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.
- If obstruction is suspected, further imaging with MRCP (magnetic resonance cholangiopancreatography) or ERCP (endoscopic retrograde cholangiopancreatography) may be necessary 1.
Additional Tests
For suspected hepatocellular causes, additional tests might include:
- Autoimmune markers
- Iron studies
- Ceruloplasmin levels
- Alpha-1 antitrypsin levels In cases of hemolysis, a peripheral blood smear, reticulocyte count, and Coombs test should be ordered 1.
Urgent Evaluation
Urgent evaluation is warranted for patients with signs of acute liver failure, such as encephalopathy or coagulopathy, or cholangitis, characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad) 1.
From the Research
Initial Evaluation
The work-up for jaundice typically begins with a comprehensive medical history, review of systems, and physical examination to differentiate potential causes 2, 3, 4, 5. This initial evaluation is crucial in guiding further laboratory tests and imaging studies.
Laboratory Tests
Initial laboratory evaluation should include:
- Assays for bilirubin (total and fractionated) to determine whether the hyperbilirubinemia is conjugated or unconjugated 2, 5
- Complete blood cell count 2, 5
- Liver function tests, such as aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, and alkaline phosphatase 2, 5
- Albumin and prothrombin time/international normalized ratio to assess liver function and coagulation 2, 5
Imaging Studies
Imaging studies, such as:
- Ultrasonography of the abdomen 2, 3, 5
- Computed tomography with intravenous contrast media 2, 3
- Magnetic resonance cholangiopancreatography 2 are used to differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders.
Further Evaluation
If the etiology of jaundice is unclear despite laboratory testing and imaging, further evaluation may include:
- Liver biopsy to establish the diagnosis, prognosis, and management of the disease 2
- Additional cancer screening, biliary imaging, autoimmune antibody assays 5
- Referral to a specialist when likelihood of malignancy, chronic autoimmune condition, or need for intervention exists 4
Classification of Hyperbilirubinemia
Hyperbilirubinemia can be categorized into: