This case report describes a 49-year-old male trauma patient, admitted to intensive care after laparotomy with intra-abdominal bleeding and haemorrhagic shock. He needed massive blood transfusion and he developed multiple organ failure (MOF). After six days, severe jaundice developed due to conjugated hyperbilirubinaemia which peaked on day nine at a total serum bilirubin concentration of 650 μmol/l of which 90% was conjugated. From day 20 his serum bilirubin suddenly dropped to subnormal levels. Liver synthesis function remained intact. No signs of extra-hepatic bile duct injury or obstruction were found. Alongside massive blood transfusion-related haemolysis and resorption of haematomas, the occurrence of shock, sepsis and MOF plays an important role in the development of conjugated hyperbilirubinaemia and hepatic dysfunction in critically-ill trauma patients. This is related to a reduced hepatic excretory capacity for conjugated bilirubin, which can be aggravated by pre-existent liver disease and use of hepatotoxic drugs. Copyright © 2009, Nederlandse Vereniging voor Intensive Care. All Rights Reserved.