Jaundice and pruritus — Rapid | Doctor’s Passport

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.
Assess liver function separately from liver injury: INR, glucose, albumin, mental state and renal function determine severity, while ALT and ALP mainly describe pattern.
Medication and supplement timing is essential. Antibiotics, antiepileptics, anabolic agents, herbal products and many other drugs can cause hepatocellular, cholestatic or mixed injury.
Abdominal ultrasound is first-line for gallstones and bile-duct dilatation; MRCP or endoscopic ultrasound follows when common-duct stones remain suspected, while ERCP is primarily therapeutic.
Painless progressive jaundice, weight loss, new diabetes, palpable gallbladder or pancreatic or biliary imaging abnormality requires the current urgent cancer pathway.
Unconjugated bilirubin with normal other liver tests suggests haemolysis or Gilbert syndrome; check anaemia and haemolysis before arranging biliary procedures.
Cholestatic pruritus is not histamine driven. Cholestyramine is a common first pharmacological step, with specialist escalation when ineffective and careful spacing from other medicines.

Key red flags

Acute ascending cholangitis

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.

Acute liver failure

Acute jaundice with new coagulopathy and encephalopathy in a person without established cirrhosis signals liver failure. Hypoglycaemia, acidosis, kidney injury and cerebral oedema risk require immediate liver-centre discussion.

Investigation priorities

Fractionated bilirubin and liver blood testsFirst step

Separate conjugated from unconjugated hyperbilirubinaemia and classify hepatocellular, cholestatic or mixed injury.

Management branches

CholangitisResuscitate and drain the source

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.
Arrange therapeutic biliary decompression, usually ERCP, on the urgency determined by sepsis and anatomy; use radiological or surgical drainage when endoscopy is unavailable or unsuccessful.
After stabilisation, define stone, stricture or malignancy cause and arrange definitive clearance, surgery or cancer management.

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.Antibiotics cannot relieve obstruction. Review cultures, C difficile and kidney risk and narrow or stop according to response and successful drainage under stewardship guidance.

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.Constipation, bloating, poor palatability, medicine binding and fat-soluble vitamin deficiency limit use. Schedule carefully and avoid assuming failure when doses were taken simultaneously with other drugs.

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