When should I consider referring a patient with suspected Gilbert's Syndrome for further investigation?

You should consider referring a patient with suspected Gilbert's syndrome for further investigation if there are any features that suggest a more serious underlying cause, as jaundice is usually indicative of serious illness requiring urgent investigation and treatment ¹. While Gilbert's syndrome can be diagnosed and managed in primary care for well individuals ¹,², referral is essential in many circumstances.

Consider immediate referral or same-day secondary care assessment if the patient with jaundice:

• Is exhibiting red flag signs and symptoms ¹.
• Has a bilirubin level greater than 100 micromol/L ¹.
• Has an abnormal clotting profile or shows signs of coagulopathy ¹.
• Has abnormal renal function ¹.
• Is frail or has significant co-morbidities ¹.

Additionally, refer for further investigation if:

• The patient is aged 40 years and over, using a suspected cancer pathway referral (for an appointment within 2 weeks) to exclude pancreatic cancer ¹,³.
• There is a cholestatic or obstructive picture on liver function tests (LFTs), requiring referral to an upper gastrointestinal surgeon, gastroenterologist, or liver clinic ¹.
• There is a hepatitic picture on LFTs, requiring urgent referral to a liver clinic or gastroenterologist ¹.
• The episode of jaundice is more severe or persistent than usual, as this may indicate an alternative diagnosis that could co-exist with Gilbert's syndrome ².
• The jaundice is unexplained ¹.