Jaundice

Related Subjects: |Chronic liver disease |Cirrhosis |Alkaline phosphatase (ALP) |Liver Function Tests |Ascites Assessment and Management |Budd-Chiari syndrome |Autoimmune Hepatitis |Primary Biliary Cirrhosis |Primary Sclerosing Cholangitis |Wilson disease |Hereditary Haemochromatosis |Alpha-1 Antitrypsin (AAT) deficiency |Non alcoholic steatohepatitis (NASH) |Spontaneous Bacterial Peritonitis |Alcoholism and Alcoholic Liver Disease |Hepatitis C |Child-Pugh score |Gallstone ileus |Gallstones and biliary colic |Cholestatic Jaundice

🌟 Jaundice = yellow discolouration of skin, sclera, and mucous membranes due to bilirubin deposition. 👉 Becomes clinically visible when serum bilirubin > 40 µmol/L. 🔎 Always classify by level of pathology: Pre-hepatic (before liver), Hepatic (within liver), Post-hepatic (after liver).

🟥 Pre-Hepatic (Haemolytic) Jaundice

• ⚡ Causes: Increased RBC breakdown → haemolytic anaemia, sickle cell disease, thalassaemia, malaria, autoimmune haemolysis.
• 🩸 Features: Anaemia, pallor, dark urine (urobilinogen ↑), splenomegaly. No pale stools.
• 🔬 Investigations: FBC + reticulocytes (↑), blood smear, LDH ↑, haptoglobin ↓, unconjugated bilirubin ↑, Coombs test if autoimmune.
• 💊 Treatment: Cause-specific (transfusions, folate, hydroxyurea in SCD, splenectomy if severe haemolysis).

🟨 Hepatic (Hepatocellular) Jaundice

• ⚡ Causes: Viral hepatitis (A–E), alcoholic liver disease, NAFLD/NASH, cirrhosis, autoimmune hepatitis, hepatocellular carcinoma.
• 😴 Features: Malaise, anorexia, nausea, dark urine, pale stools, tender hepatomegaly, stigmata of chronic liver disease.
• 🔬 Investigations: LFTs (AST/ALT ↑ > ALP), viral serology, autoimmune screen, ultrasound/CT/MRI, ± liver biopsy.
• 💊 Treatment: Antivirals (HBV, HCV), alcohol cessation, nutrition, transplant if decompensated liver failure.

🟩 Post-Hepatic (Obstructive/Cholestatic) Jaundice

• ⚡ Causes: Gallstones, biliary strictures, pancreatic cancer, cholangiocarcinoma, PSC/PBC.
• 🤢 Features: Dark urine, pale stools, pruritus (bile salts), RUQ/epigastric pain, Courvoisier’s sign (palpable gallbladder in pancreatic cancer).
• 🔬 Investigations: LFTs (ALP & GGT ↑ > ALT), ultrasound (first-line), MRCP/ERCP, CT pancreas if malignancy suspected.
• 💊 Treatment: ERCP ± stenting/stone removal, cholecystectomy, oncological management (Whipple procedure in pancreatic cancer).

🧬 Inherited Jaundice

• ⚡ Conditions: Gilbert’s syndrome (benign, common), Crigler–Najjar syndrome, Dubin–Johnson syndrome.
• 🙂 Features: Intermittent mild jaundice (Gilbert’s) triggered by stress/fasting; usually incidental finding.
• 🔬 Investigations: Bilirubin (unconjugated ↑), normal LFTs, genetic tests if unclear.
• 💊 Treatment: Gilbert’s = reassurance. Crigler–Najjar may need phototherapy, liver transplant if severe.

💊 Drug-Induced Jaundice

• ⚡ Causes: Hepatotoxic drugs (paracetamol overdose, isoniazid, statins, amiodarone, antibiotics like flucloxacillin).
• 🤢 Features: Jaundice, nausea, fatigue, ± hepatitis features (RUQ tenderness, hepatomegaly).
• 🔬 Investigations: LFTs (mixed hepatocellular/cholestatic), careful drug history, ± biopsy if diagnostic uncertainty.
• 💊 Treatment: Stop drug, supportive care, antidotes where available (e.g. N-acetylcysteine for paracetamol).

