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.