ALGORITHM FOR PT WITH JAUNDICE

History (focus on medication/drug exposure)

Physical examination
Lab tests: Bilirubin with fractionation, ALT, AST, alkaline phosphatase, prothrombin time, and albumin

Inherited disorders

Dubin-Johnson syndrome
Rotor syndrome

Viral serologies


Hepatitis A IgM
Hepatitis B surface antigen and core antibody (IgM)
Hepatitis C RNA


Toxicology screen


Acetaminophen level


Ceruloplasmin (if pt <40 years of age)
ANA, SMA, SPEP

Hepatitis A IgM
Hepatitis B surface antigen and core antibody (IgM)
Hepatitis C RNA

Acetaminophen level

Results negative

Additional virologic testing

CMV, DNA, EBV capsid antigen
Hepatitis D antibody (if indicated)
Hepatitis E IgM (if indicated)

Results negative

Liver biopsy

Ultrasound

CT/MRCP/ERCP

Serologic Testing

AMA
Hepatitis serologies
Hepatitis A, CMV, EBV

Review drugs (see Table: 44-3)

MRCP/Liver biopsy

Liver biopsy

End

Isolated elevation of the bilirubin

Bilirubin and other liver tests elevated

Dilated ducts
Extrahepatic cholestasis

Ducts not dilated
Intrahepatic cholestasis

Results negative

AMA positive

ALT, alanine aminotransferase; AMA, antimitochondrial antibody; ANA, antinuclear antibody; AST, aspartate aminotransferase; CMV, cytomegalovirus; EBV, Epstein-Barr virus; ERCP, endoscopic retrograde cholangiopancreatogram; MRCP, magnetic resonance cholangiopancreatography; SMA, smooth-muscle antibody; SPEP, serum protein electrophoresis.

Indirect hyperbilirubinemia (direct <15%)
See Table 44-1

Direct hyperbilirubinemia (direct >15%)
See Table 44-1

Drugs

Rifampicin
Probenecid

Inherited disorders

Gilbert's syndrome
Crigler-Najjar syndromes

Hemolytic disorders
Ineffective erythropoiesis

Hepatocellular pattern: ALT/AST elevated out of proportion to alkaline phosphatase
See Table 44-2

Cholestatic pattern: Alkaline phosphatase out of proportion ALT/AST
See Table 44-3