Mistakes in acute jaundice and how to avoid them

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Mistakes in acute jaundice and how to avoid them

Spyridon Siakavellas, Georgios Papatheodoridis

Summary

AI Generated

Jaundice arises from abnormalities in bilirubin formation, metabolism, or excretion, or from biliary tree obstruction at any anatomical level, and numerous conditions can cause it.

Jaundice can result from abnormalities in bilirubin formation, metabolism, and excretion processes
Obstruction of the biliary tree from intrahepatic origins to the ampulla of Vater can cause jaundice even when bilirubin processing is functioning properly
The material presents the view that a careful diagnostic approach is warranted to identify the underlying cause
The material states that prompt intervention saves lives in many cases, contrasting with conventional wisdom that jaundice by itself never killed anyone

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Fevery J. Bilirubin in clinical practice: a review. Liver Int 2008; 28: 592–605. [Link]

Silverberg NB and Lee-Wong M. Generalized yellow discoloration of the skin. The diagnosis: carotenemia. Cutis 2014; 93: E11–E12. [Link]

Erlinger S, Arias IM and Dhumeaux D. Inherited disorders of bilirubin transport and conjugation: new insights into molecular mechanisms and consequences. Gastroenterology 2014; 146: 1625–1638. [Link]

Marchand A, Galen RS and Van Lente F. The predictive value of serum haptoglobin in hemolytic disease. JAMA 1980; 243: 1909–1911. [Link]

Vitek L, et al. Gilbert syndrome and ischemic heart disease: a protective effect of elevated bilirubin levels. Atherosclerosis 2002; 160: 449–456. [Link]

European Association for the Study of the Liver. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66: 1047–1081. [Link]

Taylor T and Wheatley M. Jaundice in the emergency department: meeting the challenges of diagnosis and treatment. Emerg Med Pract 2018; 20: 1–24. [Link]

Vuppalanchi R, Liangpunsakul S and Chalasani N. Etiology of new-onset jaundice: how often is it caused by idiosyncratic drug-induced liver injury in the United States? Am J Gastroenterol 2007; 102: 558–562. [Link]

European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune hepatitis. J Hepatol 2015; 63: 971–1004. [Link]

10.

Chand N and Sanyal AJ. Sepsis-induced cholestasis. Hepatology 2007; 45: 230–241. [Link]

11.

Giallourakis CC, Rosenberg PM and Friedman LS. The liver in heart failure. Clinics Liv Dis 2002; 6: 947–967. [Link]

12.

van Lingen R, et al. Jaundice as a presentation of heart failure. J R Soc Med 2005; 98: 357–359. [Link]

13.

Okwara CJ, et al. Jaundice: A thyroid problem? Dig Dis Sci 2017; 62: 1901–1905. [Link]

14.

Saik RP, et al. Spectrum of cholangitis. Am J Surg 1975; 130: 143–150. [Link]

15.

Miura F, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 47–54. [Link]

16.

Thursz MR, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med 2015; 372: 1619–1628. [Link]

17.

Crabb DW, et al. Standard definitions and common data elements for clinical trials in patients with alcoholic hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia. Gastroenterology 2016; 150: 785–790. [Link]

18.

Moreau R, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426–1437, e1–9. [Link]

19.

Desmet VJ, et al. Classification of chronic hepatitis: diagnosis, grading and staging. Hepatology 1994; 19: 1513–1520. [Link]

20.

Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464–470. [Link]

Abstract

Jaundice can be caused by abnormalities in any of the steps comprising the formation, metabolism and excretion of bilirubin. In addition, these processes may be functioning properly, but jaundice can be seen because of an obstruction of the biliary tree at any point, from its intrahepatic origins to its end at the ampulla of Vater. For this reason, it is clear that numerous conditions can result in jaundice. When faced with a patient presenting with jaundice a reasonable and careful diagnostic approach is, therefore, warranted to elucidate the underlying cause of this sign. Conventional wisdom may be that “jaundice by itself never killed anyone,” but it is imperative to find the cause as soon as possible, as prompt intervention saves lives in many cases.

Topics

Hepatobiliary

Citation

Siakavellas S and Papatheodoridis G. Mistakes in acute jaundice and how to avoid them. UEG Education 2018; 18: 24–26.

