Acute jaundice — adult primary care

Red Flags

Acute liver failure (jaundice + coagulopathy + encephalopathy within 26 weeks of symptom onset) — admit; hepatology and transplant centre referral^[1]
Cholangitis (Charcot's triad: jaundice + fever + RUQ pain; Reynolds pentad adds shock + altered mental status) — emergency biliary decompression and broad-spectrum antibiotics^[1]
Painless progressive jaundice with weight loss in older adult — suspect pancreatic or biliary malignancy; urgent imaging^[1]
Pregnancy with new jaundice — exclude HELLP, acute fatty liver of pregnancy, viral hepatitis E (high mortality in pregnancy)^[1]

First-line treatment

Interventions

Identify and treat underlying cause^[1]
Pre-hepatic (haemolysis): treat underlying disorder. Hepatic (viral, alcohol, drug, autoimmune): aetiology-specific. Post-hepatic: relieve obstruction (stone, stricture, mass)
Stop hepatotoxic medications and substances^[1]
Discontinue paracetamol overdose risk, isoniazid, methotrexate, herbal supplements, amoxicillin-clavulanate as feasible; abstain from alcohol
Biliary decompression^[1]
ERCP with stone extraction, sphincterotomy, or stenting for obstructive jaundice; PTC if ERCP fails or proximal obstruction; surgical drainage for malignant obstruction not amenable to endoscopy

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
N-acetylcysteine (paracetamol overdose)^[1]	Hepatic glutathione precursor	150 mg/kg IV over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h (21-h regimen)	Same per kg	Paracetamol toxicity per Rumack-Matthew nomogram; consider in non-paracetamol acute liver failure too (KCH/Wilson criteria)
Ursodeoxycholic acid (selected cholestatic disease)^[1]	Hydrophilic bile acid	13–15 mg/kg/day PO divided BD	—	Primary biliary cholangitis; intrahepatic cholestasis of pregnancy; not a routine treatment for all jaundice
Ceftriaxone + metronidazole (cholangitis)^[1]	Empirical IV antibiotics	Ceftriaxone 2 g IV daily + metronidazole 500 mg IV TID; piperacillin-tazobactam alternative	Per weight	Acute ascending cholangitis; biliary decompression (ERCP, PTC, surgery) is definitive

N-acetylcysteine (paracetamol overdose)^[1]

Hepatic glutathione precursor

Adult: 150 mg/kg IV over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h (21-h regimen)
Paediatric: Same per kg

Paracetamol toxicity per Rumack-Matthew nomogram; consider in non-paracetamol acute liver failure too (KCH/Wilson criteria)

Ursodeoxycholic acid (selected cholestatic disease)^[1]

Hydrophilic bile acid

Adult: 13–15 mg/kg/day PO divided BD
Paediatric: —

Primary biliary cholangitis; intrahepatic cholestasis of pregnancy; not a routine treatment for all jaundice

Ceftriaxone + metronidazole (cholangitis)^[1]

Empirical IV antibiotics

Adult: Ceftriaxone 2 g IV daily + metronidazole 500 mg IV TID; piperacillin-tazobactam alternative
Paediatric: Per weight

Acute ascending cholangitis; biliary decompression (ERCP, PTC, surgery) is definitive

Safety-net

Avoid alcohol completely until cause confirmed and liver tests normalise^[1]
Avoid paracetamol for fever or pain in liver disease — use small doses (≤2 g/day) only if essential; discuss alternatives with clinician^[1]
Worsening confusion, drowsiness, easy bruising, vomiting blood, or black stools — call emergency services (acute liver failure or variceal bleed)^[1]

Referral criteria

Suspected acute liver failure (coagulopathy + encephalopathy)Hepatology and transplant centre same-day^[1]
Cholangitis or sepsis with biliary obstructionEmergency department; ERCP within 24 h^[1]
Painless progressive jaundice with weight lossHepatobiliary surgery and oncology — urgent CT/MRCP^[1]
Persistent unexplained hepatocellular jaundice >2 weeks despite stopping potential triggersHepatology for autoimmune workup, MRI/MRCP, biopsy if needed^[1]

Clinical summary

Initial primary-care evaluation of new jaundice in adults — distinguishing pre-hepatic, hepatic, and obstructive aetiologies with stepped investigations.

References

1.MoHFW Standard Treatment Guidelines — Jaundice; AASLD Practice Guidance on Liver Disease (2021)