Pre-hepatic jaundice due to haemolysis

Suggested by: jaundice and anaemia (the combination often seen as ‘lemon’ or pale yellow). Normal dark stools and normal looking urine.
	Confirmed by: ↑(unconjugated and thus insoluble) serum bilirubin but normal (conjugated and thus soluble) bilirubin and in turn no bilirubin in urine. Evidence of haemolysis as: ↑urinary urobilinogen and ↓serum haptoglobin. ↑Reticulocyte count. Normal liver function tests, Hb↓.

Some differential diagnoses and typical outline evidence

Hereditary haemolytic anaemia	Suggested by: family history, anaemia, splenomegaly, leg ulcers.
	Confirmed by: above evidence of haemolysis, ↑osmotic fragility; enzyme deficiency e.g. G6PD, pyruvate kinase.
	Management: OHCM pp624, 636, 638.
Acquired haemolytic anaemia	Suggested by: sudden onset, in later life, and on medication.
	Confirmed by: above evidence of haemolysis, blood film, +ve Coombs’ test in autoimmune type.
	Management: OHCM pp624, 636, 638.
Septicaemic haemolysis due to pneumonia, UTI, etc	Suggested by: fever, ± shock symptoms and signs of infection.
	Confirmed by: evidence of haemolysis, blood culture positive.
	Management: OHCM pp624, 636, 638.
Malaria	Suggested by: recent travel to malaria zone, periodic paroxysms of rigors, fever, sweating, nausea.
	Confirmed by: Plasmodium in blood smear.
	Management: OHCM pp549, 560–3