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JAUNDICE

• 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.

Key history

• 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

• 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

• 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.

Infective viral hepatitis

Hepatitis

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

• A and E—faeco–oral transmission

• B, C, ...