Reasoning GP · Algorithm · 1-page summary
Jaundice in adults — new presentation
For: adults with new jaundice or a raised bilirubin in primary care. Not for: babies (neonatal jaundice algorithm); abnormal LFTs without jaundice (abnormal LFTs algorithm). Pregnancy → blocks 0 and 2.
Core rule: jaundice is a symptom, not a diagnosis — exclude liver failure, cholangitis and paracetamol first; at 40 or over, jaundice alone meets the pancreatic suspected cancer pathway, whatever the scan shows.
0Stop — call 999 now — do not wait for outpatient imaging
- Suspected acute liver failure — prolonged INR plus new confusion, drowsiness or asterixis, hypoglycaemia, acidosis or rapidly worsening jaundice → 999 + urgent liver or critical-care discussion.
- Cholangitis with hypotension, confusion, severe sepsis or hypoxia · shock · active GI bleeding → 999
- Any suspected paracetamol overdose → ED now (999 if unwell) + TOXBASE/NPIS. Late, uncertain-timing or staggered: do not delay acetylcysteine for bloods.
- Pregnant and unstable, confused, bleeding or severely unwell (acute liver failure, HELLP, AFLP) → 999
1Where is the block? — split bilirubin + LFT pattern
| Pre-hepatic | Unconjugated, LFTs usually normal, no dark urine; anaemia, splenomegaly → haemolysis screen |
| Hepatitic | ALT >3× ULN, ALP <3× ULN (often >10× in acute) → virology, autoimmune screen |
| Cholestatic | ALP >3× ULN + GGT, ALT <3× ULN; pale stools, dark urine, itch → ultrasound |
| Mixed | Both raised. Suspected DILI: R-ratio ≥5 hepatocellular, 2–5 mixed, ≤2 cholestatic |
| Caution | Conjugated bilirubin is not synonymous with obstruction |
2Screen — one row is enough
- Fever or rigors + RUQ pain + jaundice (cholangitis) → Same-day hospital, not outpatient ultrasound.
- Jaundice at 40 or over, with or without weight loss → Suspected cancer pathway pancreatic (NG12). Do not wait for imaging.
- Obstruction or duct dilatation at any age → Urgent HPB assessment; pancreatic-protocol CT before biliary drainage unless drainage is urgent (NG85).
- Coagulopathy, renal dysfunction, fever, significant pain, rapidly rising bilirubin, poor intake, decompensation → Same-day ED; no single bilirubin or INR number decides.
- Suspected alcoholic hepatitis · spontaneous bruising or GI bleed → Same-day ED; steroids are specialist-only.
- Pregnant → Same-day obstetric or medical assessment.
3Assess
☐ Obs, confusion, asterixis ☐ Courvoisier, liver, spleen, ascites, stigmata of chronic liver disease, nodes ☐ Drugs, OTC and herbal in 3 months; alcohol units; travel, blood-borne virus risk
☐ Split bilirubin, ALT, AST, ALP, GGT, albumin, INR, FBC, U&E, glucose; CRP if infection ☐ Unexplained: ultrasound, HBsAg, HCV antibody, ferritin + transferrin saturation, AMA, ANA, ASMA, immunoglobulins; acute: hepatitis A IgM, hepatitis E ☐ Haemolysis: film, reticulocytes, haptoglobin, LDH, Coombs'
Not: CA 19-9 without imaging evidence of malignancy; CEA or AFP without specialist advice.
4Classify — once urgency is settled
- Gilbert's — isolated unconjugated, normal ALT, ALP, GGT, albumin, INR, haemolysis excluded → reassure, no monitoring.
- Haemolysis — reticulocytes and LDH up, haptoglobin low → haematological work-up.
- Drug-induced — new drug in 3 months (co-amoxiclav, nitrofurantoin, statin, herbal) → stop if non-essential; jaundice → urgent specialist; Yellow Card.
- Viral, autoimmune — HBsAg or HCV RNA positive; autoantibodies with pattern or raised IgG → block 6.
- Obstructive — gallstones (colicky RUQ pain), stricture, PSC, cancer → ultrasound; MRCP via HPB if non-diagnostic.
- Uncertain — not improving at 4 weeks or static at 3 months → escalate the referral.
5Treat today
- Remove injury: stop suspected non-essential drug; avoid NSAIDs and sedatives; tailor paracetamol dose.
- Alcohol: thiamine if at risk; no abrupt stopping in dependence without assisted withdrawal; alcohol services.
- Cholestatic itch: colestyramine 4–8 g daily, other medicines well apart, as the SPC directs; rifampicin only on specialist advice. Doses: NICE/SPC, BNF, local formulary.
- Stable, selected: repeat LFTs + FBC in 1–2 weeks — never instead of urgent referral.
6Refer routinely
- 1–2 weeks cholestatic LFTs + normal ultrasound (PSC, PBC) · HBsAg or HCV RNA positive · supported autoantibodies.
- Routine stable chronic viral hepatitis · haemochromatosis · Wilson's · stable PBC · LFTs abnormal >6 months.
- Cirrhosis: ultrasound every 6 months ± AFP (NG50); hepatitis A and B vaccines.
7Never reassure by
- A normal ultrasound — it does not exclude pancreatic cancer.
- No weight loss or no pain at 40 or over.
- Falling LFTs — malignancy or obstruction still possible.
- "Gilbert's" before haemolysis is excluded.
- A raised INR read as "just liver" before anticoagulants and vitamin K are considered.
- A single bilirubin or INR number.
8Safety-net — say it, give it in writing, document it
999 “Call 999 for confusion or drowsiness, vomiting blood or black stools, severe abdominal pain, marked pallor or collapse.” Same day “Contact us the same day if the yellowing deepens, you get a fever, cannot eat or drink, bruise without injury or your abdomen swells.”
Then: confirm the specialist appointment is made; repeat LFTs to track the trend; static or rising → escalate.
✓Safe to leave primary care only if — all five, documented
No block 0–2 trigger: no fever, confusion, coagulopathy or bleeding
Split bilirubin, LFTs, INR, FBC done; pattern named
Aged 40 or over → pancreatic pathway referral sent
Drugs, supplements, alcohol and pregnancy reviewed
Recheck date and referral chase set; safety-net given
Summary of the full Reasoning GP jaundice algorithm, which holds the history, examination, investigations, treatment by cause and follow-up. Sources: NICE NG12 (updated April 2026), NG85, NG50, NG49; BSG guidance. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.