MBBS Year
1st Year
Subject
What Is Usually Asked
Bilirubin metabolism, Van den Bergh reaction, hereditary hyperbilirubinaemias, liver function tests
ReferenceAll Years (1st-Final)All UniversitiesJaundice
Jaundice: Notes, PPT and PYQs for MBBS
Jaundice (icterus) is yellow discolouration of the skin, sclera and mucous membranes caused by raised serum bilirubin. It is a sign rather than a disease, and working out its cause is one of the most common clinical and exam tasks in MBBS. Jaundice appears in Biochemistry and Physiology in 1st Year, Pathology and Microbiology in 2nd Year, and General Medicine and General Surgery in Final Year.
SME-reviewed. Updated 2026.
Open in GeckoMed for PPT slides and notes.Quick Summary: What You Need to Know for University Exams
- Normal total serum bilirubin is about 1 mg/dL or less; jaundice is usually visible above about 2 to 3 mg/dL.
- Jaundice is classified as prehepatic (haemolytic), hepatic (hepatocellular) and posthepatic (obstructive or cholestatic).
- Unconjugated bilirubin is not water-soluble and does not appear in urine; conjugated bilirubin does.
- Obstructive jaundice causes dark urine, pale stools and itching, with a marked rise in alkaline phosphatase.
- Ultrasound showing dilated bile ducts points to obstruction.
- Courvoisier's law: a palpable, non-tender gall bladder with jaundice is unlikely to be due to stones and suggests malignancy, such as carcinoma of the head of the pancreas.
- Treatment is directed at the underlying cause.
Jaundice Across MBBS Subjects
| MBBS Year | Subject | What Is Usually Asked |
|---|---|---|
| 1st Year | Biochemistry | Bilirubin metabolism, Van den Bergh reaction, hereditary hyperbilirubinaemias, liver function tests |
| 1st Year | Physiology | Red cell breakdown, bile formation |
| 2nd Year | Pathology | Types of jaundice, haemolytic anaemias, hepatitis, cirrhosis |
| 2nd Year | Microbiology | Hepatitis viruses and their markers |
| Final Year | General Medicine | Approach to jaundice, viral hepatitis, liver failure |
| Final Year | General Surgery | Obstructive jaundice, gallstones, carcinoma of the pancreas |
MBBS Year
1st Year
Subject
What Is Usually Asked
Red cell breakdown, bile formation
MBBS Year
2nd Year
Subject
What Is Usually Asked
Types of jaundice, haemolytic anaemias, hepatitis, cirrhosis
MBBS Year
2nd Year
Subject
What Is Usually Asked
Hepatitis viruses and their markers
MBBS Year
Final Year
Subject
What Is Usually Asked
Approach to jaundice, viral hepatitis, liver failure
MBBS Year
Final Year
Subject
What Is Usually Asked
Obstructive jaundice, gallstones, carcinoma of the pancreas
Definition and Classification
Definition: Jaundice is yellowish discolouration of the skin, sclera and mucous membranes due to hyperbilirubinaemia and deposition of bilirubin in tissues.
Classification
| Type | Main Problem | Predominant Bilirubin |
|---|---|---|
| Prehepatic (haemolytic) | Excess bilirubin production from red cell breakdown | Unconjugated |
| Hepatic (hepatocellular) | Impaired uptake, conjugation or excretion by liver cells | Mixed |
| Posthepatic (obstructive or cholestatic) | Blocked flow of bile | Conjugated |
Type
Prehepatic (haemolytic)
Main Problem
Excess bilirubin production from red cell breakdown
Predominant Bilirubin
Unconjugated
Type
Hepatic (hepatocellular)
Main Problem
Impaired uptake, conjugation or excretion by liver cells
Predominant Bilirubin
Mixed
Type
Posthepatic (obstructive or cholestatic)
Main Problem
Blocked flow of bile
Predominant Bilirubin
Conjugated
Bilirubin Metabolism
- Old red cells are broken down in the reticuloendothelial system; most bilirubin comes from haemoglobin
- Haem is converted to biliverdin by haem oxygenase, then to bilirubin by biliverdin reductase
- Unconjugated bilirubin travels in blood bound to albumin
- The liver takes up bilirubin and conjugates it with glucuronic acid using the enzyme UDP-glucuronyl transferase
- Conjugated bilirubin is excreted into bile
- In the gut, bacteria convert it to urobilinogen
- Most urobilinogen becomes stercobilin, which gives stool its colour; some is reabsorbed and excreted in urine
Van den Bergh reaction: Conjugated bilirubin reacts directly (direct bilirubin); unconjugated bilirubin reacts only after adding alcohol (indirect bilirubin).
