Diagnostic Approach to Jaundice

Initial Evaluation

The American College of Radiology recommends abdominal ultrasound as the first-line imaging study for all jaundiced patients, which can effectively rule out biliary obstruction and detect features of cirrhosis 1, 2, 4
Total and fractionated bilirubin levels are essential to distinguish between unconjugated and conjugated hyperbilirubinemia, guiding further diagnostic workup 1
Liver function tests, including AST, ALT, alkaline phosphatase, and gamma-glutamyltransferase, help determine the pattern of liver injury 1

For unconjugated hyperbilirubinemia, common causes include hemolysis, hematoma resorption, Gilbert syndrome, and Crigler-Najjar syndrome, and evaluation for hemolysis with peripheral blood smear, reticulocyte count, haptoglobin, and LDH is recommended 2
For conjugated hyperbilirubinemia, abdominal ultrasound can detect biliary dilation with specificities of 71-97% and identify cirrhosis with sensitivity of 65-95% 1, 2, 3
The most accurate sonographic finding for cirrhosis is a nodular liver surface, which is more sensitive on the undersurface (86%) than the superior surface (53%) 2

Ultrasound can detect small stones or strictures missed by initial evaluation, and MRI with MRCP is recommended to evaluate for strictures, stones, or tumors if ultrasound shows biliary dilation but no clear cause 2, 4, 5
Contrast-enhanced CT can determine the site and cause of biliary obstruction with sensitivity of 74-96% and specificity of 90-94% 4
EUS offers high-resolution imaging of the pancreaticobiliary tree and can detect small distal CBD stones 6, 7

ERCP is primarily therapeutic rather than diagnostic, with success rates of 80-95% for CBD stone clearance and >90% for stent placement in distal CBD strictures, and is recommended when there is high suspicion for CBD stones or need for biliary decompression 6, 7, 8
Liver biopsy may be necessary when imaging and laboratory tests are inconclusive, particularly for suspected medical, metabolic, or functional causes of jaundice, and the American College of Gastroenterology recommends liver biopsy if ultrasound is negative and additional laboratory testing for liver failure is inconclusive 2, 5

For obstructive jaundice, CBD stones: ERCP with stone extraction is the standard treatment, and malignant obstruction: Biliary drainage via ERCP or percutaneous transhepatic cholangiography is recommended 6, 7
For non-obstructive jaundice, treatment of underlying cause is necessary, such as alcohol cessation and nutritional support for alcoholic liver disease, and discontinuation of offending agent for drug-induced liver injury 4