[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Abdomen](https://durgical.com/en/clinical-exam/#a-abdomen) › Jaundice: prehepatic, hepatic and posthepatic

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# Jaundice: prehepatic, hepatic and posthepatic

- Syndrome

Yellow skin and eyes from too much bilirubin; the color of the urine and stool helps show where the problem is.

Updated 2026-11-01

**See it in 3D:** [Liver](https://durgical.com/en/anatomy/liver/) · [Gallbladder](https://durgical.com/en/anatomy/gallbladder/) · [Common bile duct](https://durgical.com/en/anatomy/bile-duct/) · [Common hepatic duct](https://durgical.com/en/anatomy/common-hepatic-duct/) · [Pancreas](https://durgical.com/en/anatomy/pancreas/) · [Duodenum](https://durgical.com/en/anatomy/duodenum/) · [Spleen](https://durgical.com/en/anatomy/spleen/) · [Sclera](https://durgical.com/en/anatomy/sclera/)

## Key points

- It shows first in the sclerae and under the tongue, best in daylight; carotenemia yellows the skin but spares the sclerae.
- Prehepatic: unconjugated bilirubin, normal-colored urine, normal or darker stool.
- Hepatic and posthepatic: conjugated bilirubin spills into the urine (dark urine); in obstruction the stool is pale (acholic) and there is itching.
- Painless jaundice with a palpable, non-tender gallbladder (Courvoisier) suggests a tumor of the pancreatic head or distal bile duct.
- Fever, right upper quadrant pain and jaundice (Charcot triad) suggest acute cholangitis.
- In a newborn, jaundice in the first 24 hours of life is always pathological.

## What it is

Jaundice is yellowing of the skin, sclerae and mucosa from raised blood bilirubin. By where bilirubin handling fails it is divided into prehepatic (overproduction), hepatic (hepatocyte failure) and posthepatic or obstructive (bile does not reach the gut). Urine and stool color, plus a few clinical clues, point to the type at the bedside.

## Key findings

- Urine color (dark) and stool color (pale): always ask.
- Itching and scratch marks: point to cholestasis.
- Pallor and splenomegaly: point to hemolysis.
- Tender hepatomegaly after a prodrome of malaise and nausea: points to hepatitis.
- Stigmata of chronic liver disease and ascites: point to cirrhosis.
- A palpable non-tender gallbladder (Courvoisier) or biliary pain with fever (Charcot).

## Pathophysiology

- Hemoglobin from old red cells is broken down in the spleen to unconjugated bilirubin, which travels bound to albumin and is not water-soluble, so it does not enter the urine.
- The hepatocyte takes up bilirubin, conjugates it with glucuronic acid (making it soluble) and excretes it into bile.
- In the gut, bacteria turn it into urobilinogen and stercobilin, which colors stool brown; some urobilinogen is reabsorbed and leaves in the urine.
- If bile does not reach the gut, stool loses its color and conjugated bilirubin returns to the blood and darkens the urine; retained bile salts cause itching.
- In hemolysis the liver receives more bilirubin than it can conjugate: the unconjugated fraction and urobilinogen rise.

## The three types of jaundice at the bedside

| Type | Main bilirubin | Urine | Stool | Clinical clues |
| --- | --- | --- | --- | --- |
| Prehepatic | Unconjugated (indirect) | Normal color (no bilirubinuria); more urobilinogen | Normal or dark | Pallor, splenomegaly, family history; hemolysis or Gilbert syndrome |
| Hepatic | Mixed | Dark | Normal or slightly pale | Viral prodrome, alcohol, drugs, tender hepatomegaly, liver-disease stigmata |
| Posthepatic (obstructive) | Conjugated (direct) | Dark, 'tea-colored' | Pale (acholic) | Itching, biliary pain, Charcot, Courvoisier, weight loss |

## Common causes

- Prehepatic: hemolytic anemias (hereditary spherocytosis, G6PD deficiency, sickle cell disease, malaria) and Gilbert syndrome.
- Hepatic: viral hepatitis, alcohol- or drug-induced hepatitis, cirrhosis, and yellow fever and leptospirosis in endemic areas.
- Posthepatic: choledocholithiasis, cancer of the pancreatic head, cholangiocarcinoma, biliary strictures and primary sclerosing cholangitis.
- Neonatal: physiological after the first day; pathological if it appears in the first 24 hours, progresses fast or lasts longer than expected.