(Examiner may ask you to draw the bilirubin metabolism pathway.)
Aetiology (Causes)
Prehepatic (Haemolytic)
- Hereditary spherocytosis, G6PD deficiency, sickle cell disease, thalassaemia
- Autoimmune haemolytic anaemia
- Malaria
- Mismatched blood transfusion
- Ineffective erythropoiesis, as in megaloblastic anaemia
Hepatic (Hepatocellular)
- Viral hepatitis (A, B, C, D, E)
- Alcohol-related liver disease
- Drugs such as paracetamol overdose, isoniazid and rifampicin
- Autoimmune hepatitis
- Wilson's disease
- Cirrhosis
- Leptospirosis
Posthepatic (Obstructive)
- Common bile duct stones (choledocholithiasis)
- Carcinoma of the head of the pancreas
- Periampullary carcinoma
- Cholangiocarcinoma
- Benign biliary strictures
- Chronic pancreatitis
- Primary sclerosing cholangitis
Hereditary Hyperbilirubinaemias
| Condition | Bilirubin Type | Key Features |
|---|---|---|
| Gilbert syndrome | Unconjugated | Mild reduction in conjugating enzyme; mild jaundice with fasting, illness or stress; harmless |
| Crigler-Najjar type I | Unconjugated | Absent enzyme; severe jaundice in infancy with risk of kernicterus |
| Crigler-Najjar type II | Unconjugated | Reduced enzyme; responds to phenobarbitone |
| Dubin-Johnson syndrome | Conjugated | Defect in bilirubin excretion; dark (black) liver |
| Rotor syndrome | Conjugated | Similar to Dubin-Johnson but without liver pigmentation |
Condition
Gilbert syndrome
Bilirubin Type
Unconjugated
Key Features
Mild reduction in conjugating enzyme; mild jaundice with fasting, illness or stress; harmless
Condition
Crigler-Najjar type I
Bilirubin Type
Unconjugated
Key Features
Absent enzyme; severe jaundice in infancy with risk of kernicterus
Condition
Crigler-Najjar type II
Bilirubin Type
Unconjugated
Key Features
Reduced enzyme; responds to phenobarbitone
Condition
Dubin-Johnson syndrome
Bilirubin Type
Conjugated
Key Features
Defect in bilirubin excretion; dark (black) liver
Condition
Rotor syndrome
Bilirubin Type
Conjugated
Key Features
Similar to Dubin-Johnson but without liver pigmentation
Differentiating the Types of Jaundice
| Feature | Haemolytic | Hepatocellular | Obstructive |
|---|---|---|---|
| Serum bilirubin | Unconjugated raised | Both raised | Conjugated raised |
| Urine bilirubin | Absent (acholuric jaundice) | Present | Present (dark urine) |
| Urine urobilinogen | Increased | Variable | Reduced or absent |
| Stool colour | Normal or dark | Normal or pale | Pale (clay-coloured) |
| AST and ALT | Normal | Markedly raised | Mildly raised |
| Alkaline phosphatase and GGT | Normal | Mildly raised | Markedly raised |
| Itching | Absent | May be present | Common |
| Prothrombin time | Normal | Prolonged; not corrected by vitamin K | Prolonged; corrected by vitamin K |
| Other clues | Anaemia, reticulocytosis, splenomegaly | Features of liver disease | Palpable gall bladder in some malignant causes |
Feature
Serum bilirubin
Haemolytic
Unconjugated raised
Hepatocellular
Both raised
Obstructive
Conjugated raised
Feature
Urine bilirubin
Haemolytic
Absent (acholuric jaundice)
Hepatocellular
Present
Obstructive
Present (dark urine)
Feature
Urine urobilinogen
Haemolytic
Increased
Hepatocellular
Variable
Obstructive
Reduced or absent
Feature
Stool colour
Haemolytic
Normal or dark
Hepatocellular
Normal or pale
Obstructive
Pale (clay-coloured)
Feature
AST and ALT
Haemolytic
Normal
Hepatocellular
Markedly raised
Obstructive
Mildly raised
Feature
Alkaline phosphatase and GGT
Haemolytic
Normal
Hepatocellular
Mildly raised
Obstructive
Markedly raised
Feature
Itching
Haemolytic
Absent
Hepatocellular
May be present
Obstructive
Common
Feature
Prothrombin time
Haemolytic
Normal
Hepatocellular
Prolonged; not corrected by vitamin K
Obstructive
Prolonged; corrected by vitamin K
Feature
Other clues
Haemolytic
