🩺 Jaundice

Jaundice (icterus) is the yellow discolouration of the skin and sclerae due to hyperbilirubinaemia (typically >50 µmol/L). It is categorized into pre-hepatic (unconjugated), intra-hepatic (mixed), and post-hepatic (conjugated/obstructive). The primary goal of clinical assessment is to differentiate between medical causes (hepatitis, cirrhosis) and surgical causes (biliary obstruction or malignancy) that require urgent intervention. The presence of pain, fever, and weight loss are major variables in tailoring the diagnostic pathway.

A history of pain (biliary colic/cholangitis) versus painless jaundice (malignancy) is the most critical distinction. Inquire about constitutional symptoms (weight loss, anorexia), alcohol use, medication history (including herbal supplements and paracetamol), and risk factors for viral hepatitis (travel, IV drug use, tattoos, sexual history). Ask specifically about bowel habit (pale stools) and urine colour (darkening). Recent surgery or blood transfusions should also be noted.

Inspect the sclera in natural light for the earliest signs of icterus. Look for stigmata of chronic liver disease (gynaecomastia, spider naevi, caput medusae). Palpate the RIF and RUQ for hepatomegaly (smooth vs. nodular) or a palpable gallbladder. Murphy's sign may indicate concurrent cholecystitis. Assess for ascites and peripheral oedema. Neurological assessment for asterixis (liver flap) is vital to exclude hepatic encephalopathy. Always check for lymphadenopathy (Troisier’s sign/Virchow’s node) as a marker of gastric or pancreatic malignancy.

Gallstones (Choledocholithiasis), Pancreatic Carcinoma, Viral Hepatitis, Alcoholic Liver Disease, Drug-Induced Liver Injury (e.g., Co-amoxiclav), Primary Biliary Cholangitis, Primary Sclerosing Cholangitis, Gilbert's Syndrome.

Painless progressive jaundice (malignancy), fever and RUQ pain (cholangitis), altered mental status (encephalopathy), and significant coagulopathy (liver failure).

Initial bloods: LFTs (to distinguish between a cholestatic vs. hepatitic pattern), FBC, U&Es, Clotting profile (INR is a key marker of liver synthetic function), and a secondary 'Liver Screen' (Viral serology, Auto-antibodies, Ferritin, Alpha-1-antitrypsin). Total and Split Bilirubin help identify unconjugated vs. conjugated patterns. Imaging starts with an Ultrasound (to look for ductal dilatation). If obstruction is present, MRCP provides non-invasive visualization of the biliary tree, while ERCP is reserved for therapeutic intervention (stenting/stone removal).

Dark urine and pale stools are the hallmark of 'surgical' or obstructive jaundice (excess conjugated bilirubin). Pruritus in jaundice is caused by the deposition of bile salts in the skin and is often most severe on the palms and soles. Courvoisier’s Law states that a palpably enlarged, non-tender gallbladder in a jaundiced patient is unlikely to be due to gallstones and more likely to be malignancy (e.g., pancreatic head). Gilbert’s Syndrome is a common, benign cause of mild unconjugated hyperbilirubinaemia triggered by stress or fasting.

Understand the biochemical patterns: Hepatitic (ALT/AST significantly higher than ALP) vs. Cholestatic (ALP significantly higher than ALT). Students must recognize 'Ascending Cholangitis' (Charcot's Triad: Jaundice, Fever, RUQ pain) as a medical emergency requiring urgent biliary decompression. Be aware of the NICE guidelines for pancreatic cancer referral in patients over 40 with jaundice.