The jaundiced patient: a case-based approach

The case: turning yellow

Meet "David", a fictional 58-year-old. Over two weeks his family notice that the whites of his eyes look yellow, and his skin follows. His urine has turned dark, like strong tea, and his stools have gone pale and hard to flush. He feels itchy all over and a bit off his food. He is not in severe pain but has lost a little weight. David books a GP appointment. This picture — visible jaundice with dark urine and pale stools — is a classic pattern that points towards a problem with bile flow rather than simply too many red cells breaking down. The GP knows the yellow colour is a symptom, not a diagnosis, and the real work is finding the cause.

Three main types of jaundice

Doctors group jaundice into three broad types, which helps organise the possible causes. Pre-hepatic jaundice happens when too many red blood cells break down, flooding the system with bilirubin faster than the liver can cope. Hepatic jaundice comes from the liver itself being damaged or inflamed, for example by viral hepatitis, alcohol, or certain medicines. Post-hepatic (or obstructive) jaundice happens when bile cannot drain away, often because a gallstone or a tumour blocks the bile ducts. David's dark urine, pale stools and itching strongly suggest an obstructive picture. Working out which type is present guides every test that follows, so this simple framework is one of the most useful tools a clinician has.

Tests: blood first, then pictures

The first step is blood tests, including liver function tests, a full blood count and clotting. These help separate the three types: the pattern of raised enzymes suggests whether the trouble is in the liver cells or in blocked bile ducts. Blood tests can also screen for hepatitis viruses and check how well the liver is still working. The next step is usually an ultrasound scan of the abdomen, which is painless and can show whether the bile ducts are widened by a blockage, and whether gallstones or a mass are present. If a blockage is confirmed, a more detailed scan such as an MRI of the bile ducts (an MRCP) often follows to map the problem precisely before any treatment.

Diagnosis, treatment and referral

David's ultrasound shows widened bile ducts, and an MRCP reveals a stone lodged where the bile duct meets the bowel. He is referred for an ERCP, a procedure that passes a flexible camera down to the blockage so the stone can be removed and bile can flow again. Once bile drains, the jaundice, itching and dark urine settle. Had the cause instead been hepatitis, treatment would focus on the specific virus or on stopping a triggering medicine or alcohol. Had it been a tumour, referral to a specialist cancer team would follow. The message is that jaundice has many causes, from harmless to serious, and a clear diagnosis turns an alarming symptom into a treatable problem with a definite plan.

When jaundice is an emergency

Some jaundice needs urgent attention. Call 999 or go to A&E if jaundice comes with confusion or drowsiness, vomiting blood, black tarry stools, or severe tummy pain with a high temperature and shivering, which can signal a dangerous infection of the blocked bile system. New jaundice with a swollen tummy, easy bruising or bleeding also needs urgent assessment, because it can mean the liver is failing. In a newborn baby, deepening jaundice, especially in the first day of life or lasting beyond two weeks, always needs prompt medical review. If you or someone else turns yellow, do not ignore it. This article is for education only and cannot diagnose you — if you feel very unwell, call 999 or seek urgent NHS advice.