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Summary

Jaundice is a disease in which the total serum bilirubin (TSB) level rises above 3 mg/dL. The symptoms include yellowing of your skin, the white part of your eyes, and mucous membranes (linings of internal soft organs such as mouth). Newborn babies usually have jaundice, but adults can suffer from it too. In adults, other symptoms are also seen such as stomach pain, loss of appetite, weight loss, etc. In babies, phototherapy and blood transfusion, while in adults, it includes removal of the causative factor, medications and sometimes, a surgery. If left untreated, it can affect the brain of the child, and other complications like sepsis, liver and kidney diseases or failure.

Metabolism of bilirubin

Our body keeps generating new red blood cells (RBCs) and wards off the old ones. During this process, the haemoglobin which is inside the old RBCs is broken down into globin, iron, and biliverdin. Globin and iron are re-utilised in our bone marrow to produce new haemoglobin, whereas biliverdin is broken down again to leave a byproduct called bilirubin. Our liver takes up this bilirubin for its further metabolism. This processed bilirubin flows through the bile duct and enters the intestine. The intestine also splits it down into urobilinogen and stercobilinogen. Urobilinogen is absorbed back again to be released into the blood circulation, some of which re-enters our liver while the rest of it is removed by our kidneys in the urine. Stercobilinogen is excreted out through stools.

  1. Types of Jaundice
  2. Symptoms of Jaundice
  3. Causes and Risk factors of Jaundice
  4. Diagnosis of Jaundice
  5. Treatment of Jaundice
  6. Complications of Jaundice
  7. Jaundice Prevention
  8. Doctors for Jaundice

Types of Jaundice

In babies

  • Neonatal Jaundice (jaundice in newborn babies)
  • Hemolytic Jaundice

In Adults

  • Pre-hepatic or hemolytic jaundice
  • Hepatic or hepatocellular jaundice
  • Post-hepatic or obstructive or cholestatic jaundice

Symptoms of Jaundice

In babies

  • Neonatal or Physiological jaundice
    Mostly, healthy babies present with mild to no symptoms of jaundice. But, if your newborn has a low birth weight or had a premature delivery, your baby might show distinctive features of jaundice. The symptoms may take up to one week to appear in your baby’s body and might last for almost three weeks to a month. Your baby’s skin, the inner soft lining of the mouth, the white parts the eyes, palms, and soles turn yellow, the urine becomes dark yellow coloured, and the stools get paler with time. The yellow tinge of the skin starts developing from your baby’s head and face and spreads to the rest of the body in a few days. Your baby may also face difficulty in sucking milk, feel weak and sleepy, and have a high-pitched cry.
  • Hemolytic Jaundice
    In an Rh-positive (Rh means Rhesus which is a protein found on RBCs. If a person has this protein, he/she is Rh positive) baby who is born to an Rh-negative mother (who does not have Rh protein on her RBCs), excessive destruction of RBCs takes place. Rh-positive blood has a D-antigen which acts as a foreign body to the mother’s immune system. The mother's immune system gets sensitised to this antigen and produces anti-D antibodies (proteins which recognize D-antigens and kill such RBCs). These antibodies cross her placenta (or umbilical cord) and begin the destruction of RBCs of the fetus where the D-antigens are attached. Hemolysis raises the TSB level in the serum and causes jaundice. This condition is also known as hemolytic disease of the newborn or erythroblastosis fetalis. The symptoms are similar to those seen in neonatal jaundice. Other symptoms that your baby may experience are:
    • Stomach pain.
    • A reduction in blood haemoglobin level leading to anaemia.
    • Congestive cardiac failure (heart failure).

In adults

Adults also present with typical symptoms of jaundice such as yellow discolouration of the skin, the white part of the eyes, and mucous membranes. Besides these, other symptoms of adult jaundice include stomach pain in upper right side which might radiate to other areas of the body like right side of the back, right shoulder, right lower stomach area, etc, itchiness, pale palms and soles, weight loss, loss of appetite, fever, dark yellow urine and pale yellow stools.

