Jaundice ๐ก
On-call guide to jaundice in adults for Irish hospitals: red flags, LFT pattern, investigations, cholangitis, alcohol-related hepatitis, paracetamol and decompensated cirrhosis, with HPSC notification and NPIC advice.
๐จ Red flags (escalate)
- Fever, rigors or hypotension: cholangitis. Sepsis protocol now (Sepsis), same-day imaging, drainage plan.
- Confusion, flap or INR >1.5: acute liver failure or decompensation. Registrar now.
- Paracetamol overdose or excess dosing, including staggered or late: level, treat on poisons advice.
- Pregnant or postpartum: HELLP, acute fatty liver. Call obstetrics.
- Haematemesis or melaena: upper GI bleed pathway.
- Known cirrhosis with new ascites, encephalopathy or AKI: decompensation. If there is ascites, diagnostic tap without delay to rule out SBP.
๐ Basics
- Visible from about 40 to 50 ยตmol/L. Normal <21 ยตmol/L.
- Unconjugated: haemolysis or Gilbert. Conjugated: hepatocyte injury or bile not draining.
- Four questions: septic or failing? conjugated? ducts dilated? what did they take?
๐ History
- Tempo: days with pain (stones), weeks with weight loss (mass), hours after overdose (paracetamol).
- Dark urine and pale stools: conjugated. Pruritus: cholestasis.
- Alcohol: standard drinks per week, last drink, previous withdrawal. Pint of beer 2, bottle of wine 7 to 8, bottle of spirits 22.
- Every drug in the last 3 months, including herbal and gym supplements. Usual culprits: co-amoxiclav, flucloxacillin, nitrofurantoin.
- Viral risk: travel, injecting, sexual history, tattoos, transfusion.
- Family history, previous biliary surgery or ERCP, IBD, pregnancy.
๐ฉบ Examination
- Encephalopathy grade, flap, fetor, temperature, haemodynamics.
- Chronic liver disease stigmata: spider naevi, palmar erythema, gynaecomastia, caput medusae.
- Abdomen: tender hepatomegaly, Murphy sign, painless palpable gallbladder (Courvoisier), splenomegaly, ascites.
- Bruising, scratch marks, lymphadenopathy. Urine dip: bilirubin positive means conjugated.
๐งช Investigations
FBC, film, reticulocytes
- Looking for
- Haemolysis, alcohol, hypersplenism
LFTs with split bilirubin, albumin
- Looking for
- Conjugated vs not; ALT vs ALP pattern
INR
- Looking for
- Synthetic function; >1.5 with encephalopathy is ALF
U&E, glucose, lactate, gas
- Looking for
- Hepatorenal AKI, hypoglycaemia, acidosis
Paracetamol level, lipase, CRP, cultures
- Looking for
- In every unexplained acute hepatitis
Haemolysis screen
- Looking for
- LDH, haptoglobin, DAT if unconjugated
Liver screen
- Looking for
- Hepatitis A, B, C (antibody, reflex RNA), E, EBV, CMV; autoimmune screen; ferritin and transferrin saturation; caeruloplasmin if <40
ฮฒhCG
- Looking for
- Anyone who could be pregnant
Ultrasound within 24 h
- Looking for
- Ducts dilated or not. Then MRCP or CT pancreas
| Test | Looking for |
|---|---|
| FBC, film, reticulocytes | Haemolysis, alcohol, hypersplenism |
| LFTs with split bilirubin, albumin | Conjugated vs not; ALT vs ALP pattern |
| INR | Synthetic function; >1.5 with encephalopathy is ALF |
| U&E, glucose, lactate, gas | Hepatorenal AKI, hypoglycaemia, acidosis |
| Paracetamol level, lipase, CRP, cultures | In every unexplained acute hepatitis |
| Haemolysis screen | LDH, haptoglobin, DAT if unconjugated |
| Liver screen | Hepatitis A, B, C (antibody, reflex RNA), E, EBV, CMV; autoimmune screen; ferritin and transferrin saturation; caeruloplasmin if <40 |
| ฮฒhCG | Anyone who could be pregnant |
| Ultrasound within 24 h | Ducts dilated or not. Then MRCP or CT pancreas |
๐ Management
- Fever, rigors or hypotension: complete the HSE sepsis screen and Sepsis 6 now (Sepsis). Probable sepsis: IV antibiotics within 1 h per your hospital antimicrobial guideline (AMRIC app). Then source control.
- Obstructed and infected: ERCP within 12 h if septic shock, 48 to 72 h if moderate, elective if mild.
- Paracetamol: 4 h level on the nomogram. Treat before the level if staggered or time unknown, or if >8 h since a dose over 150 mg/kg. After 24 h, treat if jaundiced, ALT raised or paracetamol detectable. SNAP regimen and stopping rules on emed.ie or your hospital protocol; advice from NPIC (01 809 2566).
