Jaundice in Adults

Patients rarely present with the complaint of ‘turning yellow’; more often – though still infrequently – the GP notices jaundice during an examination of the patient. A systematic clinical assessment together with relevant laboratory investigations will help pinpoint the cause.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Gallstones in Common Bile Duct
  • Viral Hepatitis (e.g. Glandular Fever, Hepatitis A, B, C)
  • Carcinoma of Head of Pancreas
  • Hepatic Carcinoma (Usually Metastases)
  • Alcoholic Cirrhosis

Occasional Diagnoses

  • Alcoholic Hepatitis
  • Primary Biliary Cirrhosis
  • Drugs: Chlorpromazine, Isoniazid, Anabolic Steroids, Methyldopa, Paracetamol Overdose
  • Haemolytic Anaemia (Many Causes, Such as Autoimmune, Malaria, Drugs)
  • Venous Congestion: Cardiac Failure, Constrictive Pericarditis
  • Cholangitis (and Stricture in Common Bile Duct Afterwards)
  • Pancreatitis

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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.