Causes and Risk factors of Jaundice

In babies

  • Physiological or neonatal jaundice
    In babies, it happens merely due to raised levels of TSB (total serum bilirubin) and the liver is completely healthy. During pregnancy, the child’s bilirubin passes through the umbilical cord (a cord that connects the mother and the baby in the uterus) and enters the mother’s blood circulation and is metabolised by her liver. After birth, the baby’s bilirubin level rises because it takes a few days for the liver to develop and become fully functional. As a result, your baby may develop jaundice.
  • Hemolytic jaundice
    It occurs in a baby who is Rh-positive and is born to a mother who is Rh-negative because of the incompatibility of their blood.
  • Other causes of severe jaundice in babies 
    These include infections like syphilis and rubella, galactosemia [lack of enzymes to process galactose (milk sugar), high levels of which can cause damage to the liver leading to jaundice)], lack of bilirubin processing enzymes, internal bleeding in the head because of a difficult delivery, hepatitis, etc.

In adults

  • Pre-hepatic or hemolytic jaundice
    When there is an excessive breakdown of your RBCs, for example, in hemolytic anaemia, the level of TSB shoots up to a value which is more than what a healthy liver can take up and excrete. This is called hemolytic jaundice.
  • Hepatic or hepatocellular jaundice
    In this type of jaundice, the breakdown of RBCs is normal, but your liver is damaged. When your liver is damaged, its ability to process and excrete bilirubin into the intestine via bile duct also reduces. As a result, the TSB level rises. Some of the liver diseases and conditions in which jaundice is common are as follows:
    • Acute inflammation of the liver in which the liver swells up and is filled with fluid.
    • Hepatitis disease which is caused by virus and bacteria. It can also occur as an autoimmune disease. Autoimmune diseases are those in which the immune system starts destroying your own normal body cells. 
    • Alcoholic fatty liver disease which is caused by excessive alcohol intake.
    • Drug overdose such as taking high doses of acetaminophen or poison.
    • Recent liver surgery.
    • Infected blood transfusion.
    • Liver cancer, etc. 
  • Post-hepatic jaundice
    In post-hepatic jaundice, the process of RBC breakdown and the liver function, both are normal, but your bile duct is obstructed, for example, in inflammation (swelling) of the bile duct, cholestasis (decrease in bile flow), bile duct obstruction, gallstones and pancreatic cancer that cause obstruction of the bile duct. An obstructed bile duct makes the release of bilirubin processed by your liver into the intestine difficult. As a result, your liver is unable to take up bilirubin from the blood until the processed bilirubin is released into the intestine. This causes an increase in TSB levels of your blood serum due to the continued breakdown of old RBCs.
  • Other causes 
    These may include falciparum infection causing malaria, pregnancy hyperemesis gravidarum (a condition which occurs during pregnancy in which the woman experiences severe vomiting, dehydration, fatigue, jaundice, and low blood pressure) etc.

Diagnosis of Jaundice

Based on the symptoms mentioned above, if you suspect that you might be suffering from jaundice, please refer to a doctor and get your complete examination and tests done in order to get early treatment. This will not only prevent further damage to your body but also save your time and expenditure.

Physical examination

Your doctor may conduct a complete physical examination starting from the history of your illness, for example, the onset of symptoms, duration, location and severity of pain, weight loss, exposure to drugs, medications and toxins, social history including alcohol intake, sexual activities, etc, any previous history of surgery or infection, followed by a check-up to see color changes in your skin, eyes and mouth, a detailed examination of your stomach area, etc. Mostly, physical examinations provide enough information for a diagnosis, but sometimes, it may be followed by laboratory and radiologic tests which will provide your doctor with a confirmatory diagnosis for your illness.  

Laboratory Tests

  • Blood tests
    • Complete blood count (CBC)
      Your CBC will identify whether there is a presence of hemolysis (breakdown of red blood cells), blood cells which are abnormally shaped, parasite infection, etc.
      An increase in the number of your WBCs (white blood cells) signifies alcoholic hepatitis, cholangitis (inflammation of bile duct), infection, toxic hepatitis, hypersensitivity, etc.
       
