Jaundice

Hyperbilirubinemia
B1>B2

B1<B2
Hepatocellular/ Cholecysta:c

Pre-hepa:c

AlkPhos, AST/ALT, g-GT

AlkPhos, AST/ALT, g-GT

Cholecysta:c
Congenital defect

Hemolysis

Hepatocellular
Check

Bilirubin >20mg/dL Bilirubin 6mg/dL

B1=100%
B1>90%

present

Gilberts
syndrome
Consider
RBC:
B-thalassemia
Sickle cell disease
Hereditary spherocytosis
G6PD deciency
Hypersplenism
Autoimmune hepa::s
ABO incompa:bility

WBC:
Malaria

Normal albumin and PTT

absent

Consider:
drug toxicity
hematoma

present

Albumin and PTT

Blood lm analysis for abnormali:es

Crigler-Najan
syndrome

Ultrasound for presence of dilated ducts

Extrahepa:c Cholestasis

Recheck ALT/AST
Elevated, <300UI

Consider

AST:ALT>2

Check
Chronic Hepatocellular
disease

Pa:ent History
Age
Sexual Ac:vity
Medica:ons (Drug-induced liver
damage)
Serologic Markers
IgMAn:-HAV (Hepa::s A)
HbsAg and IgM An:-HBV (Hepa::s B)
An:-HCV (Hepa::s C)
SMA ANA (Autoimmune disease)
Ceruloplasmin (Wilsons disease)

Intrahepa:c Cholestasis

Low albumin, high PTT

CT/ERCP

Acute
Hepatocellular
disease

absent

Check

Sexual ac:vity of pa:ent

Serologic Markers
HbsAg and IgM An:-HBV (Hepa::s
B)
An:-HCV (Hepa::s C)
SMA ANA (Autoimmune disease)
Ceruloplasmin (Wilsons disease)
Fe satura:on (Haematochromasis)
Ultrasound (Fibrosis)

Alcoholic liver
diseases/Cirrhosis
Check

Alcohol intake
(alcoholic liver
disease)
-an: trypsin
(cirrhosis)

Malignant
Cholangiocarcinoma
Pancrea:c cancer
Gallbladder cancer
Ampullary cancer
Malignant
involvement of the
porta hepa:s lymph
nodes

Benign
Choledolithiasis
Post-op biliary
structures
Primary sclerosing
cholangi:s
Chronic pancrea::s
AIDS cholangiopathy
Mirfzzis syndrome
Parasi:c disease
(ascariasis)

Serologic tes:ng
AMA
Hepa::s serologies
Hepa::s A, CMV, EBV
Drugs
Results posi:ve

Results nega:ve

MRCP
Liver biopsy

Liver biopsy

Consider
Viral hepa::s
Alcoholic hepa::s
Drug toxicity
Chloropromazine
Erythromycin estolate
Prochloroperazine
Primary biliary cirrhosis
Primary sclerosing
cholangi:s
Vanished bile duct
syndrome
Inherited
Cholestasis of pregnancy
Total parenteral nutri:on

Non-hepatobiliary sepsis
Benign post-opera:ve
cholestasis
Paraneoplas:c syndrome
Veno-occlusive disease
Grae-vs-host disease
Inltra:ve disease
Infec:ons
Malaria
Leptospirosis
(serological assays MAT
and ELISA)