What is Jaundice?
Jaundice, or hyperbilirubinemia, is a condition where the skin and body tissues turn yellow. This happens when there’s too much bilirubin in the body – a substance our bodies produce naturally, but in excessive amounts, can cause problems. Normally, our bodies have less than 1mg/dl of bilirubin, but if it goes above 3mg/dl, that’s when we can start to see the signs of jaundice, like yellowing of the whites of the eyes, a phenomenon known as scleral icterus.
As bilirubin levels continue to rise, the skin can even begin to turn colors from a yellow to a green hue, creating something that might resemble a green apple. This is more likely to occur if bilirubin levels have been high for a long period of time.
Now, bilirubin can be in an unconjugated (indirect) form, or a conjugated (direct) form, and the increase in either of these forms can cause jaundice. This condition is significant because it’s a strong indicator of potential liver disease, along with other health issues.
It’s important to note that if the skin looks yellow but the whites of the eyes don’t, that’s not jaundice. It might be carotenoderma, which can happen if someone eats too many foods that are rich in carotene, like carrots. This is a harmless condition that can happen to anyone.
What Causes Jaundice?
Conjugated hyperbilirubinemia refers to a condition where a substance called bilirubin, made when our body breaks down red blood cells, builds up in the blood because it’s not properly cleared out by the liver. This can occur due to different reasons:
A disorder in the way your liver cells transport organic anions, as seen in Dubin-Johnson syndrome, or a decrease in your liver’s ability to reabsorb bilirubin, a characteristic of Rotor syndrome. Additionally, several conditions can cause the liver to excrete less bilirubin. This includes viral or alcoholic hepatitis, cirrhosis (scarring of the liver), nonalcoholic steatohepatitis (inflammation and liver cell damage), and some bacterial or viral infections like mononucleosis or herpes. Other causes include diseases that cause liver damage (like primary biliary cholangitis or primary sclerosing cholangitis), conditions that infiltrate the liver (such as amyloidosis or tuberculosis), and external factors like sepsis, certain drugs and toxins (e.g., oral contraceptives, some antibiotics, steroids, specific herbal medications), or pregnancy.
Another way bilirubin can build up is if there’s a blockage in the bile ducts, tubes that carry bile from the liver to the gallbladder, and then to the intestines. This could be due to gallstones, tumors, congenital malformation of the bile ducts (biliary atresia), pancreatitis, stricture (narrowing) of the ducts, or certain parasitic infections.
Apparently, the build-up of bilirubin can also occur when there’s either too much bilirubin being produced in the body, like in cases of hemolytic anemias or when there’s internal bleeding, or when the liver cells don’t take in enough bilirubin, as can happen with Gilbert’s syndrome. Conditions that affect the liver’s ability to convert bilirubin into a form that can be easily removed from the body, like Crigler-Najjar syndrome, hyperthyroidism, or the presence of estrogen, can also lead to high levels of bilirubin in the blood.
Risk Factors and Frequency for Jaundice
Jaundice is a condition that changes how common it is depending on the patient’s age group, particularly striking newborns and the elderly more often. The causes of jaundice also depend on the age. For example, about 20% of full-term babies develop natural jaundice in their first week due to the immature liver process. Other causes for jaundice in babies and children can include birth defects, problems with overproduction from breaking down red blood cells, issues with bilirubin uptake, and defects in conjugation. Hepatitis A, in particular, has been identified as a main cause of jaundice in children. Additionally, in older people, jaundice can be caused by bile duct stones, drug-induced liver disease, and cancerous bile obstruction.
It’s also worth noting that gender can influence the prevalence of certain conditions leading to jaundice. Men are more commonly affected by alcohol and non-alcohol related cirrhosis, chronic Hepatitis B, pancreatic malignancy, and sclerosing cholangitis. On the other hand, women are more likely to develop gallbladder stones, primary biliary cirrhosis, and gallbladder cancer.
