This document provides an approach to evaluating a patient presenting with jaundice. It defines jaundice and describes the production and metabolism of bilirubin. The causes of jaundice are divided into unconjugated and conjugated hyperbilirubinemia. A clinical history and physical exam are outlined to determine the underlying etiology. Key laboratory investigations including liver function tests and imaging studies are also reviewed to diagnose the cause of jaundice.

1. APPROACH TO A PATIENT WITH
JAUNDICE
Prepared by:
Kritika Jha
M.B.B.S Intern.

2. JAUNDICE
It is defined as yellowish discoloration of tissue
resulting from the deposition of bilirubin.
It is best appreciated by inspecting the sclera
under natural light. In dark skinned individuals,
mucous membrane below the tongue
demonstrates jaundice.
• Latent jaundice- when bilirubin<2.5mg/dl.
• Clinical jaundice-when bilirubin</=3mg/dl.

3. Production and metabolism of
bilirubin

4. Causes of hyperbilirubinemia
I. Unconjugated hyperbilirubinemia
A. Increased bilirubin production
1. Hemolytic disorder
• inherited: hereditary spherocytosis, sickle cell anemia,
thalassemia, enzyme deficiency: G6PD and pyruvate
kinase deficiency
• acquired: hemolytic uremic syndrome, immune
hemolysis, malaria.
2. Ineffective erythropoiesis
thalassemia;deficiency of iron, folate or vitamin
B12;lead poisoning.

5. B. Decreased hepatic bilirubin clearance
• decreased hepatic uptake: rifampicin,probenecid.
• Impaired conjugation:
physiological neonatal jaundice
acquired conjugation defects: advanced hepatitis or
cirrhosis; drugs-chloramphenicol, gentamycin; breast
milk jaundice.
C. Hereditary defects in conjugation
Crigler-najjar syndrome type I and II
Gilbert’s syndrome

6. Causes of conjugated hyperbilirubinemia
A. Inherited conditions: dubin johnson syndrome
rotor syndrome
B. Hepatocellular conditions:
• Viral hepatitis-hepatitis A,B,C,D,E; EBV; CMV;HSV
• Alcohol
• Drug- acetaminophen, isoniazid, halothane,
sodium valproate, amiodarone, phenytoin, statins,
cotrimoxazole,
• Toxins- wild mushroom, herbal tea, bee pollen,etc
• Wilson’s disease
• Autoimmune hepatitis.

7. C. Cholestatic jaundice
1. Intrahepatic
Viral hepatitis- hepatitis b and c
Alcoholic hepatitis
Drug: steroids, erythromycin, chlorpromazine
Primary biliary cirrhosis
Primary sclerosing cholangitis
Cholestasis of pregnancy
Infiltrative disease- TB, lymphoma
Venoocclusive disease
2. Extrahepatic : Cholangiocarcinoma, pancreatic, gall
bladder, ampullary cancer; choledocolithiasis.

8. CLINICAL HISTORY
• Duration of jaundice, dark urine, light stools, itching.
• Arthralgia, myalgia, rash, anorexia, weight loss,
abdominal pain, fever.
• Nausea may accompany fatigue, provoked by odors
of food or eating fatty foods; vomiting may occur.
• Diarrhea-in severe jaundice due to lack of bile acids.
• History of risk factors- blood transfusion, iv drug use,
tattoos and body piercing, sexual activity, use of any
chemical or medication, recent travel history, contact
history, alcohol consumption.

9. Physical examination
• Nutritional assesment-temporal and proximal muscle
wasting
• Icterus
• Stigmata of CLD-spider nevi, palmer erythema,
gynecomastia, caput medusae, dupuytren’s contractures,
parotid gland swelling, testicular atrophy.
• Virchow’s node and sister mary joseph’s node in abdominal
malignancy.
• Abdominal examination-
inspection- caput medusae, flank fullness
palpation- hepatomegaly ( tender- viral or alcoholic
hepatitis, right heart failure leading to hepatic congestion)
- Murphy’s sign- cholecystitis or cholangitis
percussion- for ascites.

10. Laboratory investigations
• Measurement of serum bilirubin
total serum bilirubin-0.2-0.9mg/dl
conjugated-0.2-0.7; unconjugated-0.1-0.4
• Serum albumin and globulin
• Alanine and aspartate aminotransferase[ALT and AST]-
AST:ALT >2:1 = alcoholic hepatitis
>500U/l in viral hepatitis,toxin or drug induced
liver injury
• Alkaline phosphatase and gamma glutamyl transferase.
• PT and INR
• Other diagnostic tests- USG= Gall stones, biliary
obstruction
Cholangiography-MRCP,ERCP
CT scan and MRI; Percutaneous liver biopsy.

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