Anaemia, reticulocytosis, splenomegaly
Hepatocellular
Features of liver disease
Obstructive
Palpable gall bladder in some malignant causes
Pathophysiology of Symptoms in Obstructive Jaundice
| Feature | Mechanism |
|---|---|
| Dark urine | Conjugated bilirubin is water-soluble and excreted by the kidneys |
| Pale stools | Bilirubin does not reach the gut, so less stercobilin forms |
| Itching | Bile salts accumulate in the skin |
| Steatorrhoea | Lack of bile salts impairs fat absorption |
| Bleeding tendency | Poor absorption of vitamin K reduces clotting factors |
| Bradycardia | Bile salts may slow the heart |
Feature
Dark urine
Mechanism
Conjugated bilirubin is water-soluble and excreted by the kidneys
Feature
Pale stools
Mechanism
Bilirubin does not reach the gut, so less stercobilin forms
Feature
Itching
Mechanism
Bile salts accumulate in the skin
Feature
Steatorrhoea
Mechanism
Lack of bile salts impairs fat absorption
Feature
Bleeding tendency
Mechanism
Poor absorption of vitamin K reduces clotting factors
Feature
Bradycardia
Mechanism
Bile salts may slow the heart
Clinical Features
History to take:
- Onset and duration of jaundice
- Colour of urine and stools
- Itching
- Abdominal pain (colicky pain with fever suggests stones and cholangitis; painless progressive jaundice suggests malignancy)
- Fever and prodromal symptoms (viral hepatitis)
- Alcohol, drugs, transfusions, injections, travel and contacts
- Weight loss and anorexia (malignancy)
- Family history (hereditary disorders, haemolytic anaemias)
Examination:
- Pallor (haemolysis), signs of chronic liver disease, scratch marks
- Hepatomegaly, splenomegaly, palpable gall bladder, ascites
- Charcot's triad (fever with rigors, jaundice and right upper quadrant pain) in acute cholangitis; Reynolds' pentad adds shock and confusion
Pseudojaundice: In carotenaemia, the skin is yellow but the sclera remain white.
Diagnosis
| Investigation | Purpose |
|---|---|
| Serum bilirubin (total, direct, indirect) | Confirms and types jaundice |
| Liver enzymes (AST, ALT, ALP, GGT) | Hepatocellular versus cholestatic pattern |
| Serum albumin and prothrombin time | Liver synthetic function |
| Urine bilirubin and urobilinogen | Helps classify the jaundice |
| Complete blood count, reticulocyte count, peripheral smear | Haemolysis |
| Viral markers (IgM anti-HAV, HBsAg, IgM anti-HBc, anti-HCV, IgM anti-HEV) | Viral hepatitis |
| Ultrasound abdomen | First imaging test; dilated ducts suggest obstruction; shows stones and masses |
| MRCP | Non-invasive imaging of the biliary tree |
| ERCP | Diagnostic and therapeutic (stone removal, stenting) |
| CT abdomen and endoscopic ultrasound | Staging of pancreatic and biliary tumours |
| Liver biopsy | Unclear hepatocellular causes |
Investigation
Serum bilirubin (total, direct, indirect)
Purpose
Confirms and types jaundice
Investigation
Liver enzymes (AST, ALT, ALP, GGT)
Purpose
Hepatocellular versus cholestatic pattern
Investigation
Serum albumin and prothrombin time
Purpose
Liver synthetic function
Investigation
Urine bilirubin and urobilinogen
Purpose
Helps classify the jaundice
Investigation
Complete blood count, reticulocyte count, peripheral smear
Purpose
Haemolysis
Investigation
Viral markers (IgM anti-HAV, HBsAg, IgM anti-HBc, anti-HCV, IgM anti-HEV)
Purpose
Viral hepatitis
Investigation
Ultrasound abdomen
Purpose
First imaging test; dilated ducts suggest obstruction; shows stones and masses
Investigation
MRCP
Purpose
Non-invasive imaging of the biliary tree
Investigation
ERCP
Purpose
Diagnostic and therapeutic (stone removal, stenting)
Investigation
CT abdomen and endoscopic ultrasound
Purpose
Staging of pancreatic and biliary tumours
Investigation
Liver biopsy
Purpose
Unclear hepatocellular causes
Reference ranges: normal lab values chart.