👶 Neonatal Jaundice

• ⚡ Causes: Physiological (common, 1st week) or pathological (Rh/ABO incompatibility, sepsis, G6PD deficiency, breast milk jaundice).
• 🙂 Features: Yellow skin/sclera, usually within 1st week. Kernicterus risk if bilirubin very high.
• 🔬 Investigations: Serum bilirubin, Coombs test, G6PD assay, blood type/crossmatch.
• 💊 Treatment: Phototherapy, exchange transfusion if severe, treat underlying cause, ensure hydration and feeding support.

📊 Patterns of Jaundice – Quick Comparison

💡 Clinical Pearls

• 🌟 Gilbert’s syndrome is very common - mild intermittent jaundice with normal LFTs.
• 🟩 Post-hepatic jaundice + painless mass + palpable gallbladder = think pancreatic head cancer.
• ⚡ Always distinguish conjugated vs unconjugated bilirubin in workup.
• 👶 In neonates, prolonged jaundice (>14 days) = always pathological → investigate.
• 🧪 First-line imaging for obstructive jaundice = ultrasound (look for dilated ducts, gallstones, masses).

Cases - Jaundice

• Case 1 - Pre-hepatic (haemolysis) 🩸: A 25-year-old man with sickle cell disease presents with scleral icterus, dark urine, and mild splenomegaly. Bloods: raised unconjugated bilirubin, reticulocytosis, low haptoglobin. Diagnosis: haemolytic jaundice. Managed by optimising sickle care and transfusion if needed.
• Case 2 - Viral hepatitis (hepatocellular) 🦠: A 22-year-old student returns from travel with malaise, anorexia, and right upper quadrant pain. Exam: tender hepatomegaly, jaundice. Bloods: ALT 1500, AST 1300, bilirubin 95 µmol/L. Hepatitis A IgM positive. Diagnosis: acute viral hepatitis A causing jaundice. Managed with supportive care.
• Case 3 - Alcoholic hepatitis 🍺: A 46-year-old man with chronic alcohol misuse presents with jaundice, fever, and right upper quadrant tenderness. Bloods: bilirubin 180 µmol/L, AST 180, ALT 70 (AST:ALT >2). Maddrey score elevated. Diagnosis: alcoholic hepatitis with jaundice. Managed with alcohol withdrawal support, corticosteroids (if severe), and nutritional therapy.
• Case 4 - Obstructive jaundice (malignancy) 🎗️: A 70-year-old man presents with painless jaundice, pruritus, and pale stools. Exam: palpable gallbladder (Courvoisier’s sign). LFTs: cholestatic pattern (ALP 720, bilirubin 230). Ultrasound: dilated bile ducts, pancreatic head mass. Diagnosis: obstructive jaundice from pancreatic cancer. Managed with biliary stenting and oncology referral.
• Case 5 - Gallstone obstruction 🪨: A 45-year-old woman presents with jaundice, fever, and right upper quadrant pain. Exam: positive Murphy’s sign. LFTs: cholestatic pattern. Ultrasound: gallstones and common bile duct dilation. Diagnosis: choledocholithiasis with obstructive jaundice. Managed with IV antibiotics and ERCP stone removal.

Teaching Point 🩺: Jaundice results from raised bilirubin due to pre-hepatic (haemolysis), hepatic (hepatitis, cirrhosis), or post-hepatic (biliary obstruction) causes. Work-up includes LFT pattern, haemolysis screen, viral serology, and imaging of the biliary tree. Always ask about alcohol, drugs, travel, and family history.

