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Approach to jaundice

The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.

  1. Immediate threats

    • Ascending cholangitis: fever, rigors, RUQ pain with jaundice
    • Acute liver failure: jaundice with coagulopathy or encephalopathy
    • Massive hemolysis

  2. History that discriminates

    • Pain pattern: painful and febrile (stones, cholangitis) versus painless and progressive (malignancy)
    • Dark urine and pale stools declare a conjugated, obstructive problem
    • Alcohol, medications and supplements, viral risk factors, travel
    • Weight loss and age push toward pancreatic or biliary malignancy

  3. Examination

    • Depth of icterus; stigmata of chronic liver disease
    • Courvoisier's palpable painless gallbladder
    • Asterixis and mentation: the failure questions
    • Fever and RUQ tenderness: the cholangitis triad

  4. Problem representation

    Painless progressive jaundice with weight loss and a palpable gallbladder in a 70-year-old (malignant obstruction) versus febrile painful jaundice after known gallstones (cholangitis, urgent drainage).

  5. Differential, by mechanism

    Pre-hepatic

    • Hemolysis
    • Ineffective erythropoiesis

    Hepatic

    • Viral hepatitis
    • Alcoholic and drug injury
    • Cirrhosis
    • Gilbert (unconjugated, benign)

    Post-hepatic

    • Choledocholithiasis
    • Pancreatic head cancer
    • Cholangiocarcinoma
    • Strictures
    • PSC/PBC

  6. Investigations

    • Split the bilirubin first: conjugated or not
    • The enzyme pattern: hepatocellular (ALT/AST) versus cholestatic (ALP/GGT)
    • INR and albumin measure function, not injury
    • Ultrasound for duct dilation: the branch point of the whole workup
    • Hemolysis screen when unconjugated: LDH, haptoglobin, reticulocytes, smear

  7. Interpretation

    • Dilated ducts mean a plumbing problem: image the plumbing (MRCP/EUS) and plan drainage
    • Non-dilated ducts turn the workup toward the hepatocyte: serology, toxins, autoimmunity

  8. Next steps

    • Cholangitis gets cultures, antibiotics, and urgent biliary drainage
    • Every drug and supplement on the chart is a suspect until cleared

Connected

LabsThe cholestatic panelLabsThe hepatocellular panelCompareLiver injury patterns

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