## Tests that confirm it

- Total and fractionated bilirubin (direct and indirect).
- Liver test pattern: transaminases predominate (hepatocellular) or alkaline phosphatase and GGT predominate (cholestatic).
- Abdominal ultrasound: dilated bile ducts in obstruction; blood count and reticulocytes if hemolysis is suspected.

## Memory aid

'Dark urine: the liver already conjugated; white stool: the bile never arrived.'

## Test yourself

Think of the answer, then tap the question to see it.

## Why does the urine stay normal in color in hemolytic jaundice?

The bilirubin that rises is unconjugated: it travels bound to albumin and is not water-soluble, so the kidney does not filter it.

## What does the combination of dark urine, pale stool and itching mean?

Cholestasis or bile duct obstruction: conjugated bilirubin returns to the blood and leaves in the urine, no pigment reaches the gut, and retained bile salts cause itching.

## What does painless jaundice with a palpable, non-tender gallbladder suggest?

Courvoisier sign: a slow, distal bile duct obstruction, classically from a tumor of the pancreatic head; with gallstones the gallbladder is usually fibrosed and does not distend.

## Where is jaundice looked for first, and in what light?

In the sclerae and under the tongue, in daylight, because artificial light can hide a faint yellow tint.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/jaundice-prehepatic-hepatic-and-posthepatic/)

## See it in 3D

The structures of Durgical's 3D anatomy where it is found.

- [Liver](https://durgical.com/en/anatomy/liver/)
- [Gallbladder](https://durgical.com/en/anatomy/gallbladder/)
- [Common bile duct](https://durgical.com/en/anatomy/bile-duct/)
- [Common hepatic duct](https://durgical.com/en/anatomy/common-hepatic-duct/)
- [Pancreas](https://durgical.com/en/anatomy/pancreas/)
- [Duodenum](https://durgical.com/en/anatomy/duodenum/)
- [Spleen](https://durgical.com/en/anatomy/spleen/)
- [Sclera](https://durgical.com/en/anatomy/sclera/)

## Related

- [Pallor, cyanosis and jaundice](https://durgical.com/en/clinical-exam/pallor-cyanosis-and-jaundice/)
- [Courvoisier sign](https://durgical.com/en/clinical-exam/courvoisier-sign/)
- [Murphy sign](https://durgical.com/en/clinical-exam/murphy-sign/)
- [Palpation of the liver and spleen](https://durgical.com/en/clinical-exam/palpation-of-the-liver-and-spleen/)
- [Portal hypertension and the signs of chronic liver disease](https://durgical.com/en/clinical-exam/portal-hypertension-and-the-signs-of-chronic-liver-disease/)
- [Anemia syndrome](https://durgical.com/en/clinical-exam/anemia-syndrome/)

## Related conditions

- [Viral hepatitis](https://durgical.com/en/conditions/viral-hepatitis/)
- [Neonatal jaundice](https://durgical.com/en/conditions/neonatal-jaundice/)
- [Gilbert syndrome](https://durgical.com/en/conditions/gilbert-syndrome/)
- [Choledocholithiasis](https://durgical.com/en/conditions/choledocholithiasis/)
- [Acute cholangitis](https://durgical.com/en/conditions/acute-cholangitis/)
- [Pancreatic cancer](https://durgical.com/en/conditions/pancreatic-cancer/)
- [Hereditary spherocytosis](https://durgical.com/en/conditions/hereditary-spherocytosis/)
- [Glucose-6-phosphate dehydrogenase (G6PD) deficiency](https://durgical.com/en/conditions/glucose-6-phosphate-dehydrogenase-deficiency/)
- [Cirrhosis](https://durgical.com/en/conditions/cirrhosis/)

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: [Jaundice | Icterus | MedlinePlus](https://medlineplus.gov/jaundice.html) (MedlinePlus, U.S. National Library of Medicine, 2026); [18.3 Erythrocytes - Anatomy and Physiology 2e | OpenStax](https://openstax.org/books/anatomy-and-physiology-2e/pages/18-3-erythrocytes) (OpenStax, Rice University, 2022); [23.6 Accessory Organs in Digestion: The Liver, Pancreas, and Gallbladder](https://openstax.org/books/anatomy-and-physiology-2e/pages/23-6-accessory-organs-in-digestion-the-liver-pancreas-and-gallbladder) (OpenStax, Rice University, 2022).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/clinical-exam/jaundice-prehepatic-hepatic-and-posthepatic/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/jaundice-prehepatic-hepatic-and-posthepatic/