Jaundice
Red flags
Acute liver failure - jaundice + coagulopathy + encephalopathy
- INR >=1.5 with any encephalopathy in a patient without known cirrhosis
- -> discuss with a liver transplant unit the same day. Do not wait for a diagnosis
- Hypoglycaemia, lactic acidosis, rapidly rising bilirubin with falling transaminases (loss of viable hepatocytes, not recovery)
- Paracetamol history - including staggered/therapeutic-excess ingestion. Start NAC on suspicion
Ascending cholangitis - obstruction + infection
- Charcot triad: fever + RUQ pain + jaundice. Reynolds pentad adds hypotension + confusion
- -> blood cultures, IV antibiotics, and biliary decompression by ERCP within 24-48 h (within hours if septic shock)
Other immediate concerns
- Painless jaundice with weight loss -> pancreatic or biliary malignancy until proven otherwise
- Jaundice + fever + rash + eosinophilia 2-8 weeks after a new drug -> DRESS
- Jaundice + anaemia + reticulocytosis + dark urine -> haemolysis, consider intravascular causes and TTP
- Jaundice in pregnancy -> HELLP, acute fatty liver of pregnancy - both obstetric emergencies
- New jaundice in known cirrhosis -> decompensation; look for SBP, variceal bleed, HCC, portal vein thrombosis, drug or alcohol trigger
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