Jaundice in an adult
Jaundice is always a sign of something else. The question at first-level care is not the exact virus but the type of jaundice, whether the liver is failing, and whether malaria, a medicine or a blocked bile duct needs action today.
- Setting: Health centre in a peri-urban settlement with seasonal malaria and an unreliable piped water supply
- For clinical officers, nurses and doctors at first-level facilities
- Reviewed October 2026
The presentation
Samuel, 34, a mechanic, noticed his eyes were yellow 5 days ago. For about a week before that he felt as if he had flu: tired, aching, off his food and nauseated. His urine is dark like tea. He has a dull ache under the right ribs.
| Vital sign | Value |
|---|---|
| Temperature | 37.6 °C |
| Pulse | 84 per minute |
| Blood pressure | 124/78 mmHg |
| Breathing rate | 16 per minute |
| Conscious level (AVPU) | Alert |
Tests at hand: Malaria rapid diagnostic test (RDT) · Blood glucose (finger-prick) · Haemoglobin (Hb) · Urine dipstick · HIV rapid test
- Acute viral hepatitis (A, B, C, E)Still possible
- Severe malaria with jaundice Must not missStill possible
- Acute liver failure Must not missStill possible
- Blocked bile duct with infection (cholangitis) Must not missStill possible
- Liver injury from medicines, herbs or toxinsStill possible
- Alcohol-related liver diseaseStill possible
- Haemolysis (sickle cell disease, G6PD deficiency)Still possible
- Liver or pancreatic cancerLess likely
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
Before the history: is Samuel in danger? What do you check first?
Model answer
Do the quick check: airway, breathing, circulation, conscious level. Then look for the dangers that come with jaundice: shock, severe anaemia, confusion or drowsiness (liver failure or cerebral malaria), bleeding from gums or puncture sites, and low glucose.
He is alert and talking, his pulse and BP are normal and he walked in. He is not an emergency now. If he had abdominal pain with fever and rigors, cholangitis would need same-day attention.
TipLook at the sclerae in daylight. In dark skin, the mucosa under the tongue also shows jaundice.Differential now- Acute viral hepatitis (A, B, C, E)Still possible
- Severe malaria with jaundice Must not missStill possible
- Blocked bile duct with infection (cholangitis) Must not missStill possible
- Liver injury from medicines, herbs or toxinsStill possible
- Alcohol-related liver diseaseStill possible
- Haemolysis (sickle cell disease, G6PD deficiency)Still possible
- Acute liver failure Must not missLess likely (moved down)
- Liver or pancreatic cancerLess likely
- Step 2 of 7 · Ask
Which questions point to each type of cause? Name the ones that change what you do.
Model answer
- Illness before the jaundice: fever, poor appetite and nausea first suggests viral hepatitis.
- Other people with yellow eyes nearby, and the drinking water (hepatitis A and E spread through contaminated water and food).
- Blood transfusion, injections, tattoos, shared needles, sexual partners (hepatitis B and C, HIV).
- Fever and travel in malaria areas.
- Every medicine in the last 3 months: TB treatment, ART, painkillers including paracetamol, traditional remedies, herbal teas.
- Alcohol: how much and for how long.
- Pale stools, itching and colicky pain after food (bile duct blockage); weight loss and night sweats (TB or cancer).
- Known sickle cell disease or previous episodes of jaundice with anaemia (haemolysis).
Three neighbours in the same block have had yellow eyes in the past month; the water has been off and people are using a nearby stream. No transfusion, injections or tattoos; one regular partner. No high fevers. He took paracetamol for the aches for 4 days, no other medicines or herbs. He drinks on Saturdays only. Stools paler than usual; mild itch. No weight loss. No sickle cell disease.
Differential now- Acute viral hepatitis (A, B, C, E)Leading (moved up)
- Severe malaria with jaundice Must not missStill possible
- Blocked bile duct with infection (cholangitis) Must not missStill possible
- Acute liver failure Must not missLess likely
- Liver injury from medicines, herbs or toxinsLess likely (moved down)
- Alcohol-related liver diseaseLess likely (moved down)
- Haemolysis (sickle cell disease, G6PD deficiency)Less likely (moved down)
- Liver or pancreatic cancerSet aside for now (moved down)
- Step 3 of 7 · Look
What do you look for on examination, and what does each sign suggest?
Model answer
- Liver: size, tenderness, consistency. Tender and smooth suggests hepatitis; hard and irregular suggests a tumour.
- A palpable gall bladder (obstruction); spleen (malaria, haemolysis, portal hypertension).
- Signs of chronic liver disease: palmar erythema, spider naevi, ascites, swollen ankles, enlarged breasts in men.