Kernicterus or Bilirubin-induced neurologic dysfunction (BIND), a serious complication of severe jaundice, is quite rare. However, it can be lethal in newborns, with a death rate of 0.28 deaths per one million live births.
Signs and Symptoms of Jaundice
When diagnosing a patient with symptoms like yellowish skin and itching, doctors typically ask detailed questions to narrow down potential causes. Some patients might not show any symptoms. Doctor’s will ask about the use of medication, alcohol, or other harmful substances, as well as any risk factors for hepatitis, such as travel or unsafe sex. They may also ask about HIV status and any personal or family history of inherited or blood disorders. Other crucial information includes how long the patient has been experiencing jaundice and the presence of any other symptoms, like joint pain, skin rash, muscle soreness, or changes in urine and stool. History of pain in joints and muscles before the onset of yellow coloration hints towards hepatitis, which might be due to drugs or viral infections.
Some additional symptoms such as fever, chills, severe right-sided abdominal pain, and significant weight loss could indicate conditions like inflammation of the bile duct (cholangitis), hepatitis, or a malignancy obstructing the bile ducts. Patients with a history of ulcerative colitis might experience increased bilirubin levels due to primary sclerosing cholangitis (PSC).
A doctor’s physical examination typically starts with assessing the patient’s overall appearance and nutrition status. Observations of wasting in the temples and muscles close to the center of the body could signal cancer or cirrhosis, an advanced liver disease. Common signs of chronic liver disease include spider-like blood vessels, reddening of the palms, breast enlargement in men, enlarged parotid glands, and testicular atrophy. An examination might also reveal noticeably enlarged lymph nodes, which can be a sign of cancer. The presence of jugular vein distension – when veins in the neck become enlarged due to heart failure – suggests liver congestion caused by the heart not effectively pumping blood.
During the abdominal examination, the doctor will look for any enlargement of the liver or spleen (hepatosplenomegaly), or the buildup of fluid in the abdomen (ascites). If a patient with jaundice also has ascites, this can be a sign of either cirrhosis or cancer that has spread to the abdomen.
Tenderness in the right side of the upper abdomen, combined with a palpable gallbladder – a condition known as Courvoisier sign – may suggest that cancer is blocking the cystic duct, a tube that carries bile from the gallbladder.
Testing for Jaundice
If your doctor suspects an issue with your liver, you may need to undergo a series of laboratory tests known commonly as liver function tests. These tests check the levels of various chemicals in your blood, including the enzymes aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP). They also look at the level of gamma-glutamyltransferase, serum albumin, protein, and bilirubin.
If the levels of AST and ALT increase while ALP stays low, the issue is likely coming directly from the liver. For instance, if the ratio of AST to ALT is more than 2 to 1, alcoholic liver disease may be the culprit. If AST and ALT values are very high (in the 1000s), the liver problem may be due to toxins like acetaminophen, a lack of blood to the liver (ischemia), or a virus.
If on the other hand, ALP levels increase to five times the normal level while liver transaminase levels stay normal or less than twice as high as normal, the problem could be caused by a blockage in the bile ducts, which carry bile from the liver to the intestine to aid in digestion. Sometimes it’s hard to tell if high levels of ALP are from the liver or bone diseases, but another blood test for GGT can help confirm if the high ALP is due to an issue in the liver.
When the levels of AST, ALT, and ALP are normal, but there is jaundice (a yellowing of the skin and eyes), it could be due to pre-liver problems such as inherited liver or blood disorders, or problems with the liver’s ability to excrete bilirubin.
The liver tests may also measure levels of bilirubin, a yellow substance produced during the normal breakdown of red blood cells. An increase in bilirubin levels may cause jaundice. These tests also look at the liver’s production of serum albumin, a protein made by the liver, and prothrombin time – a measure of how long it takes your blood to clot.