    • Transaminases (SGOT and SGPT)
      SGOT (serum glutamic oxaloacetic transaminase) and SGPT (serum glutamic pyruvic transaminase) are the enzymes which are specifically produced by the skeletal and heart muscles, liver, and kidneys. Hence, a test to check the levels of transaminases in your serum is almost always confirmatory. The serum levels of transaminases are found to be higher in hepatocellular jaundice as compared to those in obstructive jaundice. In alcoholic hepatitis, the levels of SGPT may rise above 600, while SGOT may be lower than that. In viral hepatitis, both the enzymes are raised more than ten times the upper limit of their normal range.
       
    • Total Serum bilirubin (TSB)
      As the name suggests, this test is done to check the levels of bilirubin in your serum. A TSB value of up to 2 mg/dL per day is mostly seen in cases of obstruction of bile duct outside the liver (extrahepatic obstruction), but anything more than this points towards hemolysis, liver damage or liver diseases.
       
    • Serum Alkaline Phosphatase
      This is also an enzyme produced by your intestinal mucosa, liver, bone marrow, etc. Elevation of the serum value to three times the upper limit of the normal range of this enzyme indicates an obstruction in your bile duct. In the case of liver diseases, the levels are not raised that much. In alcoholic liver disease, the elevation in serum level of ALP is more than five times the normal range.
       
    • Liver Function Tests (LFT)
      However, not very confirmatory, but tests for your liver enzymes are helpful in the overall diagnosis of your illness based on your detailed history and a thorough physical examination. Hence, LFTs have more of an additive effect in the overall diagnosis.
       
    • Prothrombin precursor protein
      This protein is one of the many coagulation proteins produced in the body and its action is dependent on Vit.K. It is primarily produced by your liver and its levels reduce whenever you have any liver disease in your body. Levels returning to normal indicate restoration of your liver function.
       
    • Serological assays for hepatitis A and B
      If your jaundice is developing in a short duration of time, it can be caused by hepatitis A virus, whereas, hepatitis B virus causes a chronic (occurring over a long period of time) liver disease. Hence, a serological essay can be done based on the duration of illness.
       
    • Albumin
      Albumin is a protein produced by your liver. Any fall in the level of your serum albumin indicates that some kind of liver disease is there since last 1-2 weeks because the plasma half-life of albumin (time required to reduce the concentration of albumin to half) is 1-2 weeks.

Radiological Tests

Although, your history of present illness and physical examination provide enough information for its diagnosis, but radiological tests give a clearer picture of obstructive and surgical causes of jaundice and hence are of great importance. Some of the radiological tests that your doctor may advise you in jaundice are:

  • X-ray
    An abdominal X-ray is useful in identifying the presence of gallbladder stones or gallstones, and calcifications in your liver and pancreas.
     
  • Sonography
    If there is a dilation of the bile duct, presence of gallstones, and abnormal enlargement or reduction in the size of liver and pancreatic tissue, it can be detected by performing this test. However, this test can be inconclusive in cases where the patient has obesity (tummy fat) and bowel gas accumulation because in such cases, transmission of sound waves is hindered.  
     
  • Computerized tomography (CT)
    It gives a clearer picture of your complete stomach area and its organs like the pancreas, liver, bile ducts, gallbladder, etc. It also identifies the level where the obstruction is present much better than that done by an abdominal sonography.
     
  • Percutaneous transhepatic cholangiography
    In this test, a thin needle is passed into the liver using a fluoroscopic guide and a contrast (a dye) is injected into the bile duct system. This helps in locating the areas with bile duct dilations within and outside the liver.
     
  • Hepatobiliary scintigraphy (HBS)
    Hepatic scintigraphy with computer assistance has proven to be an accurate tool for diagnosing obstruction in large as well as small bile ducts.
     
  • Endoscopic retrograde cholangiopancreatography
    In this test, a fibre optic endoscope is inserted into the upper part of the person's intestine (duodenum), and a cannula is inserted into his/her pancreatic and common bile ducts, and under fluoroscopy, a contrast medium is injected into these structures. The procedure can easily identify pancreatic cancer and other tumours.
     