- Signs of liver failure: confusion, slurred speech, flapping tremor, bruising or bleeding.
- Pallor (haemolysis, malaria, bleeding), lymph nodes and mouth thrush (HIV).
Deep yellow sclerae. The liver edge is 2 cm below the ribs, smooth and tender. No palpable gall bladder or spleen. No signs of chronic liver disease. Alert and oriented, no flapping tremor, no bruising. Not pale.
Differential now- Acute viral hepatitis (A, B, C, E)Leading
- Severe malaria with jaundice Must not missStill possible
- Acute liver failure Must not missLess likely
- Blocked bile duct with infection (cholangitis) Must not missLess likely (moved down)
- Liver injury from medicines, herbs or toxinsLess likely
- Haemolysis (sickle cell disease, G6PD deficiency)Less likely
- Alcohol-related liver diseaseSet aside for now (moved down)
- Liver or pancreatic cancerSet aside for now
- Step 4 of 7 · Test
You have a malaria RDT, glucose, haemoglobin, a urine dipstick and an HIV test. What does each one tell you here?
Model answer
- Malaria RDT: in a malaria area, jaundice with a positive test may be severe malaria. WHO counts jaundice as a sign of severity when it comes with a high parasite count, which a health centre cannot measure, so a positive test with jaundice is treated as possible severe malaria.
- Glucose: low glucose is a sign of severe liver disease (and of severe malaria).
- Haemoglobin: a low Hb with jaundice suggests haemolysis or malaria; a normal Hb makes them less likely.
- Urine dipstick: bilirubin in the urine means conjugated bilirubin, as in hepatitis and obstruction. In haemolysis the urine shows urobilinogen but little bilirubin.
- HIV test, with consent: hepatitis B and C share routes with HIV, and HIV changes the causes to consider.
Results: RDT negative. Glucose 5.2 mmol/L. Hb 13.8 g/dL. Urine: bilirubin 2+, urobilinogen normal, no protein. HIV test negative.
Differential now- Acute viral hepatitis (A, B, C, E)Leading
- Acute liver failure Must not missLess likely
- Blocked bile duct with infection (cholangitis) Must not missLess likely
- Liver injury from medicines, herbs or toxinsLess likely
- Severe malaria with jaundice Must not missSet aside for now (moved down)
- Alcohol-related liver diseaseSet aside for now
- Haemolysis (sickle cell disease, G6PD deficiency)Set aside for now (moved down)
- Liver or pancreatic cancerSet aside for now
- Step 5 of 7 · Do
Classify the jaundice. What is the most likely cause, and what can you not tell at the health centre?
Model answer
This is hepatic jaundice: a prodrome of malaise, poor appetite and nausea, then jaundice with dark urine and a tender, smooth, enlarged liver, normal Hb and bilirubin in the urine. Pale stools and itch can occur in hepatitis as well as in obstruction.
The likely cause is acute viral hepatitis. A cluster of cases in people sharing contaminated water points to hepatitis A or E. Hepatitis B is still possible: symptoms cannot tell the viruses apart; only blood tests can.
There is no specific antiviral treatment for acute hepatitis A, B or E. Care is supportive. Paracetamol is unlikely to have caused this at the doses he took, but it is a medicine to avoid while the liver is inflamed.
Differential now- Acute viral hepatitis (A, B, C, E)Leading
- Acute liver failure Must not missLess likely
- Severe malaria with jaundice Must not missSet aside for now
- Blocked bile duct with infection (cholangitis) Must not missSet aside for now (moved down)
- Liver injury from medicines, herbs or toxinsSet aside for now (moved down)
- Alcohol-related liver diseaseSet aside for now
- Haemolysis (sickle cell disease, G6PD deficiency)Set aside for now
- Liver or pancreatic cancerSet aside for now
- Step 6 of 7 · Do
Does Samuel need admission? What is the plan?
Model answer
He has no sign of liver failure, is eating a little, drinking well and has no other danger sign. Most people with acute viral hepatitis recover at home. He can be managed as an outpatient with review.
- Rest as needed, regular small meals, plenty of safe fluids.
- No alcohol. Avoid unnecessary medicines that can harm the liver, including paracetamol, and traditional remedies.
- Send a blood sample, or refer as an outpatient, for hepatitis B surface antigen and hepatitis C antibody when the service is available: a positive result changes long-term care and contact testing.
- Hygiene: hand washing with soap after the toilet and before food; boil or treat drinking water.
- Report the cluster of jaundice cases to the district surveillance officer: it may be an outbreak of hepatitis E or A linked to the water.
