Jaundice

Jaundice Overview

Jaundice is a yellow discoloration of the skin, mucous membranes, and the whites of the eyes caused by increased amounts of bilirubin in the blood. Jaundice is a sign of an underlying disease process.

Bilirubin is a by-product of the daily natural breakdown and destruction of red blood cells in the body. The hemoglobin molecule that is released into the blood by this process is split, with the heme portion undergoing a chemical conversion to bilirubin. Normally, the liver metabolizes and excretes the bilirubin in the form ofbile. However, if there is a disruption in this normal metabolism and/or production of bilirubin, jaundice may result.

Jaundice Causes

Jaundice may be caused by several different disease processes. It is helpful to understand the different causes of jaundice by identifying the problems that disrupt the normal bilirubin metabolism and/or excretion.

Pre-hepatic (before bile is made in the liver)

Jaundice in these cases is caused by rapid increase in the breakdown and destruction of the red blood cells (hemolysis), overwhelming the liver's ability to adequately remove the increased levels of bilirubin from the blood.

Examples of conditions with increased breakdown of red blood cells include:

malaria,

sickle cell crisis,

spherocytosis,

thalassemia,

glucose-6-phosphate dehydrogenase deficiency (G6PD),

drugs or other toxins, and

autoimmune disorders.

Hepatic (the problem arises within the liver)

Jaundice in these cases is caused by the liver's inability to properly metabolize and excrete bilirubin. Examples include:

hepatitis (commonly viral or alcohol related),

cirrhosis,

drugs or other toxins,

Crigler-Najjar syndrome,

Gilbert's syndrome, and

cancer.

Post-hepatic (after bile has been made in the liver)

Jaundice in these cases, also termed obstructive jaundice, is caused by conditions which interrupt the normal drainage of conjugated bilirubin in the form of bile from the liver into the intestines.

Causes of obstructive jaundice include:

gallstones in the bile ducts,

cancer (pancreatic and gallbladder/bile duct carcinoma),

strictures of the bile ducts,

cholangitis,

congenital malformations, 

pancreatitis,

parasites,

pregnancy, and

newborn jaundice.

Jaundice in newborn babies can be caused by several different conditions, although it is often a normal physiological consequence of the newborn's immature liver. Even though it is usually harmless under these circumstances, newborns with excessively elevated levels of bilirubin from other medical conditions (pathologicjaundice) may suffer devastating brain damage (kernicterus) if the underlying problem is not addressed. Newborn jaundice is the most common condition requiring medical evaluation in newborns.

The following are some common causes of newborn jaundice:

Physiological jaundice

This form of jaundice is usually evident on the second or third day of life. It is the most common cause of newborn jaundice and is usually a transient and harmless condition. Jaundice is caused by the inability of the newborn's immature liver to process bilirubin from the accelerated breakdown of red blood cells that occurs at this age. As the newborn's liver matures, the jaundice eventually disappears.

Maternal-fetal blood group incompatibility (Rh, ABO)

This form of jaundice occurs when there is incompatibility between the blood types of the mother and the fetus. This leads to increased bilirubin levels from the breakdown of the fetus' red blood cells (hemolysis).

Breast milk jaundice

This form of jaundice occurs in breastfed newborns and usually appears at the end of the first week of life. Certain chemicals in breast milk are thought to be responsible. It is usually a harmless condition that resolves spontaneously. Mothers typically do not have to discontinue breastfeeding.

Breastfeeding jaundice

This form of jaundice occurs when the breastfed newborn does not receive adequate breast milk intake. This may occur because of delayed or insufficient milk production by the mother or because of poor feeding by the newborn. This inadequate intake results in dehydration and fewer bowel movements for the newborn, with subsequent decreased bilirubin excretion from the body.

Cephalohematoma (a collection of blood under the scalp)

Sometimes during the birthing process, the newborn may sustain a bruise or injury to the head, resulting in a blood collection/blood clot under the scalp. As this blood is naturally broken down, sudden elevated levels of bilirubin may overwhelm the processing capability of the newborn's immature liver, resulting in jaundice.

Jaundice Symptoms

Jaundice is a sign of an underlying disease process. .

