History to Elicit in a Patient with Jaundice
Obtain a detailed medication history including all over-the-counter drugs and herbal supplements, as drug-induced liver injury accounts for 0.5-7% of jaundice cases and represents one of the four most common causes in the United States. 1, 2
Timing and Onset Characteristics
- Sudden onset of jaundice with fatigue, pallor, and tachycardia strongly suggests hemolytic anemia rather than hepatobiliary disease, particularly in younger patients 1
- Duration of symptoms helps differentiate acute from chronic processes, with jaundice persisting beyond 3 weeks requiring specific evaluation for cholestasis 3
Medication and Substance Exposure History
- Complete medication inventory must include prescription drugs, over-the-counter medications, herbal supplements, and traditional remedies, as toxic reactions to drugs or herbs represent a leading cause of jaundice 1, 3, 2
- Alcohol consumption history is critical, as alcoholic liver disease accounts for 16% of jaundice cases, with alcoholic hepatitis commonly presenting as the first manifestation of decompensated disease 2
Infectious and Systemic Disease History
- Recent infections or sepsis must be explored, as sepsis/shock is the most common etiology in U.S. studies (22-27% of severe jaundice cases), causing both hemolysis and hepatic dysfunction 1, 2
- Viral hepatitis risk factors including travel history, sexual contacts, intravenous drug use, and blood transfusions should be documented 3, 4
Pre-existing Liver Disease
- History of chronic liver disease or cirrhosis is essential, as decompensation of pre-existing cirrhosis is the second most common cause of new-onset jaundice (20.5%) 2
- Previous episodes of jaundice may suggest constitutional conditions like Gilbert syndrome (5.6% of cases) 2
Biliary Symptoms
- Right upper quadrant pain, fever, and pruritus suggest biliary obstruction, with choledocholithiasis representing 13-14% of jaundice cases 2
- History of gallstones, particularly multiple small stones (<5 mm), creates a 4-fold increased risk for common bile duct migration 3, 2
Constitutional and Hemolytic Indicators
- Pallor, tachycardia, and fatigue without travel history in younger patients strongly favors hemolysis over primary liver disease 1
- Dark urine and pale stools help differentiate conjugated (obstructive) from unconjugated hyperbilirubinemia 4, 5
Red Flag Symptoms
- Weight loss and abdominal mass raise concern for malignancy, which accounts for 6.2% of U.S. jaundice cases but is the most common etiology of severe jaundice in European populations 2
- Hemodynamic instability, chest pain, or dyspnea in the context of jaundice indicates severe anemia requiring urgent intervention 1