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Gastroenterology
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Hyperbilirubinemia in Adults
Flowchart
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Conjugated vs unconjugated, then enzyme pattern.
Decision
Outcome
Decision
Hyperbilirubinemia — initial branch?
✓
Conjugated vs unconjugated
✗
Total bilirubin only
Decision
Predominant fraction?
✓
Unconjugated
✓
Conjugated
Outcome
Hemolysis, drug reduced uptake, Gilbert, Crigler–Najjar
Decision
Conjugated — enzyme pattern?
✓
AST/ALT predominant → hepatocellular
✓
Alk phos predominant → cholestatic
✓
Normal enzymes → Dubin–Johnson, Rotor
Outcome
Viral, autoimmune, toxic/drug, ischemic, alcoholic hepatitis, hemochromatosis, Wilson
Outcome
PBC, PSC, malignancy (pancreas/ampullary/cholangio), choledocholithiasis, pregnancy cholestasis
Abdominal imaging + AMA; ERCP/MRCP as warranted.
Outcome
Dubin–Johnson or Rotor syndrome
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