Approach to Evaluating Jaundice

Initial Evaluation

The initial evaluation of jaundice should begin with laboratory testing to differentiate between unconjugated and conjugated hyperbilirubinemia, followed by abdominal ultrasound as the first-line imaging study for suspected biliary obstruction, as recommended by the American College of Radiology 1, 2
The most common causes of jaundice in the United States are hepatitis/sepsis, alcoholic liver disease, common bile duct obstruction by stones or tumor, and toxic reactions to drugs or herbs, according to the American College of Radiology 3, 4

Initial laboratory testing must include total and fractionated bilirubin, complete blood count, liver enzymes, and synthetic function tests, as recommended by the American College of Radiology and the American Academy of Pediatrics 1, 5
Categorization based on laboratory findings can help differentiate between unconjugated and conjugated hyperbilirubinemia, with unconjugated hyperbilirubinemia suggesting hepatitis, sepsis, or drug-induced liver disease, and conjugated hyperbilirubinemia suggesting biliary obstruction, as recommended by the American College of Radiology 1, 2, 6

Abdominal ultrasound is the recommended initial imaging study for jaundiced patients, with high sensitivity for detecting cirrhosis and variable sensitivity for biliary obstruction, as recommended by the American College of Gastroenterology and the American College of Radiology 1, 6
Additional imaging studies, such as CT with IV contrast, MRCP, and ERCP, may be necessary based on ultrasound findings and clinical suspicion, as recommended by the American College of Radiology 6

A diagnostic algorithm for jaundice should include laboratory testing, abdominal ultrasound, and potentially additional imaging studies, as recommended by the American College of Radiology 1, 6
If predominantly conjugated hyperbilirubinemia is present, abdominal ultrasound should be performed to assess for biliary dilation and liver parenchyma, as recommended by the American College of Radiology 1, 6

Jaundice persisting beyond 3 weeks requires measurement of total and direct bilirubin to identify cholestasis, as recommended by the American Academy of Pediatrics 5
Sensitivity of CBD stone detection on ultrasound can be increased by combining tissue harmonic imaging with findings of elevated bilirubin, patient age, and CBD dilation, as recommended by the American College of Radiology 6
A normal CBD caliber on ultrasound has a high negative predictive value for choledocholithiasis in patients with symptomatic gallstones, as recommended by the American College of Radiology 6
Multiple small gallstones in the gallbladder create a increased risk for migration into the CBD, as recommended by the American College of Radiology 6