Differential diagnosis of jaundice. Hepatocellular versus obstructive disease

The patient with jaundice may be accurately diagnosed through clinical history, physical findings, and noninvasive laboratory and radiologic examinations available in most community hospitals. Ultrasonography is usually the procedure of choice in initial evaluation, but if acute cholecystitis is suspected, hepatobiliary scintigraphy is highly reliable and easy to perform. Computed tomography (CT) should be used if ultrasonography has not yielded the information needed; however, transient biliary obstruction cannot be diagnosed with CT unless ductal dilatation is present. The presence of laboratory data indicative of almost certain parenchymal liver disease should alert the physician to avoid unnecessary tests that are both costly and potentially dangerous. The final assessment of biliary duct patency may require transhepatic or retrograde cholangiography. Both procedures are effective but carry important potential complications.