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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

Red flags for jaundice: unexplained weight loss, progressive jaundice (incl. painless jaundice), cerebral dysfunction, e.g. confusion, somnolence.

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Table J1 Jaundice (adults): diagnostic strategy model

Probability diagnosis

Hepatitis A, B, C

Gallstones in common bile duct

Alcoholic hepatitis/cirrhosis

Drugs (e.g. flucloxacillin, sodium valproate)

Serious disorders not to be missed


  • pancreas

  • biliary tract

  • hepatocellular (hepatoma)

  • metastases

Severe infections

  • septicaemia

  • ascending cholangitis

  • fulminant hepatitis



  • Wilson syndrome

  • Reye syndrome

  • acute fatty liver of pregnancy

Pitfalls (often missed)


Gilbert syndrome

Cardiac failure

Primary biliary cirrhosis

Autoimmune chronic active hepatitis


Viral infections (e.g. CMV, EBV)

Chronic viral hepatitis


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.

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Table J2 Characteristic liver function tests

Liver function tests (serological)

Hepatocellular (viral) hepatitis

Haemolytic jaundice


Alcoholic liver disease


↑ to ↑↑↑

↑ unconjugated

↑ to ↑↑↑

↑ to N

Alkaline phosphatase

↑ to <2 N


↑↑↑ >2 N

Alanine transferase

↑↑↑ >5 N


N or ↑

Gamma gultamyl transferase

N or ↑





N or ↓



N to ↓↓


N or ↑



N to ↑

N = is within normal limits

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

Infective viral hepatitis

Hepatitis image 298–302

  • 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 ...

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