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We are really grateful to Trudie Pestell for sharing this fabulous education initiative that she has been producing for University Hospital Southampton Emergency Department for a while.

Each week we will bring you some clinical pearls to add in to your knowledge and understanding and also link to other resources.


Jaundice refers to a clinical sign – yellowing of the skin/sclera/mucous membranes, caused by bile pigment deposition


The body metabolises RBC after 120 days. Initially, the red cells are broken down into globin and biliverdin by the spleen. From here, the biliverdin is reduced to unconjugated bilirubin, which then travels to the liver, bound to albumin. The liver enzymatically converts the unconjugated bilirubin to conjugated bilirubin. This then gets excreted in the bile into the small intestine. Further excretion occurs in the faeces, and in the urine resulting in Jaundice can be broken down into pre-hepatic, intra-hepatic and post hepatic

Increased red blood cell destruction

  • Malaria
  • Transfusion reaction
  • Sickle cell anaemia
  • Haemolytic anaemic syndrome
  • Spherocytosis
  • Haemolytic anaemia

Anything which affects the liver’s functioning

  • Alcohol
  • Drugs – paracetamol, flucloxacillin, steroids
  • Hepatitis
  • Leptospirosis
  • Wegener’s, Wilson’s, Gilbert’s
  • Primary biliary cirrhosis
  • Neonatal jaundice
  • Obstetric cholestasis

Anything that impairs excretion or causes obstruction after the liver

  • Cancer
  • Strictures
  • Pancreatitis
  • Primary schlerosing cholangitis
  • Gallstones
  • Drugs – amitryptiline, co-amoxiclav, verapamil

Important features in the History

  • Drug history and occupation
  • Alcohol intake
  • Tattoos and intravenous drug use
  • Risk factors for HIV
  • Needlestick injuries
  • Recent transfusion
  • Recent foreign travel

Remember to ask…

  • Stool and urine colour
  • Family history
  • Weight loos and night sweats
  • Itching and rashes


  • Stool and urine colour
  • Family history
  • Weight lose and night sweats
  • Itching and rashes

Investigations (if history indicates)

  • Full blood count, blood film
  • Liver function tests, amylase, transferrin, GGT, paracetamol level
  • Coagulation screen
  • Urinalysis for bilirubin
  • Pregnancy test
  • Abdominal ultrasound
  • CT scan Acute liver failure – nystagmus, ataxia, asterixis

First follow the ABC of resuscitation – they may well be very unwell, with signs of sepsis or even septic shock.

Each cause will need its own specific treatment, and some patients may even be able to be managed as an outpatient.

The case of runner’s tummy pain

The beginning:

A 40 year old female, who is a keen runner, attends your ED with a day history of increasing abdominal pain and nausea which started after her half marathon yesterday. She has now started vomiting and complains of increased distension. 

Her observations are currently all within the normal range.

As she hasn’t passed faltus for some time and her abdomen is distended an abdominal Xray was performed

This is a caecal volvulus. There is a great article about this here