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symptom.jaundice.v1PRODUCTION
symptom.jaundice.v1

Jaundice (adult)

symptomacutesubacutechronicundifferentiatedadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm jaundice (scleral icterus, T-bili >2.5 mg/dL); rule out carotenoderma (palms/soles only, no scleral involvement); fractionate bilirubin (direct vs indirect); compute R-factor (ALT/ULN)/(ALP/ULN) — >5 hepatocellular, <2 cholestatic, 2-5 mixed; identify pregnancy phenotype if applicable (ACG 2021; ACOG 2024)

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Pattern + R-factor + bilirubin fractionation classified

Patient inputs (31)

Older adult + painless jaundice = pancreatic/biliary Ca; younger = viral / Wilson / Gilbert / autoimmune (ACG 2021)

PBC strongly female-skewed; PSC male-skewed (EASL 2017 PBC); MELD 3.0 sex-adjusted (Kim 2021)

Alcoholic hepatitis / cirrhosis — chronic use ≥40 g/day or binge episodes (AASLD 2023; STOPAH 2015 PMID 25901427)

DILI: APAP, isoniazid, nitrofurantoin, augmentin, statins, anabolic steroids, methotrexate, valproate, herbals (kava, green tea, chaparral) — LiverTox NIH (Reuben 2010 PMID 20949552)

HAV / HBV / HCV / HEV exposure (AASLD 2023; AASLD HBV 2018 PMID 29405329)

Pregnancy-specific phenotypes — HELLP / AFLP / ICP have distinct management vs general adult workup (ACOG 2024)

Acute (<2 wk — viral / DILI / APAP / cholangitis) vs subacute vs chronic (cirrhosis / PBC / PSC / malignancy) narrows differential (BSG 2017)

Painless = malignancy / PSC; pruritus = cholestasis (PBC, PSC, obstruction, ICP); RUQ pain = stones / cholangitis (Charcot triad) (BSG 2017)

Hemolysis (anemia + retic + low haptoglobin), thrombocytopenia (cirrhosis or HELLP) (ACG 2021)

AST/ALT/ALP/total + direct bilirubin (fractionation) /GGT — R-factor (ALT/ULN ÷ ALP/ULN); >5 hepatocellular, <2 cholestatic, 2-5 mixed (ACG 2021)

Synthetic function — ALF if INR ≥1.5 + encephalopathy (no prior cirrhosis); King's College criterion (O'Grady 1989 PMID 2490426)

Synthetic function (chronic) — Child-Pugh component (AASLD 2023)

Pancreatitis as obstruction cause; gallstone pancreatitis (ACG 2021)

HAV IgM, HBsAg + anti-HBc IgM + HBV DNA, anti-HCV + HCV RNA, HEV IgM (immunocompromised / pregnant / travel) (AASLD 2023; AASLD HBV 2018)

Stones, ductal dilation, mass, cirrhosis morphology, ascites, portal vein flow — first-line (ACG 2021; BSG 2017)

APAP toxic dose >150 mg/kg single ingestion or >4 g/24 h in alcoholic / malnourished; Rumack-Matthew nomogram timing dependent on 4-h post-ingestion level (Smilkstein NEJM 1988 PMID 3059186)

Hemolysis pattern (low haptoglobin + high retic + high LDH + indirect bilirubin + direct Coombs); smear for schistocytes (MAHA, HELLP) (BSG 2017)

AMA for PBC; ANA + ASMA + anti-LKM-1 + IgG for AIH; pANCA for PSC (AASLD 2023; EASL 2017 PBC PMID 28427765)

Wilson if age <40 or family history; serum ceruloplasmin <20 mg/dL + 24-h urine copper >40 µg + slit-lamp K-F rings (AASLD 2023)

α1AT deficiency phenotype (PiZZ) — quantitative + phenotyping (AASLD 2023)

Hemochromatosis — ferritin + transferrin saturation, HFE gene (AASLD 2023)

Total bile acids >10 µmol/L in pregnancy = ICP; >40 = severe (ACOG 2024)

Detail biliary tree if obstruction suspected on US but cause unclear; EUS for distal CBD / pancreatic head (BSG 2017)

