Patient handout

Jaundice (adult)

PRODUCTION

1. Your condition

This handout is for jaundice (adult). Your care team identified this based on: yellow eyes / skin (scleral icterus or jaundice) (acg 2021).

Other reasons your team may use this plan: dark urine + pale stool — cholestasis (bsg 2017); elevated total bilirubin on lfts (acg 2021); rapid-onset jaundice + altered mental status — concern for alf (aasld 2023 / lee 2011 pmid 22213561).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
acetylcysteine	150 mg/kg over 1 h then 50 mg/kg over 4 h then 100 mg/kg over 16 h (21-h IV)	IV	protocol	Standard 21-h IV protocol (Smilkstein NEJM 1988 PMID 3059186); benefit in non-APAP ALF as well (Lee 2011 PMID 22213561)
prednisolone	40 mg PO daily × 28 d	PO	daily; assess Lille at day 7	STOPAH NEJM 2015 PMID 25901427 — 28-day mortality benefit; stop if Lille day-7 >0.45
azathioprine	50-100 mg PO daily titrated	PO	daily	AASLD AIH — steroid-sparing maintenance; check TPMT first (AASLD 2023)
ursodeoxycholic acid	13-15 mg/kg/day	PO	divided BID-TID	EASL/AASLD PBC — first-line; obeticholic acid second-line (EASL 2017 PMID 28427765); URSO for ICP (ACOG 2024)
ceftriaxone	2 g IV	IV	daily	Tokyo TG18 empiric (Kiriyama 2018 PMID 29032610)
metronidazole	500 mg IV	IV	q8h	Empiric anaerobic coverage (Tokyo TG18 PMID 29032610)
piperacillin/tazobactam	4.5 g IV	IV	q6-8h	Tokyo TG18 — broader coverage for grade III / healthcare-associated cholangitis
entecavir	0.5 mg	PO	once daily	AASLD HBV 2018 PMID 29405329
tenofovir_alafenamide	25 mg	PO	once daily	AASLD HBV 2018 PMID 29405329; TAF preferred over TDF for renal/bone
sofosbuvir/velpatasvir	400/100 mg	PO	daily × 12 weeks	AASLD/IDSA HCV pangenotypic regimen
phototherapy	—	—	—	Bhutani nomogram-directed phototherapy thresholds for neonatal hyperbilirubinemia (AAP 2022)
liver_transplant_evaluation	—	—	—	King's College criteria O'Grady 1989 PMID 2490426; MELD-Na ≥15 for listing (AASLD 2023)

Plan: Diagnosis-directed therapy axis (etiology-specific) (AASLD 2023)

3. When to call your provider

Contact your care team if any of the following happen:

New encephalopathy / ascites / variceal bleed → admit (route to gi.cirrhosis.core.v1)
MELD-Na ≥15 → transplant evaluation (AASLD 2023)
HCC nodule on surveillance → hepatology / multidisciplinary tumor board
PBC URSO non-responder at 12 mo → obeticholic acid (EASL 2017 PMID 28427765)
Rising LFT trending toward Hy's Law on any new med → discontinue + admit (Reuben 2010 PMID 20949552)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Direct hyperbilirubinemia + R-factor >5 (ALT/AST ↑↑) — viral hepatitis A/B/C/D/E, autoimmune, ischemic (shock liver), drug-induced (APAP, INH, augmentin), Wilson, hemochromatosis, α1AT, severe NAFLD/MASH (ACG 2021)
Direct hyperbilirubinemia + R-factor <2 (ALP + GGT ↑↑) — extrahepatic obstruction (choledocholithiasis, cholangitis, pancreatic Ca, cholangiocarcinoma, biliary stricture, parasitic) or intrahepatic (PBC, PSC, DILI cholestatic, sepsis-related) (BSG 2017)
Acute liver failure meeting King's College criteria — APAP arm: pH <7.30 OR all of [INR >6.5 + creat >3.4 + grade 3-4 HE]; non-APAP arm: INR >6.5 OR any 3 of 5 [age <10 or >40, non-A-non-B/halothane/DILI, jaundice-to-encephalopathy >7 d, INR >3.5, bilirubin >17.5] (O'Grady 1989 PMID 2490426)(life-threatening)
Acute cholangitis — Charcot triad (jaundice + fever + RUQ pain) ± Reynolds pentad (+ hypotension + AMS); Tokyo TG18 grade I (mild — responds to abx), grade II (moderate — early ERCP 24-48 h), grade III (severe — organ dysfunction, emergent ERCP <6-12 h + ICU) (Kiriyama 2018 PMID 29032610)(life-threatening)
Pregnancy-associated jaundice — HELLP (hemolysis + elevated LFTs + low plt 2nd-3rd trimester), AFLP (acute fatty liver of pregnancy — late 3rd trimester, hypoglycemia + coagulopathy), ICP (intrahepatic cholestasis — pruritus + bile acids >10 µmol/L, 3rd trimester; severe >40) (ACOG 2024)(life-threatening)
Neonatal jaundice — physiologic (T-bili peak day 3-5, resolves by 2 wk) vs pathologic (within 24 h, rising >5 mg/dL/day, T-bili >Bhutani phototherapy threshold for age in hours, conjugated >20% — concern for biliary atresia, sepsis, hemolysis, G6PD, Crigler) (AAP 2022)
Drug-induced liver injury meeting Hy's Law — ALT >3x ULN + total bilirubin >2x ULN without obstruction or alternate cause; >10% mortality / ALF risk (Reuben 2010 PMID 20949552)
Known cirrhosis presenting with new ascites / variceal bleed / hepatic encephalopathy / hepatorenal syndrome / SBP (AASLD 2023)
Maddrey discriminant function ≥32 OR MELD ≥21 in alcoholic hepatitis (STOPAH 2015 PMID 25901427); Glasgow Alcoholic Hepatitis Score (GAHS) ≥9 also indicates severe disease
Painless jaundice + weight loss + dilated ducts + pancreatic head mass / cholangiocarcinoma / metastases on imaging + age >50 (NICE 2024)

5. Follow-up

Hepatology / GI / oncology / transplant evaluation; route decompensated cirrhosis → gi.cirrhosis.core.v1; route HE → gi.hepatic-encephalopathy.core.v1; route APAP → tox.acetaminophen-overdose.core.v1 (AASLD 2023)

6. Sources

Guideline: AASLD ALF Position Paper (Lee 2011) + King's College criteria (O'Grady 1989) + Tokyo Guidelines TG18 (Kiriyama 2018) + APAP NAC IV (Smilkstein 1988) + Hy's Law (Reuben 2010) + AASLD HCC 2018 + MELD-Na (Kim 2008) + STOPAH 2015 + EASL PBC 2017 + AASLD HBV 2018 + LiverTox NIH