Published

2025

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ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease

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ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease

Henit Yanai

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Guideline

Introduction

The therapeutic landscape of inflammatory bowel disease [IBD] has undergone a profound transformation with the advent of novel immunosuppressive and biologic agents. These advancements have revolutionised the management of Crohn’s disease [CD] and ulcerative colitis [UC], enabling tighter control of inflammation and significantly improved patient outcomes. However, while older treatment strategies, including prolonged corticosteroids, purine analogues, and anti-tumour necrosis factor [TNF]/thiopurine combination therapy, carried a substantial immunosuppressive burden, the expanding therapeutic armamentarium introduces new agents with distinct infection risk profiles that require updated, evidence-based guidance. By definition, opportunistic infections are infections caused by organisms that infrequently induce disease in immunocompetent hosts but can result in significant morbidity or mortality in immunocompromised individuals. As treatment strategies increasingly rely on potent modulation of the immune system, ranging from traditional thiopurines to advanced small molecules, a structured, evidence-based approach to infection prevention, diagnosis, and management has become indispensable for the clinician. The European Crohn’s and Colitis Organisation [ECCO] has long recognised this clinical imperative, previously publishing consensus statements in 2009 and 2014, followed by a comprehensive guideline in 2021. This 2026 update is warranted by the rapid expansion of the therapeutic armamentarium, specifically the introduction of newer small molecules, advanced biologics, and evolving vaccination strategies. This update integrates the most recent data on risk stratification, viral, bacterial, mycobacterial, and vaccine-preventable infections, emphasising a preventative strategy tailored to the contemporary IBD treatment paradigm.

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 20, Issue 7, July 2026

Published

2026

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This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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European Interdisciplinary Guidelines on Pain Management in Acute Pancreatitis: UEG, EPC, EDS, ESDO, EAGEN, ESPGHAN, ESGAR, and ESPCG Evidence-Based Recommendations

Sanjay Pandanaboyana

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Guideline

ABSTRACT

Pain is often the presenting symptom of acute pancreatitis (AP) and has a prognostic significance, with poorly treated pain affecting patient outcomes. Despite this, there are currently no international recommendations for pain management in patients admitted with AP. This current guideline was developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. Nine working groups were formed to develop statements on pain management in AP from admission to discharge. After systematic literature reviews, the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted using three rounds of Delphi method. The guidelines concluded that acute postoperative pain management guidelines are applicable for treating acute pain due to AP. The numerical rating scale is preferred for pain assessment because of better compliance. Opioids currently form the cornerstone of severe pain management. Potent opioids such as buprenorphine and pentazocine provide superior pain relief over non-opioid medications and decrease the need for rescue analgesia. Current evidence does not consistently demonstrate harm from opioids in AP. In patients with severe pain, safety concerns should not delay the timely use of opioids to ensure adequate pain management. Specific recommendations concerning the use of epidural analgesia, acupuncture and management of pain in the paediatric population and during pregnancy are provided based on evidence and expert opinions. Finally, the unmet needs for future research were discussed and proposed.

Guideline

Clinical Practice Guideline

Topics

Pancreas

Citation

United European Gastroenterology Journal, 2026

Published

2026

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This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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European Society for the Study of Coeliac Disease (ESsCD) 2025 Updated Guidelines on the Diagnosis and Management of Coeliac Disease in Adults. Part 2: Management, Follow-Up, and Complex Disease Courses

Abdulbaqi Al-Toma

Summary

AI Generated

Summary is not available for this content yet.

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Thanks for your feedback.

Guideline

ABSTRACT

Introduction

Since the publication of the first European Society for the Study of Coeliac Disease (ESsCD) guidelines in 2019, substantial advances have been made in understanding the management and complex disease courses of coeliac disease (CeD) in adults. These 2025 updated guidelines aim to integrate new evidence, refine management strategies, and promote a personalised and multidisciplinary approach to care.

Methods

The ESsCD convened a multidisciplinary panel of experts to revise the 2019 guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Evidence was appraised and graded according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Statements and recommendations were draughted within working groups and finalised through a structured Delphi consensus process.

Results

The updated guidelines are presented in two parts. Part 1, which has already been published, addresses the diagnostic approach to CeD in adults, whereas Part 2 focuses on disease management, structured follow-up, and the evaluation and treatment of persistent symptoms despite a gluten-free diet or refractory disease. New or expanded sections include guidance on the safe inclusion of oats, use of low-FODMAP diets in patients with persistent symptoms, management of exocrine pancreatic insufficiency, recognition of functional asplenia and related vaccination recommendations, and stratified bone-health screening. The guidelines also discuss nutritional and psychosocial support, digital models of care, and structured transition from paediatric to adult services. Updated therapeutic strategies for refractory CeD are provided, including immunosuppressive and novel pharmacologic options.