Therapeutic biliary decompression — emergent for grade III cholangitis or impacted stone (Tokyo TG18 PMID 29032610)

Pancreatic mass / cholangiocarcinoma / staging (NICE 2024)

Stage fibrosis non-invasively (FibroScan); biopsy for unclear hepatocellular (AIH overlap, drug vs autoimmune) (AASLD 2023)

Wilson / hemochromatosis / α1AT / autoimmune (AASLD 2023)

ICP usually 3rd trimester; AFLP late 3rd; HELLP 2nd-3rd; pre-eclampsia (ACOG 2024)

Adjunct to clinical encephalopathy assessment in ALF / cirrhosis (not specific) (AASLD 2023)

Tissue hypoperfusion in cholangitis / sepsis / ALF; metabolic acidosis (AASLD 2023; Tokyo TG18 PMID 29032610)

Acetaminophen level — interpret on Rumack-Matthew nomogram if known time of ingestion (Smilkstein 1988 PMID 3059186)

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Severity triggers (12)

12 need judgement
  • informationallife_threateningalf_kings_college
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcholangitis_tokyo
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_phenotype
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconjugated_hepatocellular
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconjugated_cholestatic
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneonatal_phenotype
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredili_hys_law
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecirrhosis_decompensated
    Known cirrhosis presenting with new ascites / variceal bleed / hepatic encephalopathy / hepatorenal syndrome / SBP (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_alcoholic_hepatitis
    Maddrey discriminant function ≥32 OR MELD ≥21 in alcoholic hepatitis (STOPAH 2015 PMID 25901427); Glasgow Alcoholic Hepatitis Score (GAHS) ≥9 also indicates severe disease
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepainless_jaundice_malignancy
    Painless jaundice + weight loss + dilated ducts + pancreatic head mass / cholangiocarcinoma / metastases on imaging + age >50 (NICE 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateunconjugated_hyperbili
    Indirect / unconjugated bilirubin >85% of total — Gilbert, hemolysis (immune AIHA, MAHA, mechanical, G6PD), ineffective erythropoiesis, drug-induced (rifampin, probenecid), Crigler-Najjar, resorbing hematoma (BSG 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesepsis_cholestasis
    ICU-associated cholestasis — elevated bilirubin + ALP in critically ill patient on TPN / vasopressors / sepsis; not primarily biliary obstruction (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Diagnosis-directed therapy axis (etiology-specific) (AASLD 2023)
axis: jaundice_directed_therapy
Selected axis "Diagnosis-directed therapy axis (etiology-specific) (AASLD 2023)" by default fallback (first axis)
  • acetylcysteine
    rescue
    glutathione_precursor
    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
    triggers: APAP_overdose_within_window, non_APAP_ALF_per_ALFSG
    Standard 21-h IV protocol (Smilkstein NEJM 1988 PMID 3059186); benefit in non-APAP ALF as well (Lee 2011 PMID 22213561)
    rxcui 197
  • prednisolone
    first line
    corticosteroid
    40 mg PO daily × 28 d • PO • daily; assess Lille at day 7
    triggers: severe_alcoholic_hepatitis_Maddrey_>=32, no_active_GI_bleed_or_uncontrolled_infection
    STOPAH NEJM 2015 PMID 25901427 — 28-day mortality benefit; stop if Lille day-7 >0.45
    rxcui 8638
  • azathioprine
    add on
    thiopurine
    50-100 mg PO daily titrated • PO • daily
    triggers: autoimmune_hepatitis_steroid_sparing
    AASLD AIH — steroid-sparing maintenance; check TPMT first (AASLD 2023)
    rxcui 1256
  • ursodeoxycholic acid
    first line
    bile_acid
    13-15 mg/kg/day • PO • divided BID-TID
    triggers: PBC_confirmed_by_AMA_+_cholestatic_LFT, ICP_in_pregnancy
    EASL/AASLD PBC — first-line; obeticholic acid second-line (EASL 2017 PMID 28427765); URSO for ICP (ACOG 2024)
    rxcui 11065
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    2 g IV • IV • daily
    triggers: acute_cholangitis_Tokyo_grade_I_II
    Tokyo TG18 empiric (Kiriyama 2018 PMID 29032610)
    rxcui 2193
  • metronidazole
    add on
    nitroimidazole
    500 mg IV • IV • q8h
    triggers: anaerobic_coverage_for_cholangitis
    Empiric anaerobic coverage (Tokyo TG18 PMID 29032610)
    rxcui 6922
  • piperacillin/tazobactam
    first line
    beta_lactam_beta_lactamase_inhibitor
    4.5 g IV • IV • q6-8h
    triggers: acute_cholangitis_Tokyo_grade_III, sepsis_or_recent_healthcare_exposure
    Tokyo TG18 — broader coverage for grade III / healthcare-associated cholangitis
    rxcui 8339
  • entecavir
    first line
    nucleoside_analog_HBV
    0.5 mg • PO • once daily
    triggers: chronic_HBV_with_active_disease
    AASLD HBV 2018 PMID 29405329
    rxcui 306266
  • tenofovir_alafenamide
    first line
    nucleotide_analog_HBV
    25 mg • PO • once daily
    triggers: chronic_HBV_with_active_disease
    AASLD HBV 2018 PMID 29405329; TAF preferred over TDF for renal/bone
    rxcui 1721603
  • sofosbuvir/velpatasvir
    first line
    DAA_pangenotypic
    400/100 mg • PO • daily × 12 weeks
    triggers: chronic_HCV
    AASLD/IDSA HCV pangenotypic regimen
    rxcui 1484911
  • phototherapy
    first line
    physical_therapy
    triggers: neonatal_jaundice_above_Bhutani_phototherapy_threshold
    Bhutani nomogram-directed phototherapy thresholds for neonatal hyperbilirubinemia (AAP 2022)
  • liver_transplant_evaluation
    rescue
    procedure
    triggers: acute_liver_failure_meeting_Kings_College, decompensated_cirrhosis_MELD_>=15
    King's College criteria O'Grady 1989 PMID 2490426; MELD-Na ≥15 for listing (AASLD 2023)

