What to do with a patient presenting with jaundice, abdominal (abd) pain tender in the right hypochondrium, and elevated liver function tests (LFTs)?

Management of Jaundice with Right Upper Quadrant Pain and Elevated Liver Function Tests

Order an abdominal ultrasound immediately as your first diagnostic test to determine if biliary obstruction is present, which will guide all subsequent management decisions. 1

Immediate Clinical Assessment

Before imaging, rapidly assess for these alarm features that indicate urgent intervention:

• Fever and chills - suggests acute cholangitis requiring emergent biliary decompression 2
• Severity of right upper quadrant tenderness - severe tenderness with guarding suggests acute cholecystitis or cholangitis 1
• Hemodynamic stability - hypotension with jaundice and fever (Charcot's triad) is a surgical emergency 2

Obtain these laboratory tests immediately alongside imaging:

• Fractionated bilirubin (conjugated vs unconjugated) to differentiate obstructive from hepatocellular causes 1, 3
• Alkaline phosphatase and GGT elevation confirms cholestatic pattern suggesting biliary obstruction 2
• Complete blood count to assess for infection (elevated WBC) or hemolysis 3
• Prothrombin time/INR to evaluate synthetic liver function 3

Diagnostic Algorithm Based on Ultrasound Findings

If Ultrasound Shows Biliary Ductal Dilatation (Obstructive Pattern)

This confirms mechanical obstruction and requires identification of the cause and level of obstruction. 1

• Proceed to MRCP or contrast-enhanced CT to identify the exact location and etiology of obstruction (stone vs tumor vs stricture) 1, 4
• MRCP is superior to CT for detecting choledocholithiasis (sensitivity 85-100%) and evaluating the biliary tree 1
• If choledocholithiasis is identified, arrange urgent ERCP for therapeutic stone extraction, which successfully clears stones in 80-95% of cases 1
• If malignant obstruction is suspected (mass, stricture), ERCP with biliary stenting provides both diagnosis and palliation 1, 5

If Ultrasound Shows NO Biliary Dilatation (Non-Obstructive Pattern)

This suggests hepatocellular disease, but does not completely exclude early or intermittent obstruction. 1

• If clinical suspicion for biliary obstruction remains high despite negative ultrasound (especially with conjugated hyperbilirubinemia and elevated alkaline phosphatase), proceed to MRCP as ultrasound can miss small distal CBD stones (sensitivity only 22.5-75%) 1, 4
• If hepatocellular pattern is confirmed (elevated transaminases >> alkaline phosphatase), investigate for hepatitis, alcoholic liver disease, drug-induced liver injury, or cirrhosis 1
• Consider liver biopsy if imaging and laboratory workup fail to establish diagnosis 1, 3

Critical Pitfalls to Avoid

• Do not skip ultrasound and go directly to MRCP or CT - ultrasound is faster, cheaper, and answers the critical first question of whether obstruction exists 1, 4
• Do not assume normal CBD caliber excludes obstruction - early or intermittent obstruction may not show ductal dilatation yet, and ultrasound has 95-96% negative predictive value but not 100% 1
• Do not delay ERCP if cholangitis is suspected - the combination of jaundice, fever, and right upper quadrant pain requires urgent biliary decompression to prevent sepsis and mortality 1, 2
• Beware of small gallstones (<5 mm) - these create 4-fold increased risk of CBD migration and may cause intermittent obstruction 1

When Ultrasound is Technically Limited

If ultrasound is non-diagnostic due to body habitus or bowel gas obscuring the CBD:

• Proceed directly to MRCP for comprehensive biliary tree evaluation 1, 4
• Consider endoscopic ultrasound (EUS) if MRCP is contraindicated or for detecting very small distal CBD stones (<4 mm) 1

Specific Management Based on Etiology

If Choledocholithiasis Confirmed

• ERCP with sphincterotomy and stone extraction is the definitive treatment 1
• For stones >15 mm, advanced endoscopic techniques (mechanical lithotripsy) are required as balloon sweep alone often fails 1

If Malignant Obstruction Confirmed

• Biliary stenting via ERCP provides immediate decompression and pain relief 5
• Metal stents are preferred over plastic stents for longer patency 5
• Consider celiac plexus neurolysis for pain control in pancreatic cancer, which provides superior outcomes compared to analgesics alone 5

If Acute Cholecystitis Confirmed

• Cholecystectomy is definitive treatment once patient is stabilized 1
• If patient is critically ill, percutaneous cholecystostomy can bridge to surgery 1