Additional related clinical topics

OSCE Jaundice

🟡 Clinical Pearl: Always be ready to suggest differentials and investigations. First-line tests 👉 LFTs, bilirubin, FBC. Imaging 👉 Abdominal ultrasound. In older patients with pronounced jaundice: – Painful jaundice → gallstone in CBD (choledocholithiasis). – Painless jaundice → cancer of head of pancreas (classic exam favourite). 🛠️ Management: ERCP for stone removal or stenting for obstruction.

👋 Introduction

• 🧼 Hand Hygiene: Wash your hands before beginning.
• 🙂 Patient Introduction: Introduce yourself, check name & DOB, explain the exam.
• 📝 Consent & Privacy: Gain consent, ensure good lighting & dignity with drapes.
• 📖 Context: Jaundice = yellow discoloration of skin/sclera from raised bilirubin due to liver, biliary, or haemolytic pathology.

🧰 Equipment Needed

• Gloves
• Good natural/artificial light (pen torch if needed)
• Towel or drape for dignity
• Stethoscope (if extending into abdominal exam)

📚 Background Information

Category	Cause	Mechanism	Key Features
Pre-hepatic	Haemolytic Anaemia	↑ RBC breakdown → unconjugated bilirubin	Anaemia, dark urine, splenomegaly, ↑ reticulocytes
Hepatic	Viral Hepatitis	Hepatocyte injury → impaired conjugation	RUQ pain, malaise, jaundice, ↑ ALT/AST
	Alcoholic Hepatitis	Alcohol-induced hepatocellular damage	Tender hepatomegaly, AST:ALT > 2, jaundice
	Drug-Induced	Medication hepatotoxicity	Jaundice + systemic features, temporal drug link
	Gilbert’s Syndrome	UGT deficiency → mild unconjugated rise	Intermittent jaundice triggered by stress/fasting
Post-hepatic	Choledocholithiasis	CBD obstruction by gallstone	Dark urine, pale stools, pruritus, biliary colic
	Pancreatic Ca (Head)	Tumour compressing CBD	Painless jaundice, weight loss, Courvoisier’s sign
	Cholangiocarcinoma	Bile duct malignancy	Progressive jaundice, itching, pale stools

🪜 Examination Steps

• 👀 General Inspection:
  • Look for cachexia (malignancy/alcoholism), jaundice in face/skin, spider naevi, palmar erythema, dilated veins.
  • Check hands for clubbing, nails for leukonychia (chronic liver disease).
• 👁️ Eye Examination: Inspect sclera for yellow discoloration (scleral icterus) – usually seen before skin changes.
• 👄 Mucous Membranes: Look under tongue & inner cheeks for yellowing – useful in darker skin tones.
• 🩺 Focused Abdomen:
  • Palpate RUQ → hepatomegaly/tenderness.
  • Percuss liver span, check for splenomegaly/ascites.
  • Cancer → hard irregular liver, Ascites → advanced cirrhosis/obstruction.
• 📋 History Adjunct:
  • Urine colour (dark) + stool colour (pale) = obstructive.
  • RUQ pain/fever = cholangitis/stone.
  • Painless jaundice + weight loss = pancreatic malignancy.

✅ Closure

• Thank patient, allow to redress, maintain dignity.
• Explain findings: “You appear jaundiced - we would need to do blood tests and imaging to find the cause.”
• Wash hands, document findings clearly.

⭐ Key OSCE Points

• Always examine in good light.
• Look at sclera and mucous membranes first (early jaundice signs).
• Systematic: General → Eyes → Skin → Mucosa → Abdomen.
• Be ready to suggest investigations + management (LFTs, US, ERCP).

🚫 Common Pitfalls

• Examining in poor light → missing subtle icterus.
• Not checking mucous membranes (can miss early jaundice).
• Rushing → skipping abdominal exam.
• Not correlating with systemic signs of liver disease.

📚 References

• Clinical Examination by Talley & O’Connor
• Geeky Medics OSCE Resources
• OSCEstop – Online practice stations