Jaundice can be reported by a patient, found on a physical exam, or suspected by a clinician on the basis of elevated bilirubin. In any of these scenarios, a clinician can build an approach to jaundice based upon dividing probable diagnoses into pre-hepatic, hepatic and post-hepatic causes. While this method of dividing the differentials is not necessarily conducive to a clinician collecting a history and physical exam related data in an efficient manner, this method is conducive to efficient recall of differential diagnoses. Similar to the patient presentation of elevated liver enzymes, an additional clinical context may or may not be available when a clinician evaluates a patient with jaundice or elevated bilirubin. This clinical mind map addresses jaundice in adult patients only, and several causes of jaundice in pediatric population are not discussed here.
Urgent/emergent situations include end stage liver failure arising from any underlying pathology (such as viral, alcoholic, or infiltrative liver disease), advanced pathology of any kind which led to jaundice during the course of advancing disease (such as hemolysis or sepsis) and severe adverse drug reactions which pose immediately life-threatening situations. These urgent/emergent situations are reflected in the form of an abnormal patient appearance, such as visible jaundice, altered mental status, distress, and abnormal vital signs. Pathologies which typically result in a rapid and precipitous decline in liver function are sepsis and primary sclerosing cholangitis.
Weighing and removing anchor bias involves a clinician asking questions which can differentiate among several diagnoses, performing a physical exam, and gathering additional lab and/or imaging data. High yield questions in the jaundice mind map involve the duration and determining whether the bilirubin is conjugated or unconjugated. This information helps in differentiating among pre-hepatic, hepatic and post hepatic causes. Pre-hepatic causes usually result is unconjugated hyperbilirubinemia, post-hepatic causes result in conjugated hyperbilirubinemia, and hepatic causes can result in either unconjugated or conjugated hyper bilirubinemia. As this differentiating information may not be available in the beginning, a clinician faces a challenge to efficiency and must rely on gathering comprehensive clinical data.