Causes of jaundice in an older person and their management

Definition and framework. Jaundice is yellow discoloration of skin and sclerae when serum bilirubin exceeds about 2.5–3 mg/dL. Classify as pre-hepatic, hepatocellular or post-hepatic (obstructive). In older adults, obstructive and malignant causes predominate, and drugs must always be excluded first.

Pre-hepatic causes. Haemolysis (autoimmune, drug-induced, transfusion reaction), ineffective erythropoiesis (megaloblastic anaemia, myelodysplastic syndrome) and resorption of a large haematoma. Features: unconjugated hyperbilirubinaemia with normal liver enzymes, raised LDH, low haptoglobin and reticulocytosis.

Hepatocellular causes. Drug-induced liver injury (the commonest cause in the elderly), viral hepatitis (A and E are more severe in old age; B and C), alcoholic hepatitis, autoimmune hepatitis, ischaemic hepatitis or "shock liver", cirrhosis with decompensation, and sepsis-associated cholestasis. The transaminases rise disproportionately.

Post-hepatic (obstructive) causes. Choledocholithiasis, and malignancy — carcinoma of the head of the pancreas, cholangiocarcinoma and periampullary carcinoma giving painless progressive jaundice with a palpable gallbladder (Courvoisier's law); also benign strictures, primary sclerosing cholangitis, primary biliary cholangitis and drug-induced cholestasis. Features: conjugated hyperbilirubinaemia with raised ALP and GGT, pale stools, dark urine and pruritus.

Evaluation. History of drugs including ayurvedic and herbal preparations, alcohol, transfusion and travel; examination for stigmata of chronic liver disease, palpable gallbladder, nodes and masses. Investigations: LFT pattern with R value, PT/INR (the best marker of severity), albumin, viral serology, autoantibodies and ferritin. Ultrasound abdomen is the first imaging test — if ducts are dilated proceed to MRCP, EUS or ERCP; if not dilated, complete the hepatocellular workup ± biopsy.

Management. Treat the cause — withdraw the offending drug, antivirals for hepatitis B and C, corticosteroids for autoimmune or severe alcoholic hepatitis, and ERCP with stone extraction or stenting for obstruction (percutaneous transhepatic drainage if ERCP fails). Supportive care: vitamin K, correction of dehydration and acute kidney injury, nutritional support, cholestyramine or rifampicin for pruritus, and avoidance of hepatotoxic drugs and sedatives. Ascending cholangitis (Charcot's triad of fever, jaundice and right upper quadrant pain) requires urgent antibiotics plus biliary drainage.

New nomenclature for steatotic liver disease (multi-society Delphi consensus, Hepatology 2023) — NAFLD is replaced by MASLD (metabolic dysfunction-associated steatotic liver disease), NASH by MASH, and a new category MetALD covers patients with both metabolic risk factors and significant alcohol intake, which is exactly the overlap commonly seen in older Indian patients. MASLD is now the commonest chronic liver disease worldwide and an increasingly frequent background cause of jaundice in the elderly, and resmetirom became the first drug approved for MASH with F2–F3 fibrosis (2024). Cross-reference: The MASLD/MetALD nomenclature introduced here is expanded, with the new drug therapy, in Question 14.