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THE COMPLETE JAUNDICE ALGORITHM

For Ward, ER, FCPS Part 2 TOACS & MRCP

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THE MASTER FLOWCHART (Harrison's 22E, Fig. 52-1)

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SECTION 1: THE GOLDEN RULE - FIRST 3 QUESTIONS IN YOUR HEAD

1. Is bilirubin elevated alone, or are other LFTs also elevated? 2. Is it conjugated (direct) or unconjugated (indirect)? 3. Is the pattern hepatocellular or cholestatic?

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SECTION 2: THE "3 ZONES" CLASSIFICATION - PREHEPATIC / HEPATIC / POSTHEPATIC

Memory Mnemonic: "PRE-HEP-POST" or think of a factory analogy:

• PRE = Too much raw material (excess bilirubin production)
• HEP = Factory broken (liver can't process)
• POST = Pipe blocked (can't export what's made)

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SECTION 3: HISTORY TAKING - THE STRUCTURED APPROACH

The "DRUG-FAT-SIS" Mnemonic for history:

Additional HIGH-YIELD History Points:

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SECTION 4: GENERAL PHYSICAL EXAMINATION - THE STRUCTURED HEAD-TO-TOE APPROACH

STEP 1: GENERAL INSPECTION (look before you touch)

• Nutritional state - Temporal wasting, muscle wasting = chronic disease (cirrhosis, malignancy)
• Depth of jaundice - Mild yellowing (sclera only) vs deep orange-green (chronic obstruction)
• Consciousness - Encephalopathy? (flapping hands, confusion)
• Build - Cachexia = malignancy, chronic liver disease

STEP 2: SKIN SIGNS - "Spider Farmer Has Dupuytren And Leuconychia, He Bruises Easily"

STEP 3: EYES & FACE

• Scleral icterus - Best place to detect early jaundice (bilirubin >2.5-3 mg/dL). Look in good daylight, pull down lower lid, compare to healthy person's sclera.
• Anaemia - Conjunctival pallor (haemolysis, bone marrow failure, chronic disease)
• Kayser-Fleischer rings - Brown-gold rings at corneal periphery (Wilson's disease - use slit lamp to confirm)
• Xanthelasma - PBC

STEP 4: HANDS

• Flapping tremor (asterixis) - hepatic encephalopathy
• Leuconychia - hypoalbuminaemia
• Palmar erythema - CLD
• Clubbing - CLD, IBD (PSC), hepatopulmonary syndrome
• Dupuytren's - alcoholic liver disease
• Bruising - coagulopathy

STEP 5: LYMPH NODES - KEY ONES TO FEEL

STEP 6: ABDOMINAL EXAMINATION - THE CORE EXAM

• Distension = ascites
• Caput medusae = portal hypertension
• Surgical scars = prior biliary surgery

"A palpable, non-tender gallbladder in a jaundiced patient suggests malignant obstruction of the common bile duct, NOT gallstones" - because gallstones cause chronic fibrosis and a shrunken non-distensible gallbladder.

• Dullness in flanks + shifting dullness = ascites
• Liver dullness span: Normal 8-12 cm in mid-clavicular line. Dullness reduced = small/shrunken liver (late cirrhosis, acute liver failure)

STEP 7: CARDIOVASCULAR

• JVD + peripheral oedema + jaundice = Congestive hepatopathy (CCF causing hepatic congestion)
• Right pleural effusion without obvious ascites = advanced cirrhosis (hepatic hydrothorax)

STEP 8: NEUROLOGICAL

• Asterixis (flapping tremor) = hepatic encephalopathy
• Confusion, slurring, behavioural change = encephalopathy
• Kayser-Fleischer rings + neuropsychiatric features = Wilson's disease

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SECTION 5: THE INVESTIGATION ALGORITHM - STEP BY STEP

FIRST-LINE INVESTIGATIONS (Order immediately on any jaundiced patient):

1. Total bilirubin + fractionation (direct vs indirect)
2. ALT, AST, ALP, GGT
3. Albumin, Prothrombin time / INR
4. Full blood count (CBC)
5. Blood urea, creatinine, electrolytes

• Urine bilirubin (dipstick) - present = conjugated hyperbilirubinemia (hepatic/posthepatic)
• Urobilinogen - increased in haemolysis/hepatitis, absent in complete obstruction

INTERPRETING THE PATTERN - THE "ENZYME COMPASS":

HEPATOCELLULAR INJURY             CHOLESTATIC PATTERN
ALT/AST very high (>500 IU)   vs.  ALP very high + ALT/AST mildly raised
Bilirubin raised (mixed)            Bilirubin raised (conjugated)
PT prolonged (doesn't correct       PT may correct with Vit K
with Vit K in severe disease)       (bile needed for Vit K absorption)

SECOND-LINE INVESTIGATIONS (based on pattern):

1. Hepatitis A IgM, Hepatitis B sAg + core Ab (IgM), Hepatitis C RNA
2. Toxicology screen, paracetamol level
3. ANA, ASMA, anti-LKM1 = Autoimmune hepatitis
4. Ceruloplasmin + 24hr urine copper = Wilson's (in patients <40)
5. Serum ferritin + transferrin saturation = Haemochromatosis
6. CMV DNA, EBV capsid antigen, Hepatitis D Ab, Hepatitis E IgM

