Synopsis
Classify jaundice by bilirubin and liver-enzyme pattern, recognise cholangitis and liver failure, investigate obstruction without delay, and treat cholestatic itch while the underlying hepatobiliary disease is established.
- Confirm jaundice in sclera and daylight, then determine whether bilirubin is predominantly conjugated or unconjugated and whether the biochemical pattern is cholestatic or hepatocellular.
- Dark urine indicates water-soluble conjugated bilirubin; pale stool and generalised itch support impaired bile flow, but neither identifies whether obstruction is intrahepatic or extrahepatic.
- Fever, right upper-quadrant pain and jaundice is the classic cholangitis triad, yet older or immunosuppressed patients may present mainly with hypotension, delirium or kidney injury.
Key red flags
Jaundice with fever, right upper-quadrant pain, rigors, hypotension or confusion indicates infected biliary obstruction. Sepsis may progress rapidly and requires antibiotics plus prompt source control through biliary drainage.
Investigation priorities
Separate conjugated from unconjugated hyperbilirubinaemia and classify hepatocellular, cholestatic or mixed injury.
Management branches
Jaundice accompanies fever, pain, rigors, hypotension or confusion.
- Begin sepsis ABCDE care, obtain cultures and urgent bloods, give locally recommended intravenous antimicrobials and correct fluid, glucose and electrolyte disturbance.
- Call gastroenterology, hepatobiliary surgery, anaesthesia and critical care early and obtain urgent ultrasound or cross-sectional imaging without delaying source-control planning.
Key medicines
Empirical antimicrobials for acute cholangitisGive the locally approved intravenous biliary-sepsis regimen promptly after cultures where feasible, adjusting for allergy, renal function, previous instrumentation and local resistance.
Cholestyramine for cholestatic pruritusStart with the current BNF low-dose oral regimen and titrate to response, separating administration from all other oral medicines by the recommended interval.