What is the appropriate diagnosis and treatment for jaundice?

Diagnosis and Treatment of Jaundice

Begin with laboratory testing to differentiate unconjugated from conjugated hyperbilirubinemia, followed by abdominal ultrasound as first-line imaging, then treat based on the underlying cause—ERCP for obstructive jaundice from stones, alcohol cessation for alcoholic liver disease, antivirals for viral hepatitis, or immediate drug discontinuation for drug-induced injury. 1, 2

Initial Diagnostic Approach

Laboratory Evaluation

• Obtain total and fractionated bilirubin, complete blood count, liver enzymes (AST, ALT, alkaline phosphatase, gamma-glutamyltransferase), and synthetic function tests (albumin, prothrombin time/INR) as the initial workup 1, 2, 3
• Fractionated bilirubin determines whether hyperbilirubinemia is unconjugated or conjugated, which guides the differential diagnosis 2, 3
• Unconjugated hyperbilirubinemia suggests hepatitis, sepsis, hemolysis, or drug-induced liver disease 2
• Conjugated hyperbilirubinemia suggests biliary obstruction or hepatocellular dysfunction 2

Imaging Studies

• Abdominal ultrasound is the recommended first-line imaging study for all jaundiced patients to differentiate obstructive from non-obstructive causes 1, 2
• Ultrasound has high sensitivity for detecting cirrhosis and variable sensitivity for biliary obstruction 2
• A normal common bile duct (CBD) caliber on ultrasound has high negative predictive value for choledocholithiasis 2
• If ultrasound shows biliary dilation or is inconclusive, proceed to CT with IV contrast or MRCP based on clinical suspicion 1, 2

Treatment Based on Etiology

Obstructive Jaundice

• For CBD stones, endoscopic retrograde cholangiopancreatography (ERCP) is the standard treatment with 80-95% success rate for stone clearance 1
• ERCP allows stent placement for distal CBD strictures with >90% success rate 1
• Be aware that ERCP carries 4-5.2% risk of major complications (pancreatitis, cholangitis, hemorrhage, perforation) and 0.4% mortality risk 1
• For malignant biliary obstruction in non-surgical candidates, use endoscopic or percutaneous transhepatic biliary drainage 1

Hepatocellular Jaundice

• For alcoholic liver disease, the primary intervention is immediate alcohol cessation 1
• Provide supportive care with nutritional support and management of complications (ascites, encephalopathy, variceal bleeding) 1
• For viral hepatitis, initiate antiviral therapy specific to the virus type (hepatitis B or C) 1
• For drug-induced liver injury, immediately discontinue the offending agent 1

Common Causes to Consider

The most common causes of jaundice in the United States include 1, 2:

• Hepatitis and sepsis
• Alcoholic liver disease (accounts for 20.5% of cases) 4
• Common bile duct obstruction by stones or tumor (choledocholithiasis and cholangiocarcinoma)
• Toxic reactions to drugs or herbs
• Malignancy (accounts for 6.2% of U.S. cases but is the most common cause of severe jaundice in European studies) 4
• Hemolysis (accounts for 2.5% of cases) 4

Critical Pitfalls to Avoid

• Do not assume a nonvisualizing gallbladder on oral cholecystogram is a contraindication to therapy—these patients can still achieve stone dissolution 5
• However, if gallbladder nonvisualization develops during treatment, this predicts failure and therapy should be discontinued 5
• Multiple small gallstones in the gallbladder increase risk for CBD migration 2
• Calcified gallstones or stones >20 mm in diameter rarely dissolve with medical therapy 5
• Jaundice persisting beyond 3 weeks requires measurement of total and direct bilirubin to identify cholestasis 2

Algorithmic Decision Framework

If predominantly conjugated hyperbilirubinemia:

• Perform abdominal ultrasound to assess for biliary dilation 2
• If dilated ducts → proceed to ERCP or MRCP for therapeutic intervention 1
• If non-dilated ducts → consider hepatocellular causes and obtain viral hepatitis serologies, autoimmune markers, and drug history 1

If predominantly unconjugated hyperbilirubinemia:

• Evaluate for hemolysis (check CBC, reticulocyte count, haptoglobin, LDH) 4
• Consider Gilbert syndrome or other inherited disorders of bilirubin metabolism 4
• Assess for impaired bilirubin conjugation from hepatocellular dysfunction 4