Obstructive jaundice

Some differential diagnoses and typical outline evidence

	Suggested by: jaundice with pale stools and dark urine. Bilirubin in urine (i.e. conjugated and thus soluble).
	Confirmed by: ↑serum conjugated bilirubin and thus urine bilirubin but no ↑urobilinogen in urine. Markedly (↑↑) alkaline phosphatase, but less abnormal (↑) liver function tests and ↑↑GT.
	Management: OHCM p484.

Some differential diagnoses and typical outline evidence

Common bile duct stones	Suggested by: pain in RUQ ± Murphy's sign.
	Confirmed by: ultrasound liver: dilatation of biliary ducts.
	Management: OHCM pp484, 485.
Cancer of head of pancreas	Suggested by: progressive painless jaundice, palpable gall-bladder (Courvoisier's law), weight loss.
	Confirmed by: ultrasound liver: dilatation of biliary ducts. CT pancreas, ERCP or MRCP: obstruction within head of pancreas.
	Management: OHCM p248.
Sclerosing cholangitis	Suggested by: progressive fatigue, pruritus.
	Confirmed by: ↑ALP. Ultrasound liver: no gallstones. ERCP: (beading of the intra-and extra-hepatic biliary ducts)
	Management: OHCM p238.
Primary biliary cirrhosis	Suggested by: scratch marks, non-tender hepatomegaly, ± splenomegaly, xanthelasmata and xanthomas, arthralgia.
	Confirmed by: +ve anti-mitochondrial antibody, ↑↑serum IgM: infiltrate around hepatic bile ducts and cirrhosis on liver biopsy.
	Management: OHCM p238.
Drug-induced	Suggested by: drug history of oral contraceptive pill, phenothiazines, anabolic steroids, erythromycin, etc.
	Confirmed by: symptoms receding when drug discontinued.
	Management: OHCM p223.
Pregnancy (last trimester)	Suggested by: jaundice during pregnancy.
	Confirmed by: resolution following delivery.
	Management: OHCS p26.
Alcoholic hepatitis or cirrhosis	Suggested by: history of excess alcohol intake, presence of spider naevi and other signs of chronic liver disease.
	Confirmed by: ultrasound or CT liver, liver biopsy, improvement if abstinence.
	Management: OHCM p254.
Dubin–Johnson syndrome (decreased excretion of conjugated bilirubin, see OHCM p722)	Suggested by: intermittent jaundice, and associated pain in the right hypochondrium. No hepatomegaly.
	Confirmed by: normal ALP, normal LFT. ↑urinary bilirubin. Pigment granules on liver biopsy.