Based on the results of these tests, your doctor can determine whether the problem lies with the liver cells themselves or with a blockage of bile ducts – and they will get a better idea of the disease’s severity and length. Doctors will recommend additional tests based on their initial assessment.
If the problem is with the liver cells, a ‘hepatocellular workup’, testing for signs of viral infections, autoimmune diseases, and levels of specific proteins may be carried out. If the problem seems to lie with the bile ducts (‘cholestatic workup’), you may need to have an abdominal ultrasound, CT scan, or other imaging to take a closer look at these ducts.
Treatment Options for Jaundice
The best way to treat jaundice is to focus on the underlying issues causing it, which could be problems with the liver, gallbladder, or blood diseases, if possible.
Itchiness, also known as pruritis, that is linked to cholestasis (a condition where bile cannot flow from the liver to the gut) can be managed according to how severe it is. For mild itchiness, things as simple as a warm bath or an oatmeal bath can bring relief. Over-the-counter medications like antihistamines can also help.
If the itchiness is moderate to severe, medications that bind to bile acids in the intestines (like cholestyramine or colestipol) could provide relief. Varying results have been reported with other treatments, including rifampin, naltrexone, sertraline, or phenobarbital, which are generally less effective. In severe cases where medical treatment options have not been successful, liver transplantation may be the only option left to stop the itchiness.
Jaundice can indicate serious liver damage, and based on the severity of this damage, evaluation for a possible liver transplant might become necessary.
What else can Jaundice be?
If someone’s skin turns yellow, there could be a few different explanations. One common cause is eating lots of fruits and vegetables that are high in carotene, like carrots. This can lead to a condition called carotenoderma, which doesn’t affect the white part of the eyes.
Another possible cause is a medication called Quinacrine. Around one in three people who are treated with Quinacrine may have their skin turn yellow.
What to expect with Jaundice
How well a person recovers from jaundice, or the yellowing of the skin and eyes due to abnormal liver function, largely depends on what’s causing it.
Various conditions can lead to jaundice, but some are associated with a very good chance of recovery. These include jaundice resulting from the body absorbing hematomas (or blood that has collected outside of blood vessels), normal jaundice in newborn babies, jaundice from breastfeeding, jaundice from breast milk, Gilbert syndrome (a mild liver condition), and choledocholithiasis (gallstones in the common bile duct).
However, not all causes of jaundice have such a positive outlook. Jaundice as a result of malignant (or cancerous) blockages in the bile duct and cirrhosis (a late stage of scarring of the liver) could lead to a worse prognosis, or outlook for recovery.
Possible Complications When Diagnosed with Jaundice
Indirect bilirubin, which isn’t easily dissolved in water, can damage cells and their structures. The danger is higher in newborn babies because their natural protective mechanisms against an increase in bilirubin aren’t fully developed yet. A part of the reason is due to their underdeveloped blood-brain barrier. High bilirubin levels can prove harmful to the nervous system and may cause a permanent brain damage condition known as kernicterus, or Bilirubin-induced neurologic dysfunction.
Potential Harm:
- Damage to cells and cell structures
- Higher risk to newborn babies
- Impacts the nervous system
- Can cause permanent brain damage (kernicterus)
Preventing Jaundice
In many cases, jaundice, a condition that causes a yellow tint to the skin and eyes, can be effectively prevented by following a few simple tips:
1. Before taking any herbal medications, always consult with your doctor. Many of these supplements can harm your liver and may lead to irreversible liver damage which can result in jaundice.
2. Avoid smoking, drinking alcohol and using drugs that are injected with a needle.
3. Always stick to the recommended dosage of your prescribed medications. Taking more can put your liver at risk.
4. If you notice your skin or eyes turning yellow, see your doctor as soon as possible as this could be a sign of jaundice.
5. Practice safe sex. Certain sexually transmitted diseases can cause jaundice.
6. If you’re planning to travel abroad, make sure you get all the recommended vaccines. Some infectious diseases in foreign countries can lead to jaundice.