Evaluation of Patients with Jaundice MOHW August 2020

Jaundice is a clinical sign which is apparent when the serum bilirubin exceeds 50 umol/l. It
can be asymptomatic or associated with abdominal pain, fever and pruritus. There are
numerous causes which demand a stepwise approach for accurate diagnosis and treatment
Jaundice can be manifestation of disorders of:

1. Underlying bilirubin metabolism

2. Hepatocellular dysfunction or
3. Biliary obstruction

Evaluation begins with liver function tests which will indicate whether the
hyperbilirubinaemia is unconjugated or not.

Causes of Isolated Unconjugated Hyperbilirubinemia are:

 Bilirubin overproduction

o Inherited diseases of Red Blood Cells Eg. Sickle cell disease and

Thalassaemia

o Auto-immune haemolytic anaemia

o Haematoma resorption

 Impaired Conjugation

o Commonest is Gilbert’s disease

Commonest cause of Conjugated Hyperbilirubinemia is Cholestasis:

The hallmark laboratory abnormality is elevation of Alkaline Phosphatase and GGT. An

ultrasound of the liver is essential to exclude extrahepatic bile duct obstruction which is seen
as dilated bile ducts with or without an obvious cause. Further evaluation to determine the
cause of the obstruction may require CT Scan and MRCP. ERCP being invasive is reserved
for therapeutic intervention mostly.

Normal bile ducts on ultrasound or CT Scan indicate Cholestatic liver diseases such as:

 Primary Sclerosing Cholangitis – Often associated with Crohn’s or Ulcerative Colitis

 Primary Biliary Cirrhosis – Jaundice is a late complication of the illness
 Always Screen for Hepatitis B and C and
  Enquire about medications which may be the cause – Liver Biopsy required

Jaundice may also be associated with other Liver diseases such as:

1. Alcoholic Hepatitis
o Rapid development of jaundice and liver failure
o Ratio AST to ALT is typically >2
o Steroids helpful. Improve survival

2. Non-Alcoholic Steato-Hepatitis (NASH)

o T2 DM and Obesity are risk factors
o Can evolve to Liver cirrhosis
o At risk of developing HCC (Hepatocellular Carcinoma)

3. Auto-immune Hepatitis
o Predominantly Women of any age, Raised globulins and auto-antibodies
o Antinuclear antibodies, Anti Smooth muscle and Anti LKM-1 antibodies

4. Wilson’s disease
o Vast majority diagnosed between Age 5 to 35 years
o May present with liver disease, Neurological symptoms, Renal abnormalities
and episodes of haemolysis
o Needs to be excluded in patients with fulminant liver failure of unknown
aetiology especially at ages <35 years
o Diagnosis may be difficult and Specialist advice required

5. Hereditary Haemochromatosis – several subtypes exist:

o Hereditary genetic types are several
o Focus on prevention of Secondary type in patients having regular blood
transfusions, monitor serum ferittin (Thalassaemia, Sickle Cell disease,
Myelodysplasia).

It is important to bear the above in mind and investigate accordingly as they require specific
treatments which are lifesaving.

Jaundice associated with Acute Hepatitis:

Transaminases are usually very high (>20 x the upper limit of normal). Causes are:
 Viral Hepatitis (A, B, C, D, E, Herpes) - at present in the lab only Hepatitis A,B and C
are available.
 Paracetamol poisoning
 Drug-induced Immuno-allergic reaction