viral hepatitis
Hepatitis A, B, C, common esp. B and C
A and E—faeco–oral transmission
B, C, ...