Conclusions

These updated guidelines offer a comprehensive, evidence-based framework for the management and follow-up of adults with CeD. By integrating recent scientific advances with pragmatic, patient-centred recommendations, they seek to optimise clinical outcomes, quality of life, and long-term health in individuals with CeD.

Guideline

Clinical Practice Guideline

Topics

Immunology Small Intestine & Nutrition

Citation

United European Gastroenterology Journal, 2026

Published

2026

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UEG Mistakes In Articles

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Mistakes in Pancreatic exocrine insufficiency and how to avoid them

Miroslav Vujasinovic, J. Enrique Domínguez Muñoz, Matthias Löhr

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References

Mistakes

References

Mistake 1 Mistake 2 Mistake 3 Mistake 4 Mistake 5 Mistake 6 Mistake 7 Mistake 8 Mistake 9 Mistake 10

Fevery J. Bilirubin in clinical practice: a review. Liver Int 2008; 28: 592–605. [Link]

Silverberg NB and Lee-Wong M. Generalized yellow discoloration of the skin. The diagnosis: carotenemia. Cutis 2014; 93: E11–E12. [Link]

Marchand A, Galen RS and Van Lente F. The predictive value of serum haptoglobin in hemolytic disease. JAMA 1980; 243: 1909–1911. [Link]

Vitek L, et al. Gilbert syndrome and ischemic heart disease: a protective effect of elevated bilirubin levels. Atherosclerosis 2002; 160: 449–456. [Link]

European Association for the Study of the Liver. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66: 1047–1081. [Link]

Taylor T and Wheatley M. Jaundice in the emergency department: meeting the challenges of diagnosis and treatment. Emerg Med Pract 2018; 20: 1–24. [Link]

European Association for the Study of the Liver. EASL Clinical Practice Guidelines: Autoimmune hepatitis. J Hepatol 2015; 63: 971–1004. [Link]

10.

Chand N and Sanyal AJ. Sepsis-induced cholestasis. Hepatology 2007; 45: 230–241. [Link]

11.

Giallourakis CC, Rosenberg PM and Friedman LS. The liver in heart failure. Clinics Liv Dis 2002; 6: 947–967. [Link]

12.

van Lingen R, et al. Jaundice as a presentation of heart failure. J R Soc Med 2005; 98: 357–359. [Link]

13.

Okwara CJ, et al. Jaundice: A thyroid problem? Dig Dis Sci 2017; 62: 1901–1905. [Link]

14.

Saik RP, et al. Spectrum of cholangitis. Am J Surg 1975; 130: 143–150. [Link]

15.

Miura F, et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 47–54. [Link]

16.

Thursz MR, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. New Engl J Med 2015; 372: 1619–1628. [Link]

17.

18.

Moreau R, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144: 1426–1437, e1–9. [Link]

19.

Desmet VJ, et al. Classification of chronic hepatitis: diagnosis, grading and staging. Hepatology 1994; 19: 1513–1520. [Link]

20.

Kamath PS, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464–470. [Link]

Abstract

Pancreatic exocrine insufficiency (PEI) is a common yet frequently under-recognised cause of maldigestion, malabsorption, and malnutrition. Although traditionally associated with primary pancreatic disorders such as chronic pancreatitis, cystic fibrosis, pancreatic cancer, or pancreatic surgery, it is now evident that PEI also occurs in a wide range of extra-pancreatic conditions and clinical settings. Advances in diagnostic testing and expanding clinical awareness have improved detection; however, significant misconceptions persist regarding when to suspect PEI; how to interpret diagnostic tests; and how to initiate, optimise, and monitor pancreatic enzyme replacement therapy (PERT). In everyday practice, these errors may lead to delayed diagnosis, inappropriate treatment, persistent symptoms, and preventable nutritional deficiencies. This “Mistakes in…” article highlights common pitfalls in the diagnosis and management of PEI, focusing on inappropriate reliance on faecal elastase testing, failure to recognise secondary causes, undertreatment with PERT, and inadequate nutritional assessment. By addressing these frequent mistakes, we aim to promote a more structured, patient-centred, and evidence-informed approach to PEI that improves clinical outcomes and quality of life.

Topics

Pancreas

Published

2026

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ECCO-ESGAR-ESP-IBUS Guideline on Diagnostics and Monitoring of Patients with Inflammatory Bowel Disease: Part 1: initial diagnosis, monitoring of known inflammatory bowel disease, detection of complications

Torsten Kucharzik

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UEG Standards and Guidelines

Clinical Practice Guideline

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

Not sure what you can access? Learn more about account types.

