From the Guidelines
A jaundice workup should begin with a thorough history and physical examination, followed by laboratory tests including complete blood count, liver function tests (bilirubin, ALT, AST, alkaline phosphatase, GGT), and coagulation studies, as recommended by the American College of Radiology Appropriateness Criteria 1. The initial evaluation of a patient with jaundice should focus on determining the underlying cause, which can be pre-hepatic (hemolysis), hepatic (liver disease), or post-hepatic (biliary obstruction).
- Key laboratory tests include:
- Complete blood count to evaluate for anemia or infection
- Liver function tests to assess liver damage or dysfunction
- Coagulation studies to evaluate for bleeding disorders
- Initial imaging should include an abdominal ultrasound to evaluate the liver, biliary tract, and pancreas, as it is a non-invasive and highly sensitive test for detecting biliary obstruction and liver disease 1. Based on the results of the initial evaluation, further testing and management can be directed toward the suspected cause of jaundice.
- For pre-hepatic causes, additional tests like hemolysis markers (haptoglobin, LDH) may be needed 1.
- For hepatic causes, viral hepatitis serologies, autoimmune markers, and drug screens are appropriate 1.
- For suspected obstruction, further imaging such as MRCP, ERCP, or CT may be necessary to confirm the diagnosis and guide treatment 1. The choice of imaging modality should be based on the clinical presentation and laboratory findings, with abdominal ultrasound being the initial imaging modality of choice, followed by CT or MRCP if necessary 1. Management depends on the underlying cause, and may include treating infections, discontinuing hepatotoxic medications, addressing autoimmune conditions with immunosuppressants, or performing procedures to relieve biliary obstruction.
- Urgent referral to gastroenterology or hepatology is warranted for severe jaundice, signs of liver failure, or when diagnosis remains unclear after initial evaluation 1. This systematic approach helps identify the cause of jaundice efficiently and guides appropriate treatment, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Initial Evaluation
The initial evaluation of a patient presenting with jaundice (hyperbilirubinemia) should include a comprehensive medical history, review of systems, and physical examination to differentiate potential causes 2.
Laboratory Tests
Laboratory tests should include:
- Liver chemistry tests such as bilirubin (conjugated and unconjugated), alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and total protein 3
- A complete blood cell count, aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, alkaline phosphatase, albumin, prothrombin time, and international normalized ratio 2
- Measuring fractionated bilirubin to determine whether the hyperbilirubinemia is conjugated or unconjugated 2
- Urine test for bilirubin to indicate the presence of conjugated hyperbilirubinemia 4
Imaging Studies
Imaging studies should include:
- Ultrasonography of the abdomen 2
- Computed tomography with intravenous contrast media 2
- Magnetic resonance cholangiopancreatography 2
- Cholangiography or liver biopsy may be needed in some cases to arrive at a diagnosis 4, 5
Diagnostic Approach
A stepwise approach to evaluation can be cost and time saving as well as a framework to improve patient outcomes 3. The differential diagnosis should be organized by prehepatic, intrahepatic, and posthepatic causes to make the work-up more manageable 4. Key questions should be addressed during initial assessment, including whether the patient is critically ill, has fulminant hepatic failure, or has an intra- or extrahepatic cause of jaundice 6.
Potential Causes
Potential causes of jaundice include:
- Hemolysis and hematoma resorption (prehepatic) 4
- Intrahepatic disorders such as alcohol, infectious hepatitis, drug reactions, and autoimmune disorders 4
- Posthepatic disorders such as gallstone formation, biliary tract infection, pancreatitis, and malignancies 4
- Alcoholic liver disease, biliary strictures, choledocholithiasis, drug-induced liver injury, hemolysis, or hepatitis 2