Jaundice in adults

Probability diagnosis

Hepatitis A, B, C (mainly B, C)

Gallstones

Alcoholic hepatitis/cirrhosis

Serious disorders not to be missed

Malignancy:

• pancreas

• biliary tract

• hepatocellular (hepatoma)

• metastases

Infection:

• septicaemia

• ascending cholangitis

• fulminant hepatitis

• HIV/AIDS

• leptospirosis

Paracetamol overdose

Rarities:

• Wilson syndrome

• Reye syndrome

• acute fatty liver of pregnancy

Pitfalls (often missed)

Gallstones in common bile duct

Genetic disorders: Gilbert syndrome, Wilson syndrome, galactosaemia, others

Cardiac failure

Primary biliary cirrhosis

Autoimmune chronic active hepatitis

Primary sclerosing cholangitis

Chronic viral hepatitis

Amyloidosis

Haemochromatosis

Viral infections (e.g. CMV, EBV)

Masquerades checklist

Drugs (several, see list)

Anaemia (haemolytic)

Is the patient trying to tell me something?

Not usually applicable.

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

Diagnostic tips

• All drugs should be suspected as potential hepatotoxins.

• All patients with jaundice should be tested for hepatitis B surface antigen (HBsAg).

• Clinical jaundice manifests only when the bilirubin level exceeds 50 → mol/L.

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

• Haemolytic anaemia leading to jaundice has multiple causes (e.g. autoimmune, malaria, drugs, hereditary disorders, metabolic defects).