Pre-hepatic: decreased conjugation (↑ indirect bilirubin)

  • Differential diagnosis: Hemolysis, Gilbert’s (defect in uptake of indirect bilirubin), Crigler Najjar (gluconosyl transferase)

Hepatic: impaired excretion (↑ alk phos, ↑↑ AST/ALT)

  • Differential diagnosis: Viral, alcohol abuse, medications (tylenol, erythromycin, isoniazid, phenytoin, valproate, OCP), cirrhosis, Dubin-Johnson syndrome (impaired excretion by liver)

Post-hepatic: biliary obstruction (↑↑ alk phos, ↑ AST/ALT, ↑ direct) – dark urine, pale stools

  • Blocked common bile duct(stone, cancer of head of pancreas, lymphoma, stricture) – Courvoisier’s law (palpable nontender gall bladder – ?malignant obstruction)
  • Ascending cholangitis (E coli, klebsiella, pseudomonas, enterobacter, proteus, serratia, enterococci – amp, cipro/gent, flagyl)


  • Jaundice: onset, who noticed, associated features, pain?
  • Change in bowel habits: diarrhoea, malabsorption, colour of stools,
  • Nausea, vomitting, pain after eating, anorexia, GI upset
  • Skin – bruising, pruritis, rash, colour change
  • Bleeding: CRC and liver mets; Liver disease and hemorrhoids
  • B symptoms (weight loss, fevers, night sweats)
  • Family history
  • Past medical history– hepatitis, gallbladder, blood transfusion, bleeding disorder, depression
  • Social – smoking, alcohol use, intravenous drug use
  • Contact – sexual, travel, others with jaundice
  • Medications
  • Allergies

Physical examination

  • Vitals
  • Skin colour, general appearance
  • HEENT: scleral icterus, enlarged parotids, jaundice under tongue, clavicular node, encephalopathy
  • Skin: spider nevi, jaundice, bruising
  • Hands: palmar erythema, dupuytren’s contracture, clubbing, asterixis
  • Abdominal: gynecomastia, caput medusa, hepatosplenomegaly, Murphy’s sign, palpable gall bladder, masses, ascites


  • Alk Phos – Common bile duct blockage
  • Lipase – pancreas irritation
  • Total bilirubin
  • BUN – will increase in hemolysis
  • Creatinine
  • LFTs (protein, albumin, PT/PTT)
  • CBC – infection, hemolysis
  • U/A (bilirubin and urobilirubin)
  • Viral assays (EBV, CMV, hep A, hep B, Hep C)


  • Abdominal x-ray — flat plate (gas in biliary tree, stones)
  • Ultrasound – stones, dilatation, thickening of gall bladder, pericholecystic fluid
  • HIDA – acute cholecystitis; radioisotope concentration in liver, secreted into bile, no opacification of GB due to cystic duct obstruction
  • Liver scan
  • CT abdomen
  • ERCP – common bile duct stone

Charcot’s triad, Reynold’s pentad

  • Fever
  • RUQ pain
  • Jaundice
  • Mental status changes
  • Shock

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