• Clinical science

Jaundice and cholestasis


Jaundice, or icterus, refers to the yellowish discoloration of tissue caused by accumulated deposits of bilirubin. Bilirubin deposition most commonly occurs in the skin and the sclerae. It results from elevated bilirubin, starting at levels > 2 mg/dL. Hyperbilirubinemia may be of prehepatic, intrahepatic, or posthepatic origin. Prehepatic causes include an accumulation of unconjugated bilirubin; intrahepatic and posthepatic jaundice may be due to cholestasis (i.e., the reduced formation or secretion of bile or extrahepatic biliary obstruction). In addition to jaundice, clinical features can include pruritus, pale stool in cases of intrahepatic or posthepatic cholestasis, and darkening of urine. Diagnosis relies on the analysis of laboratory values for cholestasis, liver function, and hemolysis, as well as ultrasound of the biliary tract. Management of jaundice involves treatment of the underlying condition. In cases of moderate to severe pruritus, medication such as cholestyramine, rifampin, opioid antagonists, or ursodeoxycholic acid may be administered.




Jaundice is not always a sure sign of cholestasis; it may also indicate prehepatic causes. Conversely, cholestasis may be present in the absence of jaundice, particularly during the early stages of cholestasis!

Common causes of hyperbilirubinemia can be remembered with HOT Liver: Hemolysis, Obstruction, Tumor, and Liver disease!

Hepatitis and cirrhosis can cause conjugated or unconjugated hyperbilirubinemia!



Jaundice is due to an elevated level of serum bilirubin, which may be caused by prehepatic, intrahepatic, or posthepatic defects. Serum bilirubin concentration depends on the rate of formation and hepatobiliary elimination of bilirubin.


Clinical features



Liver function tests (LFTs)


Differentiating types of jaundice

Bilirubin Effects
Cause Color of stool Indirect bilirubin Direct bilirubin Bilirubin in urine Urinary urobilinogen

Other significant findings

Prehepatic jaundice Dark ↑↑ Normal Normal ↑↑ (no darkening of urine , but dark urine may occur in the case of hemoglobinuria)

Hemolytic markers


Intrahepatic jaundice Pale, clay-colored (rarely dark) ↑ (dark urine)

Normal or ↑


Cholestatic enzymes

Extrahepatic jaundice Pale, clay-colored Normal ↑↑ ↑↑ (very dark urine) Low

Dilated bile ducts

Cholestatic enzymes


Differential diagnoses

  • Pseudojaundice
    • Deposition of carotene in the skin (carotenoderma) can also cause yellowing and usually occurs following excessive consumption multivitamin supplements or fruits and vegetables rich in carotenes, such as carrots, sweet potatoes, kale, and oranges.
    • In contrast to jaundice, it does not lead to scleral icterus.

The differential diagnoses listed here are not exhaustive.




We list the most important complications. The selection is not exhaustive.