What is the approach to hyperbilirubinemia (jaundice)?

From the Guidelines

The approach to hyperbilirubinemia (jaundice) involves a systematic evaluation to determine its cause and appropriate management, prioritizing the identification of life-threatening conditions such as biliary obstruction or severe liver disease. First, obtain a detailed history including onset, associated symptoms, medication use, alcohol consumption, and family history. Perform a physical examination focusing on vital signs, skin color, abdominal findings, and signs of chronic liver disease. Laboratory testing should include liver function tests (bilirubin levels with direct and indirect fractions, ALT, AST, alkaline phosphatase, GGT), complete blood count, coagulation studies, and viral hepatitis markers 1. Imaging studies like ultrasound should be performed to evaluate the liver, biliary tract, and pancreas. If obstructive jaundice is suspected, consider MRCP, ERCP, or CT scan. For non-obstructive causes, manage the underlying condition - for viral hepatitis, supportive care with hydration and rest is recommended; for drug-induced jaundice, discontinue the offending agent; for alcoholic hepatitis, alcohol cessation and nutritional support are essential, as emphasized by the EASL clinical practice guidelines 1. If hemolysis is causing jaundice, treat the underlying hemolytic process. For obstructive jaundice, intervention may include ERCP with stone removal or stent placement, or surgery for malignant obstruction. The pattern of liver enzyme elevation often provides clues to etiology - hepatocellular patterns (elevated ALT/AST) suggest viral hepatitis or toxin exposure, while cholestatic patterns (elevated alkaline phosphatase/GGT) suggest biliary obstruction or infiltrative diseases.

Some key considerations in the management of jaundice include:

• The importance of early identification and treatment of underlying conditions, such as biliary obstruction or severe liver disease, to prevent morbidity and mortality 1.
• The use of imaging studies, such as ultrasound and MRCP, to evaluate the liver, biliary tract, and pancreas, and to guide further management 1.
• The need for a multidisciplinary approach to care, including consultation with specialists in gastroenterology, hepatology, and surgery, as needed.
• The importance of patient education and support, including counseling on alcohol cessation and nutritional support, to improve outcomes and reduce the risk of complications.

Overall, the approach to hyperbilirubinemia (jaundice) requires a systematic and thorough evaluation, with a focus on identifying and treating underlying conditions, and preventing morbidity and mortality.

From the Research

Approach to Hyperbilirubinemia (Jaundice)

The approach to hyperbilirubinemia (jaundice) involves a stepwise evaluation to determine the underlying cause of the condition.

• The evaluation begins with a detailed medical history, review of systems, and physical examination to identify potential causes of jaundice, such as alcoholic liver disease, biliary strictures, choledocholithiasis, drug-induced liver injury, hemolysis, or hepatitis 2.
• Initial laboratory evaluation should include assays for bilirubin (total and fractionated), a complete blood cell count, aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, alkaline phosphatase, albumin, prothrombin time, and international normalized ratio 2, 3.
• Measuring fractionated bilirubin allows for determination of whether the hyperbilirubinemia is conjugated or unconjugated, which can help guide further evaluation and treatment 2, 3.
• Imaging modalities, such as ultrasonography, computed tomography, and magnetic resonance cholangiopancreatography, can be used to further evaluate the cause of jaundice and guide treatment 2, 3.

Laboratory Evaluation

The laboratory evaluation of jaundice should include:

• Bilirubin (total and fractionated) to determine the level and type of hyperbilirubinemia 4, 2, 3
• Complete blood count to evaluate for hemolysis or other blood disorders 2, 3
• Liver enzymes, such as aspartate transaminase, alanine transaminase, and alkaline phosphatase, to evaluate for hepatocellular damage or cholestasis 4, 2, 3
• Gamma-glutamyltransferase to evaluate for cholestasis or hepatocellular damage 3
• Prothrombin time and international normalized ratio to evaluate for coagulopathy 2, 3
• Albumin and protein to evaluate for synthetic dysfunction 4, 2

Imaging Evaluation

Imaging modalities can be used to further evaluate the cause of jaundice and guide treatment.

• Ultrasonography is a non-invasive and cost-effective imaging modality that can be used to evaluate the liver, gallbladder, and biliary tree 5, 3
• Computed tomography can be used to evaluate the liver, gallbladder, and biliary tree, as well as to detect any masses or obstructions 5, 2
• Magnetic resonance cholangiopancreatography can be used to evaluate the biliary tree and detect any strictures or obstructions 2