Diagnostic Approach to Jaundice

Initial Evaluation

The American College of Radiology recommends beginning with initial laboratory testing including total and fractionated bilirubin, complete blood count, liver enzymes, albumin, prothrombin time/INR, followed immediately by abdominal ultrasound as the first-line imaging study 1, 2
Fractionated bilirubin testing determines whether hyperbilirubinemia is conjugated or unconjugated, with unconjugated hyperbilirubinemia suggesting hemolysis, hematoma resorption, or bilirubin metabolism defects 3
Conjugated hyperbilirubinemia indicates hepatocellular disease or biliary obstruction, with elevated alkaline phosphatase and GGT suggesting biliary obstruction rather than hepatocellular injury 2

The American College of Radiology recommends ultrasound as the initial imaging modality for all patients with jaundice, with a sensitivity of 32-100% and specificity of 71-97% for detecting biliary obstruction 1, 3
If biliary obstruction is confirmed, proceed to either MRCP or contrast-enhanced CT to determine the site and cause of obstruction, with MRCP preferred for more detailed biliary tree visualization, pregnancy, hilar obstruction, or failed ERCP 4, 5
Contrast-enhanced CT is preferred for rapid evaluation, suspected malignancy, or suspected complications like cholangitis, cholecystitis, or pancreatitis 1, 5

ERCP is indicated for therapeutic intervention, high suspicion for choledocholithiasis with dilated CBD, or malignant obstruction requiring palliation 1, 5
EUS with FNA is indicated for tissue diagnosis of pancreatic or periampullary mass, with a sensitivity of 90.8% and specificity of 96.5% 4, 5
Percutaneous transhepatic biliary drainage is reserved for failed ERCP, altered anatomy precluding endoscopic access, or hilar obstructions 5, 8