How can I differentiate between cholangitis and other causes of jaundice in a primary care context?

In a primary care setting, differentiating between cholangitis and other causes of jaundice primarily involves identifying red flag signs and symptoms that necessitate urgent or emergency secondary care referral, as most cases of jaundice indicate a serious underlying cause ¹.

• Suspected Cholangitis: If a person with jaundice is systemically unwell and there is a suspected complication of gallstone disease, such as acute cholecystitis, cholangitis, or pancreatitis, emergency admission to secondary care should be arranged ². Urgent referral to gastroenterology or a surgical service with expertise in managing biliary diseases is also indicated for people with known gallstones and jaundice, or if there is a clinical suspicion of biliary obstruction (e.g., significantly abnormal liver function tests) ².
• General Jaundice Assessment and Referral: Most people presenting with jaundice should be admitted or referred to secondary care, as it is usually indicative of a serious underlying cause like malignancy ¹.
• Red Flag Signs for Immediate Admission: Arrange admission for same-day secondary care assessment if a person with jaundice exhibits red flag signs and symptoms, has a bilirubin level greater than 100 micromol/L, an abnormal clotting profile or signs of coagulopathy, abnormal renal function, suspected paracetamol overdose, or is frail or has significant co-morbidities ¹.
• Other Causes and Referral Pathways:
  • Pancreatic Cancer: People aged 40 years and over with jaundice should be referred using a suspected cancer pathway (for an appointment within 2 weeks) to exclude pancreatic cancer ¹.
  • Cholestatic/Obstructive Jaundice: Refer people with a cholestatic or obstructive picture on liver function tests (LFTs) to an upper gastrointestinal surgeon, gastroenterologist, or liver clinic, with urgency depending on clinical judgement ¹.
  • Hepatitic Jaundice: Refer people with a hepatitic picture on LFTs urgently to a liver clinic or gastroenterologist ¹.
  • Alcohol-Related Liver Disease: Refer people with suspected alcohol-related liver disease to a specialist experienced in its management, with urgency depending on clinical judgement ¹.
  • Chronic Hepatitis B: All adults who are hepatitis B surface antigen (HBsAg) positive should be referred to a hepatologist or a gastroenterologist/infectious disease specialist with an interest in hepatology, along with initial test results ³.
  • Cirrhosis: People diagnosed with cirrhosis should be referred to a specialist in hepatology ⁶.
  • Primary Care Management Exceptions: People who are well and have been diagnosed with Gilbert's syndrome or serologically confirmed Hepatitis A can be managed in primary care ¹.