Common signs and symptoms seen in individuals with jaundice include:

yellow discoloration of the skin, mucous membranes, and the whites of the eyes,

light-colored stools,

dark-colored urine, and

itching of the skin.

The underlying disease process may result in additional signs and symptoms. These may include:

nausea and vomiting,

abdominal pain,

fever,

weakness, 

loss of appetite,

headache,

confusion,

swelling of the legs and abdomen, and

newborn jaundice.

In newborns, as the bilirubin level rises, jaundice will typically progress from the head to the trunk, and then to the hands and feet. Additional signs and symptoms that may be seen in the newborn include:

poor feeding,

lethargy,

changes in muscle tone,

high-pitched crying, and 

seizures.

Exams and Tests

The health care pracitioner will need to take a detailed history of the patient's illness, and he or she will also be examined to see if there are any findings that indicate the cause of the patient's jaundice. However, additional testing is usually required to clearly determine the underlying cause of jaundice. The following tests and imaging studies may be obtained:

Blood tests

These may initially include a complete blood count (CBC), liver function tests (including a bilirubin level), lipase/amylase level to detect inflammation of the pancreas (pancreatitis), and an electrolytes panel. In women, a pregnancy test may be obtained. Additional blood tests may be required depending upon the initial results and the history provided to the practitioner.

Urinalysis: Urinalysis is an analysis of the urine and is a very useful test in the diagnosis of screening many diseases.

Imaging Studies

Ultrasound: This is a safe, painless imaging study that uses sound waves to examine the liver, gallbladder, and pancreas. It is very useful for detecting gallstones and dilated bile ducts. It can also detect abnormalities of the liver and the pancreas.

Computerized tomography (CT) scan: A CT scan is imaging study similar to an X-ray that provides more details of all the abdominal organs. Though not as good as ultrasound at detecting gallstones, it can identify various other abnormalities of the liver, pancreas, and other abdominal organs as well. 

Cholescintigraphy (HIDA scan): A HIDA scan is an imaging study that uses a radioactive substance to evaluate the gallbladder and the bile ducts.

Magnetic resonance imaging (MRI): MRI is an imaging study that uses a magnetic field to examine the organs of the abdomen. It can be useful for detailed imaging of the bile ducts.

Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is a procedure that involves the introduction of an endoscope (a tube with a camera at the end) through the mouth and into the small intestine. A dye is then injected into the bile ducts while X-rays are taken. It can be useful for identifying stones, tumors, or narrowing of the bile ducts.

Liver Biopsy

In this procedure, a needle is inserted into the liver after a local anesthetic has been administered. Often ultrasound will be used to guide placement of the needle. The small sample of liver tissue which is obtained is sent to a laboratory for examination by a pathologist (a physician who specializes in diagnosis of tissue samples). Among other things, a liver biopsy can be useful for diagnosing inflammation of the liver, cirrhosis, and cancer.

Jaundice Treatment

Treatment depends on the cause of the underlying condition leading to jaundice and any potential complications related to it. Once a diagnosis is made, treatment can then be directed to address that particular condition, and it may or may not require hospitalization.

Treatment may consist of expectant management (watchful waiting) at home with rest. 

Medical treatment with intravenous fluids, medications, antibiotics, or blood transfusions may be required.

If a drug/toxin is the cause, these must be discontinued. 

In certain cases of newborn jaundice, exposing the baby to special colored lights (phototherapy) or exchange blood transfusions may be required to decrease elevated bilirubin levels.

Surgical treatment may be required.

Medical Treatment

Treatment varies based on the medical condition responsible for causing jaundice, and the associated symptoms and complications. Treatments may include the following:

supportive care,

IV fluids in cases of dehydration,

medications for nausea/vomiting and pain,

antibiotics,

antiviral medications,

blood transfusions,

steroids,

chemotherapy/radiation therapy, and

phototherapy (newborns).

Surgery

Surgical treatment may be necessary in certain cases of cancer, congenital malformations, conditions that obstruct the bile ducts,gallstones, and abnormalities of the spleen. Sometimes, a liver transplant may be necessary.