- Alcohol: IV thiamine before glucose, CIWA-Ar, check Mg and PO4. Benzodiazepines can precipitate encephalopathy: senior input if liver impairment is severe.
- Decompensated cirrhosis: bloods, cultures, ascitic tap, ultrasound, lactulose. Albumin, terlipressin and SBP antibiotics: senior decision on the same shift.
- Itch: colestyramine 4 g OD to BD. Raised INR with cholestasis: vitamin K 10 mg IV OD for 3 days.
- Encephalopathy: lactulose 20 to 30 ml QDS for 2 soft stools a day, no sedatives, treat the precipitant.
- Hepatitis A, B, C and E are notifiable to the Medical Officer of Health.
โ ๏ธ Prescribing
- Paracetamol: 1 g TDS max in compensated cirrhosis or alcohol use disorder; 1 g BD if decompensated; 15 mg/kg QDS under 50 kg.
- No NSAIDs in cirrhosis. Small doses of opioids and benzodiazepines, reviewed early.
- Prophylactic LMWH unless actively bleeding or platelets <50. A raised INR does not protect against VTE.
๐ Escalation
- Medical registrar now: fever, encephalopathy, INR >1.5, AKI or paracetamol.
- Gastro or hepatology: ERCP, acute liver failure, alcohol-related hepatitis, decompensation. HPB surgery: stones and masses.
- Acute liver failure: discuss early with the National Liver Transplant Unit, St Vincent's, via hepatology. Do not wait for King's criteria.
- Painless obstructive jaundice: no national rapid-access pathway. CT in hospital and a named HPB or hepatology follow-up before discharge.
- NPIC clinician line: 01 809 2566 or 01 837 9964, 24 h.
Based on
HSEHPSC: Hepatitis A (case definition and notification)HSEHPSC: Hepatitis B (case definition and notification)HSEHPSC: Hepatitis E (notifiable since December 2015)NCECHepatitis C Screening, National Clinical Guideline No. 15 (July 2017)HSEPatient Safety Supplement: Paracetamol dosing for patients under 50 kg (with SVUH hepatology) (May 2026)GuidelineNational Poisons Information Centre (Beaumont): information for health professionalseMed.ieParacetamol overdose in adults (SNAP acetylcysteine) (reviewed Oct 2026)GuidelineBSG: Guidelines on the management of abnormal liver blood tests (Newsome et al, Gut 2018;67:6-19) (2017, reviewed Dec 2021)
Note Template
Ready-to-use clinical note structure
๐ 08 / 11 / 2026 โ 16:30 ATRP re: jaundice Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [liver disease / gallstones / alcohol / IBD / malignancy] ๐งพ Hx: โข Onset: [days / weeks] Pain: [RUQ / none] Fever or rigors: [yes / no] โข Urine: [dark / normal] Stools: [pale / normal] Pruritus: [yes / no] โข Alcohol: [standard drinks per week, last drink] โข Drugs in last 3 months (incl. OTC, herbal): [list] Paracetamol: [any / none] โข Risk factors: [travel / IVDU / sexual / transfusion / family history] ๐ฉบ Exam: โข HR: __ BP: __ Temp: __ RR: __ SpOโ: __ โข Encephalopathy: [none / grade __] Flap: [yes / no] โข Abdo: [tender RUQ / hepatomegaly / splenomegaly / ascites / palpable GB] โข Stigmata of CLD: [yes / no] Bruising: [yes / no] ๐งช Results: โข Bilirubin __ (conjugated __) ALT __ ALP __ GGT __ Albumin __ INR __ โข Pattern: [hepatocellular / cholestatic / mixed / unconjugated] โข Paracetamol level: __ Lipase: __ Cultures: [sent / not sent] โข USS: [ducts dilated / not dilated / pending] ๐ Impression: [cholangitis / CBD stone / alcohol-related hepatitis / DILI / viral hepatitis / malignancy / decompensated cirrhosis / haemolysis] ๐ Plan: โข If febrile: sepsis pathway, cultures, IV antibiotics per hospital antimicrobial guideline, fluids โข Liver screen and haemolysis screen as indicated; USS within 24 h โข Paracetamol: level and SNAP acetylcysteine per emed.ie or hospital protocol; NPIC 01 809 2566 โข If decompensated cirrhosis: ascitic tap, cultures, lactulose, senior review on the same shift โข Discuss with gastro / hepatology or HPB re: [ERCP / admission / transplant unit] โข Stop suspect drugs; notify public health if viral hepatitis confirmed ๐ค [Your Name], [Role] IMC: _______
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