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Jaundice

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Pre-hepatic Causes

  • Hemolysis: Increased breakdown of red blood cells, seen in conditions like hereditary spherocytosis, sickle cell anemia, and G6PD deficiency.
  • Ineffective erythropoiesis: Conditions like thalassemia major where there is increased destruction of immature red blood cells.
  • Hemolytic disease of the newborn: Rh or ABO incompatibility leading to increased bilirubin production in neonates.

Hepatic Causes

  • Hepatitis: Viral hepatitis (A, B, C, E), autoimmune hepatitis, or drug-induced hepatitis causing liver inflammation.
  • Cirrhosis: Chronic liver disease leading to scarring and impaired bilirubin metabolism.
  • Liver cirrhosis: Alcoholic cirrhosis, non-alcoholic steatohepatitis (NASH), and other causes of chronic liver scarring.
  • Genetic disorders: Conditions like Gilbert’s syndrome, Crigler-Najjar syndrome, and Wilson’s disease affecting bilirubin metabolism.
  • Intrahepatic cholestasis: Conditions such as primary biliary cirrhosis or primary sclerosing cholangitis causing impaired bile flow.
  • Hepatocellular carcinoma: Liver cancer that can obstruct bile ducts or disrupt liver function.
  • Sepsis: Systemic infection can cause liver dysfunction and jaundice.
  • Liver abscess: Pyogenic or amoebic abscesses can cause jaundice through liver damage.
  • Acute fatty liver of pregnancy: Rare but serious cause of liver dysfunction in pregnant women.
  • Reye’s syndrome: Rare condition in children causing acute liver failure and encephalopathy.

Post-hepatic Causes

  • Gallstones: Can obstruct the common bile duct, leading to jaundice.
  • Cholangiocarcinoma: Cancer of the bile ducts causing obstruction and jaundice.
  • Pancreatic cancer: Tumors in the head of the pancreas can obstruct the bile duct, causing obstructive jaundice.
  • Primary sclerosing cholangitis: Chronic inflammation of the bile ducts leading to scarring and blockage.
  • Biliary atresia: Congenital condition in infants where bile ducts are absent or damaged, leading to jaundice.
  • Choledochal cyst: Congenital dilatation of the bile ducts that can cause obstruction.
  • Post-surgical strictures: Scar tissue formation following bile duct surgery can lead to obstruction.
  • Mirizzi syndrome: A gallstone in the cystic duct compresses the common bile duct, causing jaundice.
  • Parasitic infections: Liver flukes can obstruct bile ducts, leading to jaundice.
  • Pancreatitis: Inflammation of the pancreas can lead to bile duct obstruction and jaundice.

Key Points in History 🥼

Background

  • Onset and duration: Sudden onset may suggest acute hepatitis or gallstones, whereas a gradual onset is more typical of chronic liver disease or malignancy.
  • Associated symptoms: Pruritus suggests cholestasis, while pale stools and dark urine are classic signs of obstructive jaundice.
  • Pain: Right upper quadrant pain may suggest gallstones or hepatitis, while painless jaundice is concerning for malignancy.
  • Travel history: Recent travel to areas endemic with hepatitis A, E, or parasitic infections can be relevant.
  • Medication history: Certain drugs like paracetamol, antiepileptics, and antibiotics can cause liver damage.
  • Alcohol intake: Chronic alcohol use is a significant risk factor for cirrhosis and alcoholic hepatitis.
  • Family history: Genetic conditions like Gilbert’s syndrome or hereditary spherocytosis may be relevant.
  • Past medical history: Liver disease, previous episodes of jaundice, or gallbladder surgery can provide clues.
  • Infectious contacts: Recent contact with individuals with jaundice may suggest viral hepatitis.
  • Social history: Intravenous drug use or high-risk sexual behaviors can increase the risk of hepatitis B and C.
  • Occupational history: Exposure to hepatotoxins in the workplace might contribute to liver disease.
  • Dietary habits: Consumption of shellfish or raw seafood is associated with hepatitis A.
  • Surgical history: Previous abdominal surgeries may lead to post-surgical strictures causing jaundice.
  • Recent weight loss: Unintentional weight loss is concerning for malignancy.
  • Skin changes: Easy bruising or spider naevi may indicate chronic liver disease.

Possible Investigations 🌡️

Blood Tests

  • Full blood count (FBC): To assess for anemia, leukocytosis, or thrombocytopenia.
  • Liver function tests (LFTs): Elevated bilirubin, ALT, AST, and ALP levels help differentiate between hepatocellular and cholestatic jaundice.
  • Prothrombin time (PT)/INR: Prolongation indicates liver dysfunction or vitamin K deficiency.
  • Serum amylase/lipase: To rule out pancreatitis as a cause of jaundice.
  • Serum haptoglobin: Low levels suggest hemolysis.
  • Serum ferritin: Elevated in hemochromatosis or inflammation.
  • Hepatitis serology: To diagnose hepatitis A, B, C, or E infections.
  • Autoimmune markers: ANA, SMA, and LKM antibodies for autoimmune hepatitis.
  • Ceruloplasmin: Low levels in Wilson’s disease.
  • Alpha-1 antitrypsin levels: Low levels may indicate alpha-1 antitrypsin deficiency.
  • Blood cultures: To rule out sepsis in febrile patients with jaundice.
  • Genetic testing: For hereditary conditions like Gilbert’s syndrome or hemochromatosis.

Imaging

  • Ultrasound abdomen: First-line imaging to assess liver size, structure, and to check for gallstones or bile duct dilation.
  • CT/MRI: Detailed imaging to evaluate the liver, pancreas, and biliary tree for tumors, abscesses, or structural anomalies.
  • MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive imaging of the biliary and pancreatic ducts.
  • ERCP (Endoscopic Retrograde Cholangiopancreatography): Both diagnostic and therapeutic, particularly for stone removal or stenting in obstructive jaundice.
  • HIDA scan: Nuclear medicine scan to assess gallbladder function and biliary tree patency.
  • Liver biopsy: Considered if autoimmune hepatitis, cirrhosis, or other liver pathology is suspected and diagnosis remains unclear.

Other Tests

  • Paracentesis: In cases of ascites, to evaluate for spontaneous bacterial peritonitis or malignancy.
  • Fibroscan: Non-invasive assessment of liver fibrosis, useful in chronic liver disease.
  • Endoscopic ultrasound (EUS): To assess pancreatic tumors or cysts causing biliary obstruction.

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Gastrointestinal