outpatient playbook — drug actions (7)

  1. 1. directed therapy per diagnosis
    per axis • PO • daily
    trigger: Etiology confirmed
    Etiology-specific (AASLD 2023)
  2. 2. ursodeoxycholic acid 13-15 mg/kg/day
    13-15 mg/kg/day • PO • divided
    trigger: PBC
    EASL 2017 PMID 28427765 — first-line; obeticholic 2nd if non-responder by ALP / total bili at 1 yr (POISE trial)
  3. 3. obeticholic acid
    5 mg titrated to 10 mg • PO • daily
    trigger: PBC non-responder to URSO at 12 mo (POISE)
    EASL 2017 PMID 28427765 — second-line PBC; avoid in decompensated cirrhosis
  4. 4. tenofovir / entecavir
    standard • PO • daily
    trigger: Chronic HBV with active disease
    AASLD HBV 2018 PMID 29405329
  5. 5. sofosbuvir/velpatasvir
    400/100 mg • PO • daily × 12 wk
    trigger: Chronic HCV
    AASLD/IDSA pangenotypic DAA
  6. 6. D-penicillamine or trientine + zinc
    per agent • PO • per agent
    trigger: Wilson disease confirmed
    AASLD Wilson — chelation + zinc maintenance
  7. 7. naltrexone / acamprosate / gabapentin
    per agent • PO • per agent
    trigger: AUD
    AASLD AUD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Yellow eyes / skin (scleral icterus or jaundice) (ACG 2021); Dark urine + pale stool — cholestasis (BSG 2017); Elevated total bilirubin on LFTs (ACG 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Jaundice (adult)** (symptom.jaundice.v1).
Phenotype framing: By bilirubin fractionation + R-factor. UNCONJUGATED: Gilbert, hemolysis (immune AIHA, MAHA, mechanical, G6PD), ineffective erythropoiesis, drug-induced (rifampin, probenecid), Crigler-Najjar, resorbing hematoma. CONJUGATED HEPATOCELLULAR (R>5): viral A/B/C/D/E, autoimmune, ischemic (shock liver), drug-induced (APAP, INH, augmentin), Wilson, hemochromatosis, α1AT, severe NAFLD/MASH. CONJUGATED CHOLESTATIC (R<2): choledocholithiasis, cholangitis, pancreatic Ca, cholangiocarcinoma, PSC, PBC, DILI cholestatic, sepsis-related, biliary stricture, parasitic. PREGNANCY: ICP, HELLP, AFLP, pre-eclampsia. NEONATAL: physiologic, breast-milk, Crigler, hemolysis, biliary atresia (AASLD 2023; ACOG 2024)
Scope: Confirm jaundice (scleral icterus, T-bili >2.5 mg/dL); rule out carotenoderma (palms/soles only, no scleral involvement); fractionate bilirubin (direct vs indirect); compute R-factor (ALT/ULN)/(ALP/ULN) — >5 hepatocellular, <2 cholestatic, 2-5 mixed; identify pregnancy phenotype if applicable (ACG 2021; ACOG 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Diagnosis-directed therapy axis (etiology-specific) (AASLD 2023)**.
1. 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 (glutathione_precursor, rescue) — Standard 21-h IV protocol (Smilkstein NEJM 1988 PMID 3059186); benefit in non-APAP ALF as well (Lee 2011 PMID 22213561)
