Red flag Symptoms - Jaundice

A full history is vital to classify the condition as acute or chronic, says Dr Mareeni Raymond.

It may be easier to identify jaundice in the sclera than in the skin (Photograph: SPL)
It may be easier to identify jaundice in the sclera than in the skin (Photograph: SPL)

Jaundice is the yellow discoloration of the skin and sclera that is caused by excessive bile pigment. Causes are divided into pre-hepatic, hepatic or obstructive.

History
A full history is vital to classify whether this is a chronic or acute condition. If there is abdominal pain, gallstones may have obstructed the common bile duct, and if there is also an associated fever the patient may have associated inflammation (cholecystitis), which requires urgent hospital management.

The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause. Pruritus may be a symptom of raised bile acids. In patients with hepatitis there may be associated risk factors in the history, such as recent foreign travel, IV drug use or unprotected sexual intercourse. Glandular fever can also present with jaundice, so ask if there has been a recent viral illness.

More sinister causes may be indicated by a history of associated weight loss, loss of appetite, malaise or epigastric mass, suggestive of pancreatic cancer or metastases in the liver.

Jaundice may also be a side-effect of medication so a drug history is essential. If there is a history of cardiac problems and worsening shortness of breath, consider cardiac failure as a cause of an enlarged liver and subsequent jaundice. A social history is important, because excessive alcohol may have led to cirrhosis of the liver.

Pre-hepatic jaundice is caused by haemolysis, which can be caused by malaria or genetic diseases, such as sickle cell anaemia, so ask about foreign travel and family history.

Investigation
It is vital to check pulse, temperature and BP to define the risk of an acute illness, such as hepatitis, requiring urgent investigation. If the skin discoloration is not clear, check the sclerae, where it is easier to identify.

Examine the heart for signs of cardiac failure, and examine the abdomen for pain, masses, an enlarged liver or signs of liver cirrhosis, such as spider naevi or gynaecomastia. The general appearance of the patient, such as pallor, tiredness or cachexia, may be a sign of sinister causes such as malignancy.

Possible causes

Pre-hepatic

  • Malaria.
  • Genetic disease, for example, sickle cell anaemia or thalassaemia.

Hepatic

  • Hepatitis.
  • Glandular fever.
  • Drug misuse.
  • Cirrhosis.
  • Medication.
  • Liver cancer.

Obstructive

  • Gall stones.
  • Cholecystitis.
  • Pancreatic cancer.

Check LFTs and FBC. Raised LFTs will help isolate a cause, for example a raised gamma-glutamyl transferase is more likely in alcoholic cirrhosis.

Current guidance is to repeat LFTs in one month if ALT or AST are three times the upper limit of normal and repeat in one week if they are more than three times the upper limit of normal. If they are still raised, an ultrasound and referral to a liver specialist are required.

Management
Management of jaundice will depend on the cause. For example, gall stones may be treated surgically, cholecystitis with antibiotics and surgery, hepatitis by removal of the cause, such as alcohol or drugs, or in the case of viral hepatitis, treatment with antivirals under specialist supervision.

  • Dr Raymond is a GP and teaching associate at Royal Free and University College London Medical School

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