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Jaundice

Obstructive, hepatocellular, or hemolytic — and is the liver failing?

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobObstructive, hepatocellular, or hemolytic — and is the liver failing?

  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.
  4. Acetaminophen is the reversible cause you must not miss.

Jaundice is conjugated or unconjugated, then extrahepatic obstruction vs hepatocellular injury vs hemolysis.

The ED questions that change disposition: is this cholangitis, acute liver failure (encephalopathy + INR), massive hemolysis, or acetaminophen? Charcot’s triad is insensitive — fever and jaundice still need a biliary tree look.

Ascending cholangitis Critical

Key: Fever + jaundice ± RUQ pain (Charcot); shock/confusion (Reynolds). Tokyo criteria. Resuscitate, cultures, broad antibiotics, urgent biliary drainage (ERCP).

Acute liver failure Critical

Key: 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 Critical

Key: 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 Critical

Key: Jaundice in the septic patient is not “just Gilbert.”

Massive hemolysis (malaria, G6PD, transfusion, sickle, TTP/DIC) Emergent

Key: Unconjugated bilirubin, falling hemoglobin, LDH, smear; treat the cause.

Acute viral hepatitis / alcoholic hepatitis / choledocholithiasis without cholangitis Emergent

Key: Image the duct; score alcoholic hepatitis (MELD/MDF) for steroids per protocol once infection is excluded.

Gilbert syndrome / isolated unconjugated / pancreatic head mass Common

Key: Gilbert is benign (isolated unconjugated, normal everything else). Painless progressive jaundice with weight loss needs outpatient staging but is rarely an ED crash.

Tick what your patient has — the banner updates as you go.

Tempo

hours–days (obstruction, toxin, hemolysis) vs weeks (viral, malignant)

Fever, pale stools, dark urine, pruritus (obstructive)

Acetaminophen, alcohol, new drugs (amoxicillin-clavulanate, isoniazid), mushrooms

Travel, injections, sexual contacts, pregnancy (HELLP, AFLP)

Prior gallstones, biliary stents, hemolytic history

Encephalopathy and asterixis (ALF)

Fever, RUQ tenderness, peritoneal signs, Murphy sign

Stigmata of chronic liver disease vs an acute unmarked patient

Splenomegaly (hemolysis, chronic liver); petechiae (DIC, TTP)

Volume status and occult GI bleeding

Bedside

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

Labs

  • Fractionated bilirubin, ALT/AST, ALP/GGT, INR, albumin, glucose, CBC, smear/LDH/haptoglobin if hemolysis
  • Acetaminophen level in nearly every acute hepatocellular pattern
  • Blood cultures if febrile; viral serologies; pregnancy test

Imaging / procedures

  • RUQ US first for obstruction
  • CT/MRCP if US is inconclusive; ERCP for cholangitis drainage
  • Avoid unnecessary sedation in ALF — ICP risk
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Isolated Gilbert-pattern unconjugated bilirubin with normal exam and labs; mild choledocholithiasis without cholangitis and reliable early GI follow-up per local pathway.

Admit

  • Acute hepatitis, choledocholithiasis awaiting ERCP, alcoholic hepatitis under infection screen, hemolysis needing treatment.

ICU / transplant / ERCP now

  • Cholangitis with shock, acute liver failure, acetaminophen with rising INR, HELLP/AFLP.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Jaundice:
    • Fever with jaundice (cholangitis until excluded)
    • Any encephalopathy or INR ≥1.5 in acute liver injury
    • Hypoglycemia, shock, or GI bleeding
    • Acetaminophen exposure, mushrooms, or new drugs
    • Pale stools and dark urine with duct dilatation
    • Pregnancy with jaundice (HELLP/AFLP)
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Three buckets: obstructed duct, injured hepatocyte, lysed red cell. ALP vs ALT vs LDH/smear assigns the bucket.
  • Cholangitis needs source control (ERCP), not antibiotics alone.
  • ALF: acute liver injury with INR ≥1.5 and encephalopathy, usually without pre-existing cirrhosis. Call transplant early.
  • Acetaminophen is the reversible cause you will not forgive yourself for missing.

Pitfalls

  • Charcot’s triad is absent in a large fraction of cholangitis — do not wait for it.
  • A “normal” acetaminophen level late after ingestion does not exclude toxicity — treat on timing and enzymes/INR.
  • Giving sedation for MRI in ALF can mask and worsen intracranial hypertension.
  • Isolated unconjugated bilirubin with a normal CBC and enzymes is Gilbert until you force it to be something else.
  • Painless jaundice is cancer until staged — but it is rarely the reason they die tonight; cholangitis and ALF are.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Abdominal PainFever & SepsisPoisoning & Overdose

Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — jaundice
  • Tokyo Guidelines 2018/2023 for acute cholangitis
  • EASL / AASLD acute liver failure guidance; 2023 US/Canada acetaminophen consensus
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