2. prednisolone 40 mg PO daily × 28 d PO daily; assess Lille at day 7 (corticosteroid, first line) — STOPAH NEJM 2015 PMID 25901427 — 28-day mortality benefit; stop if Lille day-7 >0.45
3. azathioprine 50-100 mg PO daily titrated PO daily (thiopurine, add on) — AASLD AIH — steroid-sparing maintenance; check TPMT first (AASLD 2023)
4. ursodeoxycholic acid 13-15 mg/kg/day PO divided BID-TID (bile_acid, first line) — EASL/AASLD PBC — first-line; obeticholic acid second-line (EASL 2017 PMID 28427765); URSO for ICP (ACOG 2024)
5. ceftriaxone 2 g IV IV daily (3rd_gen_cephalosporin, first line) — Tokyo TG18 empiric (Kiriyama 2018 PMID 29032610)
6. metronidazole 500 mg IV IV q8h (nitroimidazole, add on) — Empiric anaerobic coverage (Tokyo TG18 PMID 29032610)
7. piperacillin/tazobactam 4.5 g IV IV q6-8h (beta_lactam_beta_lactamase_inhibitor, first line) — Tokyo TG18 — broader coverage for grade III / healthcare-associated cholangitis
8. entecavir 0.5 mg PO once daily (nucleoside_analog_HBV, first line) — AASLD HBV 2018 PMID 29405329
9. tenofovir_alafenamide 25 mg PO once daily (nucleotide_analog_HBV, first line) — AASLD HBV 2018 PMID 29405329; TAF preferred over TDF for renal/bone
10. sofosbuvir/velpatasvir 400/100 mg PO daily × 12 weeks (DAA_pangenotypic, first line) — AASLD/IDSA HCV pangenotypic regimen
11. phototherapy (physical_therapy, first line) — Bhutani nomogram-directed phototherapy thresholds for neonatal hyperbilirubinemia (AAP 2022)
12. liver_transplant_evaluation (procedure, rescue) — King's College criteria O'Grady 1989 PMID 2490426; MELD-Na ≥15 for listing (AASLD 2023)

Setting playbook (outpatient) — Chronic hepatitis / NAFLD-MASH / autoimmune / PBC / PSC / hereditary management; transplant referral; HCC surveillance; alcohol cessation; dietary counseling (AASLD 2023)
13. directed therapy per diagnosis per axis PO daily — Etiology confirmed (Etiology-specific (AASLD 2023))
14. ursodeoxycholic acid 13-15 mg/kg/day 13-15 mg/kg/day PO divided — PBC (EASL 2017 PMID 28427765 — first-line; obeticholic 2nd if non-responder by ALP / total bili at 1 yr (POISE trial))
15. obeticholic acid 5 mg titrated to 10 mg PO daily — PBC non-responder to URSO at 12 mo (POISE) (EASL 2017 PMID 28427765 — second-line PBC; avoid in decompensated cirrhosis)
16. tenofovir / entecavir standard PO daily — Chronic HBV with active disease (AASLD HBV 2018 PMID 29405329)
17. sofosbuvir/velpatasvir 400/100 mg PO daily × 12 wk — Chronic HCV (AASLD/IDSA pangenotypic DAA)
18. D-penicillamine or trientine + zinc per agent PO per agent — Wilson disease confirmed (AASLD Wilson — chelation + zinc maintenance)
19. naltrexone / acamprosate / gabapentin per agent PO per agent — AUD (AASLD AUD)