Management
Treat the underlying cause.
| Type | Management Principles |
|---|---|
| Haemolytic | Treat the cause (for example stop the offending drug, treat malaria, corticosteroids in autoimmune haemolysis); folic acid; transfusion if needed |
| Viral hepatitis | Mainly supportive for hepatitis A and E; antiviral therapy for chronic hepatitis B and C; watch for acute liver failure |
| Drug-induced | Stop the drug; N-acetylcysteine for paracetamol overdose |
| Obstructive (stones) | ERCP with stone extraction; cholecystectomy for gallbladder stones |
| Obstructive (malignancy) | Surgery where resectable (for example Whipple's operation for carcinoma of the head of the pancreas); stenting for palliation |
| Acute cholangitis | Resuscitation, intravenous antibiotics and urgent biliary drainage |
Type
Haemolytic
Management Principles
Treat the cause (for example stop the offending drug, treat malaria, corticosteroids in autoimmune haemolysis); folic acid; transfusion if needed
Type
Viral hepatitis
Management Principles
Mainly supportive for hepatitis A and E; antiviral therapy for chronic hepatitis B and C; watch for acute liver failure
Type
Drug-induced
Management Principles
Stop the drug; N-acetylcysteine for paracetamol overdose
Type
Obstructive (stones)
Management Principles
ERCP with stone extraction; cholecystectomy for gallbladder stones
Type
Obstructive (malignancy)
Management Principles
Surgery where resectable (for example Whipple's operation for carcinoma of the head of the pancreas); stenting for palliation
Type
Acute cholangitis
Management Principles
Resuscitation, intravenous antibiotics and urgent biliary drainage
Preparing a Jaundiced Patient for Surgery
- Correct clotting with vitamin K (and fresh frozen plasma if needed)
- Maintain good hydration to protect the kidneys
- Treat infection with antibiotics
- Relieve itching (for example with cholestyramine)
- Optimise nutrition
Complications
- Coagulopathy and bleeding
- Acute cholangitis and sepsis
- Renal failure in obstructive jaundice
- Acute liver failure and hepatic encephalopathy in hepatocellular jaundice
- Biliary cirrhosis in long-standing obstruction
- Kernicterus in newborns with severe unconjugated hyperbilirubinaemia (see neonatal jaundice)
Prognosis
Prognosis depends entirely on the cause. Gilbert syndrome is harmless, most acute viral hepatitis recovers fully, stone-related obstruction is curable, and malignant obstruction often carries a poor outlook.
Quick Viva Questions
Q: At what serum bilirubin level does jaundice become visible? A: Usually above about 2 to 3 mg/dL.
Q: Why is haemolytic jaundice called acholuric? A: Unconjugated bilirubin is bound to albumin and is not water-soluble, so it does not appear in urine.
Q: What is Courvoisier's law? A: A palpable gall bladder in a jaundiced patient is unlikely to be due to stones, because a gall bladder affected by stones is usually fibrosed; it suggests malignant obstruction.
Q: How does vitamin K help distinguish obstructive from hepatocellular jaundice? A: In obstructive jaundice, a prolonged prothrombin time corrects with vitamin K; in hepatocellular disease it does not, because the liver cannot make clotting factors.
Q: What is Charcot's triad? A: Fever with rigors, jaundice and right upper quadrant pain, seen in acute cholangitis.
How Jaundice Appears in MBBS University Exams
Typical question styles (not attributed to specific papers or years):
- "Classify jaundice. Describe the differences between haemolytic, hepatocellular and obstructive jaundice." (Long essay, Pathology or Medicine)
- "Discuss the causes, investigations and management of obstructive jaundice." (Long essay, Surgery)
- "Describe the metabolism of bilirubin. Add a note on hereditary hyperbilirubinaemias." (Long essay, Biochemistry)
- "Write a short note on the serological markers of hepatitis B." (Short note, Microbiology)
- "Write a short note on the preoperative preparation of a jaundiced patient." (Short note, Surgery)
Frequently Asked Questions
How do you differentiate the three types of jaundice?
Use bilirubin type, urine bilirubin and urobilinogen, stool colour and liver enzymes. Haemolytic jaundice shows unconjugated bilirubin without urine bilirubin; hepatocellular jaundice shows markedly raised transaminases; obstructive jaundice shows dark urine, pale stools and a markedly raised alkaline phosphatase.
What is the first imaging test in a jaundiced patient?
Ultrasound of the abdomen, which shows whether the bile ducts are dilated and may reveal stones or a mass.
Can I download the jaundice PPT for my presentation?
Yes. Use the Download PPT button at the top of this page. The GeckoMed app also gives offline access to the slides and notes.
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