Jaundice and pruritus: A diagnostic approach

The evaluation of the patient who presents with jaundice and pruritus is complex. Multiple potential causes must be considered, and a thorough diagnostic evaluation should be completed in a timely fashion. The symptoms, particularly the pruritus, can be tremendously bothersome to the patient and measures to increase patient comfort must be used. Details of the patient 's clinical presentation, including concurrent symptoms, medication use, and underlying disease, are important and can be particularly instrumental in guiding the diagnostic work-up. This underscores the critical importance of taking a thorough history at presentation. Management of jaundice and pruritus should focus on the underlying cause. In the absence of hemolytic conditions, efforts should be directed toward evaluation of the biliary tree. Diagnostic studies including ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography may all play a role in the evaluation of these patients. In addition, blood work can prove to be extremely valuable in determining the presence of underlying hepatic disease. Antipruritics can be beneficial and include diphenhydramine, cholestyramine (or other resins), rifampin, naltrexone, naloxone, and ondansetron. For some patients, a single agent works well at relieving the symptoms. For others, multiple agents may be employed. If obstruction is the primary cause of pruritus, ERCP may provide improvement in symptoms once the obstruction has been relieved. The presence of bile duct malignancy provides significant challenges for the clinician, and may require surgical or oncologic consultation. Finally, if end-stage liver disease is the underlying source, referral for orthotopic liver transplantation should be considered.