1. USS abdomen FIRST (cheap, accessible, non-invasive) - look for dilated biliary ducts
2. If ducts dilated (extrahepatic cholestasis): CT abdomen / MRCP / ERCP
3. If ducts NOT dilated (intrahepatic cholestasis): AMA (antimitochondrial Ab) for PBC, hepatitis serologies, drug review
4. AMA positive = PBC - proceed to liver biopsy
5. AMA negative, no cause found = MRCP or liver biopsy

• Blood film, reticulocyte count, LDH, haptoglobin, Coombs test = haemolysis screen
• No haemolysis + otherwise well = Gilbert's syndrome (no further workup needed)

• CT chest/abdomen/pelvis with contrast
• CA 19-9 (pancreatic cancer), AFP (HCC), CEA (colorectal metastases)
• ERCP/MRCP for biliary obstruction characterisation
• Biopsy/EUS for tissue diagnosis

• Blood film (dysplastic cells, blasts?)
• Reticulocyte count
• Bone marrow aspirate + trephine biopsy
• LFTs pattern (usually hepatic infiltration pattern - raised ALP, mild bilirubin)

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SECTION 6: DISEASE-SPECIFIC APPROACH - MATCHING PRESENTATION TO DIAGNOSIS

SCENARIO-BASED QUICK GUIDE FOR WARD ROUNDS:

• Think viral hepatitis - send Hep serology, ALT/AST pattern

• Gilbert's syndrome - fractionated bili (indirect up, direct normal), otherwise normal LFTs - REASSURE

• Alcoholic hepatitis - Maddrey's Discriminant Function = 4.6 x (PT patient - PT control) + bilirubin (mg/dL); if >32 = severe, consider steroids

• PBC - AMA, ALP high, check cholesterol

• Wilson's disease - ceruloplasmin, 24hr urine copper, slit-lamp

• Carcinoma head of pancreas - CT triple phase, CA19-9, ERCP/MRCP

• ASCENDING CHOLANGITIS - EMERGENCY - blood cultures, IV antibiotics, urgent ERCP

• Haemolytic anaemia - blood film, Coombs test, haemoglobin electrophoresis

• Primary Sclerosing Cholangitis - MRCP (beading of ducts), p-ANCA, colonoscopy

• Think Budd-Chiari syndrome - Doppler USS of hepatic veins (absent flow)

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SECTION 7: CLINICAL SIGNS TABLE - "WHAT SIGN POINTS TO WHAT"

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SECTION 8: VIVA HOT QUESTIONS - FOR FCPS TOACS & MRCP

Fractionated serum bilirubin (total + direct/indirect) PLUS LFT panel (ALT, AST, ALP, albumin, PT). Also urine for bilirubin and urobilinogen. First imaging = USS abdomen.

A palpable, non-tender gallbladder in a jaundiced patient suggests malignant obstruction of the bile duct, NOT gallstones. Gallstones cause chronic inflammation and fibrosis of the GB wall, making it unable to distend.

Fever + RUQ pain + Jaundice = Ascending cholangitis. Reynolds' pentad adds hypotension + altered consciousness. It is septic shock from biliary sepsis. Requires immediate blood cultures, IV broad-spectrum antibiotics, and urgent biliary decompression (ERCP).

Obstructive: ALP >> ALT/AST, conjugated bilirubin, PT corrects with Vit K, dilated ducts on USS. Parenchymal: ALT/AST >> ALP, mixed bilirubin, PT may not correct with Vit K, no duct dilation.

Benign inherited condition, reduced UGT1A1 enzyme activity. Presents with mild isolated unconjugated (indirect) hyperbilirubinemia during fasting, stress, or illness. ALL other LFTs are normal. Blood film normal. No haemolysis. REASSURE - no treatment needed.

24-hour urine copper (>100 mcg/day is diagnostic). Liver biopsy with copper quantification (>250 mcg/g dry weight) is gold standard if uncertain.

Used in alcoholic hepatitis: 4.6 x (PT_patient - PT_control) + serum bilirubin (mg/dL). Score >32 = severe alcoholic hepatitis = consider prednisolone 40 mg/day. Score <32 = conservative management.

Model for End-stage Liver Disease. Used to prioritise liver transplant. = 3.78 x ln[bilirubin mg/dL] + 11.2 x ln[INR] + 9.57 x ln[creatinine mg/dL] + 6.43. Score >15 = consider transplant listing.

Anti-mitochondrial antibody (AMA) in >90% cases. Treatment = Ursodeoxycholic acid (UDCA) 13-15 mg/kg/day. If inadequate response: Obeticholic acid.

When etiology remains unclear despite full biochemical and imaging workup. Also for: autoimmune hepatitis confirmation, grading/staging of chronic hepatitis, unexplained cholestasis with non-dilated ducts and negative serology.