ECCO-ESGAR-ESP-IBUS Guideline on Diagnostics and Monitoring of Patients with Inflammatory Bowel Disease: Part 1: initial diagnosis, monitoring of known inflammatory bowel disease, detection of complications

Torsten Kucharzik

Summary

AI Generated

Summary is not available for this content yet.

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Guideline

Abstract

The current consensus guideline offers a comprehensive and practical guidance on the diagnostic and monitoring of patients with inflammatory bowel disease (IBD). It provides recommendations on requirements for initial diagnosis, detection of complications, the use of monitoring tools in patients with IBD and diagnostics in specific situations, such as pregnancy, postoperatively and for cancer surveillance. The guideline is a joint project of the European Crohn’s and Colitis Organization (ECCO), the European Society of Gastrointestinal and Abdominal Radiology, the European Society of Pathology, and the International Bowel Ultrasonography Group under the leadership of ECCO.

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 19, Issue 7

Published

2025

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ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease

Henit Yanai

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Sanjay Pandanaboyana

European Society for the Study of Coeliac Disease (ESsCD) 2025 Updated Guidelines on the Diagnosis and Management of Coeliac Disease in Adults. Part 2: Management, Follow-Up, and Complex Disease Courses

Abdulbaqi Al-Toma

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Matthias Löhr

ECCO-ESGAR-ESP-IBUS Guideline on Diagnostics and Monitoring of Patients with Inflammatory Bowel Disease: Part 1: initial diagnosis, monitoring of known inflammatory bowel disease, detection of complications

Torsten Kucharzik

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

Javier P. Gisbert

UEG Standards and Guidelines

Clinical Practice Guideline

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

Not sure what you can access? Learn more about account types.

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

Javier P. Gisbert

Summary

AI Generated

Summary is not available for this content yet.

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Guideline

Introduction

Ulcerative colitis [UC] is a chronic inflammatory bowel disease [IBD] characterised by colonic inflammation extending to a variable extent from the rectum. Care of the patient with UC requires appropriate input from across the multiprofessional team. These guidelines summarise the recommended medical treatment for adults with UC.

In 2022, the European Crohn’s and Colitis Organisation [ECCO] published new guidelines on the management of UC in two papers focused on the medical and surgical management of the disease.¹^,² For the 2022 UC guidelines, ECCO adopted the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] approach, a systematic process for developing guidelines that addresses how to frame healthcare questions, summarise the evidence, formulate recommendations, and grade their strength and the quality of associated evidence.³ The present paper represents an update to the 2022 guidelines and focuses specifically on the medical management of UC, while a companion paper developed as part of the same process addresses optimal surgical management [ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment].

For this iteration of the guidelines, we have introduced several new, clinically relevant questions selected by members of the guidelines group, alongside a systematic approach to reviewing and updating previous topics to incorporate new evidence and to reappraise all findings within the context of contemporary practice. We have also introduced several “practice points” to summarise evidence and provide expert recommendations in key areas where the evidence remains limited but clinical decisions are still required. In such instances, where application of the GRADE methodology may be impractical, we adopted an approach based on systematic literature review, expert discussion, and voting to reach consensus recommendations outside the formal GRADE process.

Patients living with UC can have a variable disease course.⁴ In this document, we discuss therapeutic approaches stratified by disease severity [mildly-to-moderately active and moderately-to-severely active disease]. Definitions of disease severity are commonly used to establish clinical trial inclusion criteria and may be based on several distinct assessment frameworks.⁵ It is also important to remember that these definitions capture severity at a given point in time and may not reflect the cumulative long-term burden of disease experienced by a patient.⁶

It is also important to consider disease extent when planning treatment in UC, as this may affect the optimal route of drug administration. This is typically defined according to disease involving the rectum only [proctitis], disease distal to the splenic flexure [left-sided or distal UC], or disease extending proximal to the splenic flexure [extensive UC].⁷ It should be noted that disease distribution can change⁴ and that proximal disease extension can be a negative prognostic marker.⁸

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 20, Issue 7, July 2026

Published

2026

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ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease

Henit Yanai

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Sanjay Pandanaboyana

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Abdulbaqi Al-Toma

Mistakes in Pancreatic exocrine insufficiency and how to avoid them

Matthias Löhr

ECCO-ESGAR-ESP-IBUS Guideline on Diagnostics and Monitoring of Patients with Inflammatory Bowel Disease: Part 1: initial diagnosis, monitoring of known inflammatory bowel disease, detection of complications

Torsten Kucharzik

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Javier P. Gisbert