Jaundice

1 · First minutes

1. Three buckets: obstructed duct, injured hepatocyte, lysed red cell.
2. Fever + jaundice is cholangitis until the biliary tree is seen — Charcot’s triad is insensitive.
3. Acute liver injury with INR ≥1.5 and encephalopathy, usually without established cirrhosis, suggests acute liver failure; call transplant early.

3 · Immediate workup

• Glucose (ALF patients crash); POCUS for CBD dilatation, stones, abscess

4 · Don’t miss

• Ascending cholangitis
  Fever + jaundice ± RUQ pain (Charcot); shock/confusion (Reynolds). Tokyo criteria. Resuscitate, cultures, broad antibiotics, urgent biliary drainage (ERCP).
• Acute liver failure
  INR ≥1.5 plus encephalopathy in acute liver injury without established cirrhosis (distinguish acute-on-chronic failure) — transplant pathway, NAC if acetaminophen or even if etiology is unclear in many protocols, glucose, ICP precautions.
• Acetaminophen (and other toxin) hepatitis
  A treatable cause — obtain acetaminophen level, AST/ALT and INR; start NAC promptly for suspected toxic exposure with delayed testing or liver injury and use the poison-centre pathway for unknown timing or repeated ingestion.
• Ascending cholangitis mimics / hepatic abscess / sepsis
  Jaundice in the septic patient is not “just Gilbert.”