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SECTION 9: COMMON MISTAKES & BLUNDERS TO AVOID

THE "8 DEADLY SINS" IN JAUNDICE MANAGEMENT:

• Mistake: Calling RUQ pain + jaundice "gallstones" and sending home or waiting
• Correct: Charcot's triad = EMERGENCY. Start IV antibiotics immediately. Arrange urgent ERCP. Do NOT delay.

• Mistake: Not asking about herbal medicines, supplements, OTC drugs, recent antibiotics (flucloxacillin causes cholestatic jaundice weeks later), statins, OCP
• Correct: ALWAYS ask a detailed drug history including herbals and recent changes. Drug-induced liver injury is one of the most commonly missed diagnoses.

• Mistake: Attributing painless jaundice in an elderly patient to Gilbert's or viral hepatitis
• Correct: Painless progressive jaundice + weight loss = Ca head of pancreas until proven otherwise. Order CT triple phase + CA19-9.

• Mistake: Only checking bilirubin and transaminases
• Correct: PT/INR is a marker of SYNTHETIC FUNCTION. A prolonged PT that does NOT correct with Vitamin K = severe parenchymal disease / acute liver failure. This changes management urgently.

• Mistake: Just giving Vit K without checking effect
• Correct: Give IV Vit K 10 mg and recheck PT in 24 hours. Correction = obstructive; no correction = liver synthetic failure.

• Mistake: Jumping to invasive investigation
• Correct: USS abdomen is ALWAYS the first imaging modality. Cheap, non-invasive, excellent for gallstones and ductal dilation. Reserve ERCP for therapeutic intervention.

• Mistake: Treating unconjugated jaundice as Gilbert's without ruling out haemolysis
• Correct: ALWAYS check blood film + reticulocyte count + LDH + haptoglobin before diagnosing Gilbert's. Haemolysis must be excluded.

• Mistake: Assuming new jaundice in a known cirrhotic = disease progression
• Correct: Known cirrhotic + new/worsening jaundice = rule out superimposed cause: hepatocellular carcinoma (AFP, triphasic CT), spontaneous bacterial peritonitis, portal vein thrombosis, drug hepatotoxicity, or superimposed viral hepatitis.

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SECTION 10: THE EMERGENCY ER APPROACH - WITHIN THE FIRST 30 MINUTES

IMMEDIATE TRIAGE CHECKLIST:

• Fever >38.5°C + jaundice + RUQ pain = Cholangitis - IV Abx NOW
• Altered consciousness + jaundice = Hepatic encephalopathy / Acute Liver Failure - ICU consideration
• Hypotension + jaundice = Septic shock (cholangitis), Acute Liver Failure, or Haemolytic crisis
• Deep jaundice + prolonged PT not correcting with Vit K = Acute Liver Failure - liver transplant team contact
• Massive haemolysis + severe anaemia = transfusion support needed

1. IV access - take bloods at the same time: FBC, LFTs, PT/INR, renal function, blood cultures (if febrile)
2. Fractionated bilirubin + full LFT panel
3. Urine dipstick: bilirubin + urobilinogen
4. USS abdomen - same day if possible
5. Fluids if dehydrated/hypotensive
6. IV Vitamin K 10 mg if coagulopathic
7. Lactulose + protein restriction if encephalopathy
8. IV broad-spectrum antibiotics (e.g., piperacillin-tazobactam or ceftriaxone + metronidazole) if cholangitis suspected

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SECTION 11: WARD MANAGEMENT ORIENTATION - THE DAILY CHECKLIST

• Bilirubin trend (rising/falling?)
• PT/INR trend - falling = recovery; rising = deterioration
• Albumin - marker of synthetic function
• Encephalopathy grade (West Haven criteria: Grade 1-4)
• Urine output (hepatorenal syndrome risk in advanced disease)
• Any new fever/rigors (secondary infection, cholangitis)
• Medications - stop ALL hepatotoxic drugs
• Nutrition - high carbohydrate, moderate protein, avoid alcohol

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QUICK-REFERENCE SUMMARY CARD (Laminate this for your coat pocket)

JAUNDICE FIRST 3 QUESTIONS:
1. Isolated bili rise OR other LFTs too?
2. Conjugated (direct) or Unconjugated (indirect)?
3. Hepatocellular (ALT>ALP) or Cholestatic (ALP>ALT)?

URINE DARK + STOOLS PALE = Conjugated = Obstruction
URINE NORMAL + PALLOR + SPLENOMEGALY = Haemolysis

ALARMS:
- Fever + RUQ pain + jaundice = CHOLANGITIS (emergency)
- Painless jaundice + weight loss = MALIGNANCY
- Altered consciousness + jaundice = LIVER FAILURE

COURVOISIER'S LAW:
Palpable non-tender GB + jaundice = MALIGNANT obstruction

KEY DRUG HISTORY: Herbals, OCP, anti-TB, statins, paracetamol

INVESTIGATIONS ORDER:
1. FBC + LFTs + PT/INR
2. Fractionated bilirubin
3. USS abdomen
4. Then targeted: serology / MRCP / CT / Biopsy

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