Introduction
Jaundice history is a high-yield OSCE station requiring you to systematically distinguish pre-hepatic, hepatic, and post-hepatic causes. The key discriminating questions — urine colour, stool colour, itch, pain, and risk factors — are all heavily marked.
💎 Clinical Pearl
Start open: "Have you noticed any yellowing of your skin or eyes? When did you first notice it?" Then systematically work through the three categories of jaundice.
The Three Types of Jaundice
🧠 Mnemonic
PHP — Pre-hepatic, Hepatic, Post-hepatic
- Pre-hepatic: excess bilirubin production (haemolysis). Unconjugated bilirubin. Urine normal, stool normal, no itch.
- Hepatic: liver cell failure to conjugate or excrete. Mixed picture. Liver disease risk factors key.
- Post-hepatic (obstructive): bile duct obstruction. Conjugated bilirubin in urine. Dark urine, pale stool, itch.
Discriminating Questions
Urine and Stool Colour
| Finding | Suggests |
|---|---|
| Dark urine (Coca-Cola coloured) + pale stool | Post-hepatic (obstructive) jaundice — conjugated bilirubin spills into urine; bile cannot reach gut |
| Normal urine and stool | Pre-hepatic (haemolysis) |
| Dark urine + normal or dark stool | Hepatic jaundice |
Itch (Pruritus)
Intense itch — especially worse at night — strongly suggests obstructive jaundice. Bile salts deposited in skin.
Pain
| Pain pattern | Suggests |
|---|---|
| Severe RUQ colicky pain radiating to right shoulder tip | Gallstone causing biliary obstruction (choledocholithiasis) |
| Painless progressive jaundice | Pancreatic head carcinoma ("painless obstructive jaundice" = cancer until proven otherwise) |
| Dull RUQ ache | Hepatitis, liver congestion, hepatocellular carcinoma |
| No pain | Haemolysis |
⚠️ Red Flag
Painless progressive jaundice in a patient over 50 = pancreatic carcinoma until proven otherwise. Refer urgently.
Systematic History by Category
Pre-Hepatic (Haemolysis)
- Family history of haemolytic anaemia: sickle cell disease, hereditary spherocytosis, G6PD deficiency
- Recent blood transfusion
- Malaria (travel history)
- Pallor, fatigue, dark urine (haemoglobinuria), splenomegaly
Hepatic (Liver Cell Disease)
Infective:
- Travel history: hepatitis A (faeco-oral, travel to endemic areas), hepatitis E
- Sexual history: hepatitis B and C (blood-borne, sexual transmission)
- IV drug use (shared needles): hepatitis B, C
- Tattoos or body piercings (hepatitis B, C)
Toxic / Drug-induced:
- Alcohol history (units per week, CAGE questions) — alcoholic hepatitis, cirrhosis
- Drug history: paracetamol overdose (acute liver failure), statins, methotrexate, isoniazid, antifungals, herbal remedies
Autoimmune / Other:
- Autoimmune hepatitis: young women, associated with other autoimmune diseases
- Primary biliary cholangitis: middle-aged women, itch, fatigue
- Wilson's disease: young patient, psychiatric symptoms, Kayser-Fleischer rings
- Haemochromatosis: skin bronzing, diabetes, arthropathy, cardiomyopathy
Post-Hepatic (Obstructive)
- Gallstones: previous biliary colic, fatty food intolerance, Murphy's sign
- Pancreatic carcinoma: weight loss, back pain (retroperitoneal invasion), new-onset diabetes, steatorrhoea
- Cholangiocarcinoma: PSC risk factors, IBD
- Strictures, pancreatitis
Associated Symptoms Checklist
- Weight loss (malignancy, cirrhosis)
- Fever and rigors (Charcot's triad: jaundice + fever + RUQ pain = ascending cholangitis — sepsis)
- Nausea and vomiting
- Anorexia
- Steatorrhoea (pale, greasy, floating stool that is difficult to flush): fat malabsorption from obstructed bile flow
⚠️ Red Flag
Charcot's triad: RUQ pain + fever + jaundice = ascending cholangitis. Add hypotension and confusion (Reynolds' pentad) = septic shock. Requires emergency ERCP and antibiotics.
Risk Factor Screen
- Alcohol intake (exact units per week; CAGE)
- Travel (hepatitis A, E, malaria)
- Sexual history and IV drug use (hepatitis B, C)
- Blood transfusions before 1991 (hepatitis C risk)
- Family history of liver or haematological disease
- Occupational exposure
How to Present
"This is a 58-year-old man with a 3-week history of progressive painless jaundice, dark urine, and pale stool with intense pruritus. There is associated weight loss of 6 kg over 6 weeks. He has no fever, no pain, no alcohol excess, and no risk factors for viral hepatitis. This presentation is most consistent with post-hepatic obstructive jaundice, and the absence of pain with marked weight loss raises strong concern for pancreatic head carcinoma. I would arrange urgent LFTs, CA 19-9, USS abdomen, and CT pancreas protocol."
"How do you differentiate pre-hepatic, hepatic, and post-hepatic jaundice clinically?"
Pre-hepatic (haemolytic): normal urine and stool colour, no itch, anaemia, splenomegaly. Hepatic: dark urine, may have pale stool, history of liver disease risk factors (alcohol, viral hepatitis, drugs). Post-hepatic (obstructive): dark urine, pale stool, intense itch — bile cannot reach the gut and conjugated bilirubin spills into urine.
"What is Charcot's triad and what does it indicate?"
Charcot's triad is the combination of RUQ pain, fever with rigors, and jaundice. It indicates ascending cholangitis — bacterial infection of the biliary tree, usually caused by obstruction (gallstones, stricture). Adding hypotension and confusion gives Reynolds' pentad, indicating septic cholangitis shock. This is a surgical emergency requiring urgent IV antibiotics and biliary decompression (ERCP).
"What features suggest pancreatic carcinoma in a jaundice history?"
Painless progressive jaundice in a patient over 50, especially with significant unintentional weight loss, new-onset diabetes, back pain (retroperitoneal invasion), steatorrhoea, and a palpable non-tender gallbladder (Courvoisier's sign). The absence of pain distinguishes it from gallstone obstruction.
"What drug history questions are important in a jaundice history?"
Ask specifically about: paracetamol dose and overdose risk (acute liver failure), statins (drug-induced hepatitis), methotrexate (hepatic fibrosis), isoniazid (anti-TB — hepatotoxic), nitrofurantoin, antifungals (fluconazole, ketoconazole), herbal remedies (kava, comfrey), and any recreational drugs. Drug-induced liver injury can mimic any pattern of jaundice.
Related guides: How to Take an Abdominal History OSCE | Abdominal Examination OSCE | Blood Results Interpretation OSCE