Jaundice Summary

Red Flags

  • Hepatic encephalopathy
  • Severe coagulopathy
  • GI bleeding
  • Sepsis
  • Severe abdominal pain

Key Investigations

  • Bilirubin (conjugated/unconjugated)
  • ALT/AST vs ALP/GGT ratio
  • Coagulation studies
  • Ultrasound abdomen

LFT Patterns

  • Hepatocellular: ALT↑↑ > AST
  • Cholestatic: ALP↑↑ > transaminases
  • Alcoholic: AST:ALT > 2:1

Management

  • Treat underlying cause
  • Supportive care
  • Monitor complications
  • Urgent referral if red flags

Neonatal Jaundice

  • Physiological vs pathological
  • Phototherapy if needed
  • Watch for kernicterus

Jaundice (Icterus)

Comprehensive guide to diagnosis and management

Overview

Jaundice describes yellow pigmentation of skin, sclera and mucous membranes due to raised plasma bilirubin (>51 μmol/L). Normal bilirubin levels are below 21 μmol/L.

Pathophysiology

Pre-hepatic

  • Increased bilirubin production
  • Unconjugated hyperbilirubinemia
  • Causes: Hemolysis, Gilbert's syndrome

Intra-hepatic

  • Hepatocellular dysfunction
  • Both conjugated & unconjugated bilirubin
  • Causes: Hepatitis, cirrhosis, drugs

Post-hepatic

  • Biliary obstruction
  • Conjugated hyperbilirubinemia
  • Causes: Gallstones, tumors, strictures

Causes

Pre-hepatic

  • Hemolytic anemias: Sickle cell, thalassemia, G6PD
  • Gilbert's syndrome (mild, stress-induced)
  • Crigler-Najjar syndrome (severe neonatal)
  • Malaria, drugs causing hemolysis

Intra-hepatic

  • Viral hepatitis: A, B, C, D, E
  • Alcohol-related: Hepatitis, cirrhosis
  • NAFLD/NASH
  • Autoimmune: PBC, PSC, AIH
  • Metabolic: Wilson's, hemochromatosis
  • Drug-induced liver injury

Post-hepatic

  • Gallstones (choledocholithiasis)
  • Malignancy: Pancreatic, cholangiocarcinoma
  • Strictures: Post-surgical, PSC
  • Pancreatitis, parasitic infections

Clinical Assessment

History

Examination

General

  • Vital signs (fever, hypotension)
  • Nutritional status
  • Mental status (encephalopathy)

Abdominal

  • Hepatomegaly/splenomegaly
  • Masses, ascites
  • Murphy's/Courvoisier's signs

Stigmata of CLD

  • Spider naevi, palmar erythema
  • Dupuytren's contracture
  • Gynaecomastia, testicular atrophy

Red Flags (Require Urgent Assessment)

  • Hepatic encephalopathy
  • Severe coagulopathy/bruising
  • GI bleeding
  • Sepsis
  • Severe abdominal pain
  • Suspected paracetamol overdose

Investigations

Initial Tests

Test Purpose
LFTs
  • Bilirubin (conjugated/unconjugated)
  • ALT/AST (hepatocellular)
  • ALP/GGT (cholestatic)
Other Bloods
  • FBC (hemolysis, infection)
  • Coagulation (liver synthetic function)
  • Amylase (pancreatitis)
Urinalysis Bilirubin (conjugated), urobilinogen

LFT Patterns

Hepatocellular Pattern

  • ALT/AST ↑↑ > ALP
  • Viral hepatitis: ALT > AST
  • Alcoholic hepatitis: AST:ALT > 2:1
  • Acute liver injury: ALT > 10,000 U/L

Cholestatic Pattern

  • ALP/GGT ↑↑ > transaminases
  • Biliary obstruction
  • Normal transaminases unless cholangitis
  • ALP elevated in obstruction

Hemolytic Pattern

  • Unconjugated bilirubin ↑
  • Normal transaminases
  • Elevated LDH, low haptoglobin
  • Reticulocytosis

Specialized Tests

Key LFT Interpretation Points

  • A predominant rise in ALT is the most marked abnormality in hepatocellular damage
  • Acute viral hepatitis can cause ALT to rise to several thousand U/L
  • Acute liver injury from drugs or ischemia can produce ALT > 10,000 U/L
  • Alcohol-induced damage usually produces AST:ALT ratio > 2:1
  • Transaminases are not usually raised in obstructive jaundice unless complicated by cholangitis

Management

General Principles

Specific Treatments

Pre-hepatic

  • Treat hemolysis (stop causative drugs)
  • Gilbert's - reassurance only
  • Crigler-Najjar - phototherapy/liver transplant

Intra-hepatic

  • Viral hepatitis - antivirals
  • Alcohol - abstinence, nutrition
  • Autoimmune - immunosuppressants
  • Metabolic - specific therapies

Post-hepatic

  • Gallstones - ERCP + sphincterotomy
  • Strictures - stenting/dilatation
  • Malignancy - resection/palliation

Neonatal Jaundice

Physiological

  • Appears day 2-3, resolves by day 10
  • Reassurance & monitoring

Pathological

  • Appears <24h or persists >14 days
  • Phototherapy/exchange transfusion
  • Urgent evaluation for kernicterus risk