Evaluation of Jaundice in Adults

 

Am Fam Physician. 2017 Feb 1;95(3):164-168.

  Patient information: See related handout on jaundice in adults, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Jaundice in adults can be an indicator of significant underlying disease. It is caused by elevated serum bilirubin levels in the unconjugated or conjugated form. The evaluation of jaundice relies on the history and physical examination. The initial laboratory evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, γ-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein. Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders. Ultrasonography is the least invasive and least expensive imaging method. A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy. Unconjugated hyperbilirubinemia occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome. Conjugated hyperbilirubinemia occurs in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree.

Jaundice occurs when the serum bilirubin level exceeds 3 mg per dL (51.3 μmol per L). It can be difficult to detect by physical examination alone.1 Acute jaundice is often an indicator of significant underlying disease and occurs secondary to intra- and extrahepatic etiologies. A retrospective study of more than 700 individuals found that most cases (55%) of acute jaundice in adults are caused by intrahepatic disorders, including viral hepatitis, alcoholic liver disease, and drug-induced liver injury. The remaining 45% of acute jaundice cases are extrahepatic and include gallstone disease, hemolysis, and malignancy.2 This article provides a systematic approach to the diagnosis of jaundice in adults and reviews common etiologies of hyperbilirubinemia. An algorithm for the evaluation of jaundice in adults is provided in Figure 1.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The initial laboratory evaluation of jaundice in adults should include fractionated bilirubin, complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, γ-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein.

C

7

Ultrasonography should be the first-line option for imaging in patients with jaundice because it is the least invasive and least expensive modality, and can effectively evaluate for obstructive disorders.

C

3, 7

Visualization of the intra- and extrahepatic biliary tree should be evaluated by magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography.

C

7, 8

Liver biopsy should be reserved for cases of jaundice where the diagnosis is unclear after the initial evaluation and if biopsy results will impact treatment and determine prognosis.

C

7


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The initial laboratory evaluation of jaundice in adults should include fractionated bilirubin, complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, γ-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein.

C

7

Ultrasonography should be the first-line option for imaging in patients with jaundice because it is the least invasive and least expensive modality, and can effectively evaluate for obstructive disorders.

C

3, 7

Visualization of the intra- and extrahepatic biliary tree should be evaluated by magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography.

C

7, 8

Liver biopsy should be reserved for cases of jaundice where the diagnosis is unclear after the initial evaluation and if biopsy results will impact treatment and determine prognosis.

C

7


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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Evaluation of Jaundice in Adults

Figure 1.

An algorithmic approach to the evaluation of jaundice in adults.

Information from reference 3.

Evaluation of Jaundice in Adults


Figure 1.

An algorithmic approach to the evaluation of jaundice in adults.

Information from reference 3.

Pathophysiology

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The Authors

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MATTHEW V. FARGO, MD, MPH, is deputy commander for clinical services at Bavaria Medical Activity, Vilseck, Germany. At the time the article was submitted, Dr. Fargo was an assistant professor in the Department Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

SCOTT P. GROGAN, DO, MBA, FAAFP, is associate residency director at Eisenhower Army Medical Center, Fort Gordon, Ga.

AARON SAGUIL, MD, MPH, is associate dean of recruitment and admissions at the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine.

Address correspondence to Matthew V. Fargo, MD, MPH, U.S. Army Medical Department, CMR 411, Box 4384, APO, AE 09112 (e-mail: matthew.v.fargo.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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