From the Guidelines
The workup for jaundice 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), coagulation studies, and hepatitis serologies, as recommended by the American College of Radiology Appropriateness Criteria 1.
Initial Evaluation
The initial evaluation of a patient with jaundice should include a detailed history, targeted physical examination, and pertinent laboratory studies to categorize the type of jaundice into mechanical or nonmechanical causes 1.
- Laboratory tests should include:
- Complete blood count
- Liver function tests (bilirubin, ALT, AST, alkaline phosphatase, GGT)
- Coagulation studies
- Hepatitis serologies
Imaging Studies
Initial imaging typically includes an abdominal ultrasound to evaluate the liver, biliary tree, and pancreas, looking for obstruction, masses, or parenchymal disease 1.
- The ultrasound can confirm the absence of a mechanical obstruction, with specificities ranging between 71% to 97% 1.
- If the ultrasound is negative, additional laboratory testing assessing for liver failure may be recommended, ultimately suggesting a liver biopsy 1.
Further Testing
Based on the results of the initial evaluation and imaging studies, further testing may include:
- MRCP (magnetic resonance cholangiopancreatography)
- ERCP (endoscopic retrograde cholangiopancreatography)
- CT scan
- Liver biopsy The workup aims to distinguish between pre-hepatic causes (hemolysis), hepatic causes (hepatitis, cirrhosis), and post-hepatic causes (biliary obstruction) 1.
- For pre-hepatic jaundice, hemolysis workup including peripheral smear and hemoglobin electrophoresis may be needed.
- For hepatic causes, viral, autoimmune, and metabolic testing is important.
- For post-hepatic obstruction, interventional procedures like ERCP may be both diagnostic and therapeutic. The pattern of laboratory abnormalities often provides important clues - isolated hyperbilirubinemia suggests pre-hepatic causes, while elevated transaminases point to hepatocellular injury, and elevated alkaline phosphatase and GGT suggest cholestasis or biliary obstruction 1.
From the Research
Initial Evaluation
- A comprehensive medical history, review of systems, and physical examination are essential for differentiating potential causes of jaundice 2, 3, 4, 5.
- The 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, 4.
Laboratory Tests
- Measuring fractionated bilirubin allows for determination of whether the hyperbilirubinemia is conjugated or unconjugated 2, 4.
- A urine test for bilirubin can indicate the presence of conjugated hyperbilirubinemia 3.
- Laboratory tests can help categorize hyperbilirubinemia as unconjugated/prehepatic, intrahepatic, or extrahepatic/obstructive 5.
Imaging Studies
- Ultrasonography of the abdomen, computed tomography with intravenous contrast media, and magnetic resonance cholangiopancreatography are first-line options for patients presenting with jaundice, depending on the suspected underlying etiology 2.
- Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders 4.
- Ultrasonography is the least invasive and least expensive imaging method 4.
Further Evaluation
- If the etiology of jaundice is unclear despite laboratory testing and imaging, liver biopsy may be required to establish the diagnosis, prognosis, and management of the disease 2.
- A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy 4.
- Referral should be considered when likelihood of malignancy, chronic autoimmune condition, or need for intervention exists 5.