Jaundice in Adults
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 Structure 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
| Gallstones | Hepatitis | Carcinoma of Pancreas | Metastases | Alcohol Cirrhosis | |
|---|---|---|---|---|---|
| Fever | Possible | Yes | No | No | No |
| Colicky RUQ Pain | Yes | No | No | No | No |
| Rapid Weight Loss | No | Possible | Yes | Yes | No |
| Pale Stools/Dark Urine | Yes | Possible | Yes | No | No |
| Epigastric Mass | No | No | Yes | Possible | No |
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.