Pregnant women at homeHepatitis E can cause acute liver failure in pregnancy, especially in the second and third trimesters. Ask whether any woman in the household is pregnant; a pregnant woman with jaundice should be referred. - Step 7 of 7 · Ask
When should he come back, and what do you tell him?
Model answer
- Review in 2 to 3 days, then weekly until the jaundice is fading.
- Come back at once if he becomes confused, very sleepy or behaves strangely; bleeds from the gums or nose, vomits blood or passes black stool; vomits everything; or has high fever with severe pain under the right ribs.
- Jaundice usually fades over a few weeks. Fatigue can last longer.
Your liver is inflamed, most likely from a virus in the water. It usually gets better by itself in a few weeks. Do not drink alcohol or take any medicines without asking us. Come back straight away if you become confused, very sleepy or start bleeding.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Severe malaria | Fever and jaundice in a malaria area; positive RDT; pallor, prostration, confusion, dark urine, low glucose. | Pre-referral artesunate, treat low glucose, refer urgently. |
| Acute liver failure | Jaundice with confusion, drowsiness, flapping tremor, bleeding or low glucose; pregnancy (hepatitis E). | Treat low glucose, avoid sedatives, refer now. |
| Cholangitis (infected blocked bile duct) | Jaundice with fever, rigors and right upper abdominal pain; tender liver. | IV fluids if needed, first dose of antibiotic, refer the same day for ultrasound and surgical review. |
| Medicine-induced liver injury | Jaundice after starting TB treatment, nevirapine, efavirenz or another new medicine; herbal remedies. | Stop the suspected medicine (for TB or HIV treatment, discuss with the treating clinic the same day) and refer. |
Decision at first-level care
Samuel has hepatic jaundice from probable acute viral hepatitis, most likely hepatitis A or E linked to contaminated water, with no sign of liver failure, malaria or obstruction. He is managed at home with supportive care, no alcohol or unnecessary medicines, hepatitis B and C testing when available, review in 2 to 3 days and clear return advice. The cluster is reported to surveillance.
Source: IMAI district clinician manual, volume 2 (2011); WHO fact sheets on hepatitis E and hepatitis B (2026).
- Jaundice is rarely treated without referral or review at first-level care; a positive malaria test with jaundice goes to the referral column.
- Known chronic hepatitis B on a treatment programme with a mild flare: continue treatment, discuss with the clinic.
- Hepatic jaundice with a viral prodrome, alert, eating and drinking, normal glucose, no bleeding: home care and review in 2 to 3 days.
- Mild jaundice in known Gilbert's or sickle cell pattern, otherwise well: review.
- Any sign of liver failure (confusion, drowsiness, bleeding, low glucose): now.
- Jaundice with a positive malaria test or signs of severe malaria: after pre-referral artesunate, now.
- Fever, rigors and right upper quadrant pain (cholangitis): the same day.
- Pregnant women with jaundice.
- Jaundice on TB treatment or ART.
- Painless jaundice with weight loss, a hard liver or a palpable gall bladder: for investigation.
Key learning points
- Classify jaundice as pre-hepatic (haemolysis, malaria), hepatic (hepatitis, medicines, alcohol) or post-hepatic (obstruction).
- Always test for malaria in a person with jaundice in a malaria area: jaundice with a positive test is treated as possible severe malaria.
- Confusion, drowsiness, bleeding or low glucose with jaundice means liver failure: refer now.
- Ask about every medicine, herb and traditional remedy, and about alcohol.
- Acute viral hepatitis has no specific treatment: supportive care, no alcohol, no unnecessary medicines, and report clusters.
Sources
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 2. 2011. Section 10.8, jaundice: clinical approach, history (contacts, transfusion, medicines including TB drugs, ART, traditional remedies, alcohol), examination, signs of hepatic encephalopathy, classification into pre-hepatic, hepatic and post-hepatic, DDx tables; inspecting under the tongue in dark skin. Section 11.14, viral hepatitis: supportive care, no specific treatment in acute hepatitis B.
- World Health Organization. Hepatitis E: fact sheet. 2026. Faecal-oral spread through contaminated water; prodrome then jaundice, dark urine and pale stools; no specific treatment; avoid unnecessary medicines including paracetamol; fulminant hepatitis and death in pregnancy, especially second and third trimesters.
- World Health Organization. Hepatitis B: fact sheet. 2026. Transmission routes; acute symptoms; viral hepatitis types cannot be told apart clinically; no specific treatment for acute infection; chronic infection and liver cancer.
- World Health Organization. WHO guidelines for malaria (10 September 2026 version). 2026. Jaundice in the definition of severe malaria (bilirubin above 50 µmol/L with a parasite count above 100 000/µL); parasitological testing; pre-referral artesunate.