Jaundice in Adults

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Carcinoma of Bile Duct
  • Leptospirosis
  • Rotor, Dubin–Johnson and Mirizzi Syndromes
  • Cholestasis or Fatty Liver of Pregnancy
  • Genetic: Gilbert’s Syndrome, Wilson’s Disease, α1-Antitrypsin Deficiency, Galactosaemia, Glycogen Storage Diseases, Haemochromatosis
  • Amyloidosis

Ready Reckoner

Key distinguishing features of the most common diagnoses

GallstonesHepatitisCarcinoma of PancreasMetastasesAlcohol Cirrhosis
Colicky RUQ PainYesNoNoNoNo
Rapid Weight LossNoPossibleYesYesNo
Pale Stools/Dark UrineYesPossibleYesNoNo
Epigastric MassNoNoYesPossibleNo

Possible Investigations

Likely:Urinalysis, FBC, LFT, hepatitis serology.

Possible:Ultrasound, antimitochondrial antibody.

Small Print:Serum amylase, secondary care tests (e.g. ERCP, liver biopsy).

  • Urinalysis: If bilirubin is present in the urine, the jaundice is cholestatic. If present with urobilinogen, it is hepatocellular. If not, it is obstructive.
  • LFT: Bilirubin very high in biliary obstruction. AST and ALT raised in hepatic causes. Alkaline phosphatase rises moderately in hepatic causes and markedly in biliary obstruction and primary biliary cirrhosis.
  • FBC: Anaemia in chronic illness. Raised WCC in hepatitis. May be macrocytosis, reticulocytosis and other red cell abnormalities in haemolytic anaemia. MCV raised by alcohol.
  • Hepatitis serology: May reveal cause of viral hepatitis.
  • Serum amylase: Raised in pancreatitis.
  • Antimitochondrial antibody test: Positive in over 95% of patients with primary biliary cirrhosis.
  • Ultrasound useful to assess liver, pancreas and gall bladder: May reveal stones, primary tumours and metastases.
  • Referral may result in various other specialised tests including ERCP and liver biopsy, to establish the underlying cause.

Top Tips

  • Remember to look at the patient – if significant jaundice is present it will probably strike you at first glance.
  • In younger patients, the diagnosis is likely to be viral hepatitis. In older age groups, the differential is much wider.
  • Don’t forget iatrogenic causes. Remember too that the presence of jaundice implies liver dysfunction, so take great care if prescribing any medication.
  • If the patient is well, with no pain and fever, it is reasonable to arrange initial investigations – especially LFT – and arrange for review in a day or two. Most other cases will require admission.
  • Remember to ask about foreign travel, contact with travellers, drug misuse and sexual history if necessary in the suddenly jaundiced febrile patient.

Red Flags

  • Painless progressive jaundice suggests carcinoma of pancreas. Refer urgently.
  • An enlarged, knobbly, hard liver is nearly always caused by metastases.
  • Beware of restlessness, poor concentration and drowsiness. These suggest fulminant hepatic failure.

Published: 2nd August 2022 Updated: 10th April 2024

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