Assessment of Jaundice in the Hospitalized Patient

 

Meaning

Jaundice, or icterus, refers to the yellowish discoloration of the skin, sclerae, and mucous membranes due to accumulation of bilirubin in body tissues. It becomes clinically visible when serum bilirubin exceeds 2–3 mg/dL.

• Unconjugated (indirect) bilirubin elevation → usually due to increased production or impaired conjugation.

• Conjugated (direct) bilirubin elevation → due to hepatocellular dysfunction or impaired excretion.

Introduction

In the hospital setting, jaundice often signals significant underlying pathology. It may present acutely (e.g., viral hepatitis, drug-induced liver injury, gallstone obstruction) or chronically (e.g., cirrhosis, malignancy). Importantly, jaundice is not a disease but a manifestation of systemic, hepatic, or biliary disorders.
Timely evaluation is essential because:

• It helps distinguish benign and reversible causes from life-threatening conditions.

• It can uncover hidden malignancies or systemic infections.

• It guides urgent interventions, especially in obstructive jaundice or fulminant hepatic failure.

Pathophysiological Classification of Jaundice

1. Pre-hepatic (Hemolytic):

   • Excessive breakdown of red blood cells → increased unconjugated bilirubin.

   • Common causes: hemolytic anemia, sickle cell disease, thalassemia, mismatched transfusion, malaria.

2. Hepatic (Hepatocellular):

   • Impaired conjugation, uptake, or excretion within hepatocytes.

   • Causes: viral hepatitis (A, B, C, E), alcoholic hepatitis, drug-induced liver injury (paracetamol, isoniazid), autoimmune hepatitis, cirrhosis, sepsis-related cholestasis.

3. Post-hepatic (Cholestatic/Obstructive):

   • Mechanical blockage of bile flow.

   • Causes: gallstones, biliary strictures, cholangiocarcinoma, pancreatic cancer, periampullary carcinoma, postoperative biliary injury.

Detailed Clinical Assessment

1. History Taking

• Onset & duration:

  • Rapid onset → viral hepatitis, obstruction by stone.

  • Insidious → malignancy, cirrhosis.

• Associated symptoms:

  • Fever & chills → cholangitis.

  • Right upper quadrant pain → cholelithiasis, acute hepatitis.

  • Painless progressive jaundice → pancreatic carcinoma.

  • Itching (pruritus) → cholestatic/obstructive jaundice.

  • Dark urine & pale stools → conjugated hyperbilirubinemia.

• Risk factors:

  • Alcohol use, IV drug use, recent transfusions, hepatotoxic drug exposure, family history of hemolytic or hepatic disease, travel to endemic areas.

2. Physical Examination

• General inspection:

  • Scleral icterus (earliest sign).

  • Pallor (hemolysis), bruising (coagulopathy), cachexia (malignancy).

• Skin signs:

  • Scratch marks (pruritus), spider angiomas, palmar erythema.

• Abdomen:

  • Hepatomegaly (cirrhosis, hepatitis, malignancy).

  • Splenomegaly (portal hypertension, hemolysis).

  • Ascites (decompensated liver disease).

  • Courvoisier’s sign (palpable non-tender gallbladder + jaundice = pancreatic cancer until proven otherwise).

• Systemic signs:

  • Asterixis (hepatic encephalopathy).

  • Edema (hypoalbuminemia).

Laboratory Evaluation

1. Liver Function Tests (LFTs)

• Total bilirubin & fractions: Distinguish unconjugated vs conjugated.

• AST/ALT: Marked rise in hepatocellular injury (viral hepatitis, drug-induced).

• ALP & GGT: Predominant rise in cholestatic/obstructive jaundice.

• Albumin: Low in chronic liver disease.

• Prothrombin time/INR: Prolonged in severe hepatic dysfunction.

2. Additional Tests

• Complete blood count (CBC): Hemolysis (anemia, reticulocytosis).

• Hemolysis workup: LDH ↑, haptoglobin ↓, Coombs test.

• Viral markers: HAV IgM, HBsAg, anti-HCV, HEV IgM.

• Autoimmune markers: ANA, ASMA, AMA.

• Metabolic: Serum ceruloplasmin (Wilson’s), ferritin/iron studies (hemochromatosis).

Imaging Studies

• Ultrasound Abdomen: First-line, inexpensive, detects gallstones, biliary dilatation, liver masses.

• CT Scan: More detailed, identifies tumors, pancreatic pathology.

• MRI/MRCP: Excellent for biliary tree and liver characterization.

• ERCP: Diagnostic and therapeutic (stone removal, stenting).

• Liver biopsy: For unexplained hepatocellular jaundice.

Challenges in Hospitalized Patients

• Overlap of causes: E.g., a patient with cirrhosis and superimposed sepsis.

• Drug-induced liver injury: Common in hospitalized patients receiving multiple medications (antibiotics, antitubercular therapy).

• Sepsis-induced cholestasis: May mimic obstructive jaundice.

• Delayed diagnosis: Especially in ICU patients where jaundice may be overshadowed by critical illness.

Management Principles

1. Stabilization:

   • Maintain fluid/electrolyte balance.

   • Correct hypoglycemia and coagulopathy.

   • Provide nutritional support.

2. Cause-specific treatment:

   • Hemolysis → stop offending drugs, treat malaria, transfuse if needed.

   • Hepatitis → antiviral therapy, abstinence from hepatotoxic agents, corticosteroids in autoimmune hepatitis.

   • Obstructive jaundice → ERCP for stone extraction or stenting, surgical bypass for malignancy.

3. Complication management:

   • Hepatic encephalopathy → lactulose, rifaximin.

   • Ascites → diuretics, paracentesis.

   • Coagulopathy → vitamin K, plasma transfusion.

   • Renal dysfunction (hepatorenal syndrome) → careful volume management, vasopressors if indicated.

Prognostic Indicators

• Rapidly rising bilirubin with coagulopathy → acute liver failure.

• Severe hypoalbuminemia and prolonged INR → advanced cirrhosis.

• Obstructive jaundice with weight loss → often malignancy-related.

• Scores: Child-Pugh score and MELD score help predict outcomes.

Conclusion

Assessment of jaundice in hospitalized patients is a multidisciplinary process. A thorough clinical history, careful physical examination, strategic use of laboratory tests, and appropriate imaging guide clinicians toward accurate diagnosis. Distinguishing between pre-hepatic, hepatic, and post-hepatic causes is essential for timely treatment. Since jaundice can indicate both benign reversible illness and life-threatening liver failure or malignancy, early recognition and management are critical to patient survival.

Summary

• Jaundice = yellow discoloration due to bilirubin >2–3 mg/dL.

• Classified as pre-hepatic, hepatic, or post-hepatic.

• Hospitalized patients require systematic history, examination, LFTs, and imaging.

• Drug-induced and sepsis-related jaundice are important in inpatients.

• Management is supportive plus cause-specific (antivirals, ERCP, transfusion, etc.).

• Prognosis depends on underlying etiology and severity of liver dysfunction.