Non-pharmacologic actions:
- Mediterranean diet + weight loss for NAFLD/MASH (AASLD 2023)
- Sodium <2 g/day if ascites
- Alcohol cessation (counseling + pharmacotherapy)
- Phlebotomy for hemochromatosis (HFE C282Y homozygote + iron overload)
- Avoid OTC APAP >2 g/day if cirrhotic; NEVER concomitant alcohol
- Cochlear / hearing protection in Wilson on chelation
- Pregnancy counseling if female of reproductive age on hepatotoxins
- Hepatology q3-6 mo follow-up

AVOID / contraindication checks:
- NAC_within_8h_optimal_for_APAP (Smilkstein 1988 PMID 3059186)
- Steroid_AH_avoid_active_GI_bleed_uncontrolled_infection_HBV_TB (STOPAH 2015 PMID 25901427)
- Azathioprine_TPMT_test_pre_initiation (AASLD 2023)
- DAA_drug_drug_interactions_check (AASLD 2023)
- Obeticholic_avoid_in_decompensated_cirrhosis (EASL 2017 PMID 28427765)
- Piperacillin_tazobactam_renal_dose_adjust

Monitoring

Regimen monitoring:
- serial LFT INR during treatment (ACG 2021)
- Lille at day 7 for steroid AH (STOPAH 2015 PMID 25901427)
- HBV DNA q3 to 6 mo (AASLD HBV 2018 PMID 29405329)
- HCV SVR12 (AASLD/IDSA HCV)
- HCC surveillance US q6mo if cirrhotic (AASLD HCC 2018 PMID 29624699)
- serum total bile acids in ICP q1wk (ACOG 2024)

Setting (outpatient) monitoring:
- LFT q4-12 wk depending on stability (ACG 2021)
- HCC surveillance US ± AFP q6 mo if cirrhotic (Marrero 2018 PMID 29624699)
- EGD q1-3 yr if cirrhotic
- Bone density q2 yr if PBC / steroids
- HBV DNA q3-6 mo on therapy (AASLD HBV 2018 PMID 29405329)
- HCV SVR12
- PBC response to URSO at 12 mo by ALP normalization (EASL 2017 PMID 28427765)

Follow-up plan: 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)
- Close-out criterion: Referrals scheduled

Monitoring phase: Serial LFT + INR + ammonia (ALF), HCC surveillance US ± AFP q6 mo if cirrhotic (AASLD HCC 2018 PMID 29624699), EGD q1-3 yr if cirrhotic, audiometry if Wilson on chelation, repeat MELD-Na for transplant list (AASLD 2023)

Disposition

Current setting: outpatient — Chronic hepatitis / NAFLD-MASH / autoimmune / PBC / PSC / hereditary management; transplant referral; HCC surveillance; alcohol cessation; dietary counseling (AASLD 2023)

Disposition criteria:
- Continue outpatient if stable + workup complete + adherent
- Refer hepatology for complex / refractory / transplant candidate
- Step up to ED / admit for new decompensation

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)

Citations

- 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 [PMID:22213561](https://pubmed.ncbi.nlm.nih.gov/22213561/)
- Cited evidence (PMID 2490426) [PMID:2490426](https://pubmed.ncbi.nlm.nih.gov/2490426/)
- Cited evidence (PMID 29032610) [PMID:29032610](https://pubmed.ncbi.nlm.nih.gov/29032610/)
- Cited evidence (PMID 3059186) [PMID:3059186](https://pubmed.ncbi.nlm.nih.gov/3059186/)
- Cited evidence (PMID 20949552) [PMID:20949552](https://pubmed.ncbi.nlm.nih.gov/20949552/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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 — PMID:22213561
  • Cited evidence (PMID 2490426) — PMID:2490426
  • Cited evidence (PMID 29032610) — PMID:29032610
  • Cited evidence (PMID 3059186) — PMID:3059186
  • Cited evidence (PMID 20949552) — PMID:20949552