  • Mesenteric arteriography
    This procedure helps in visualizing the vascular supply and adjacent vessels of a tumour or an inflammatory mass.

Other Procedures

  • Liver Biopsy
    It is usually done when none of the above diagnostic procedures is conclusive. It can also be done using a needle or a laparoscope, which helps is visualising the obstructions both inside and outside the liver. A biopsy is a powerful tool in not only identifying diseases such as jaundice but also other chronic liver diseases, tumour, cancer, etc. It also helps in performing liver enzyme assays and chemical analysis for certain diseases.

Treatment of Jaundice

Depending on the type of jaundice, different methods are followed to treat it. A few treatment methods are explained below:

In babies

  • Neonatal jaundice
    Your baby’s symptoms may subside within 2-4 weeks when the liver becomes fully developed and is able to take up and metabolize the excess bilirubin. However, if your baby has severe jaundice and the level of TSB in the baby’s serum is high, treatment may be required. Treatment includes Phototherapy, exchange transfusion, etc.
    • Phototherapy
      In phototherapy, your baby is exposed to as much light as possible. The light and oxygen together cause photo-oxidation in which oxygen is added to bilirubin so that it dissolves in water and makes it easier for your baby's liver to break it down and excrete it from the body. The therapy is stopped for 30 minutes after every 3-4 hours so that the mother can feed the baby. If your baby’s TSB level does not fall to normal in 1-2 days, the phototherapy might be continued without any breaks.
       
    • Exchange transfusion
      If the phototherapy isn’t effective and the bilirubin level of your baby is extremely high, a blood transfusion may be recommended. Blood is taken from a suitable donor (with the same blood group and without any blood disorders or infections) and the baby’s blood is slowly replaced with it. Since the new blood isn’t high in bilirubin, the baby’s serum bilirubin level falls rapidly. The baby is monitored throughout the process and also after two hours of blood transfusion to check the bilirubin level.
       
  • Hemolytic Disease of the newborn (Erythroblastosis fetalis)
    Mild cases do not usually require any treatment. In severe cases, along with phototherapy, a blood transfusion may be recommended, or the baby’s condition might improve by injecting immunoglobulins (proteins produced by the immune system of the body to fight against foreign bodies) which prevent further breakdown of the baby’s RBCs and help to reduce the TSB levels.

In adults
In adults, the treatment of jaundice depends on the underlying cause and involves its removal. Following are the examples of the underlying causes of jaundice and the treatment involved: 

  • Anaemia
    Your doctor may prescribe iron supplements to prevent the breakdown of RBCs
  • Infection (e.g., hepatitis)
    It can be treated by using antiviral or antibiotic drugs
  • Liver damage, as in chronic liver disease or alcoholic fatty liver disease
    Your physician will advise you to quit alcohol consumption to improve your liver function and prevent it from further damage. In extreme cases, a liver transplant may also become necessary
  • Obstruction in the bile duct
    Bile duct could get obstructed due to its inflammation, pancreatic cancer pressing on the bile duct, tumours, etc. The treatment involves removing the obstruction by surgery.
  • Genetic diseases that cause jaundice
    Treatment may include infusion of the deficient factors which cause jaundice.

Self-care

Self-care is as important as the treatment. It is important to take light, balanced, and low-fat diet, lots of fluids, fresh juices, medications and adequate rest. You are advised not to eat heavy, spicy, and street food. Do not drink water from unknown sources and maintain personal hygiene.

Complications of Jaundice

If left untreated, jaundice may have severe complications in babies as well as adults. A few complications are listed below:

Kernicterus
If the level of TSB in your baby's serum becomes drastically high, bilirubin might make it across the tissue that separates the brain from the rest of the body (blood-brain barrier) and enter the brain causing kernicterus. Your baby may experience impaired muscle activity, seizures, involuntary movements like twisting and writhing, impaired body senses like hearing, and in extreme cases, it may also lead to death. It causes hearing loss along with the loss of other senses (the baby does not respond to voices), nerve damage, floppy muscles, weakness, and difficulty in feeding.   

Complications of obstructive jaundice
Complications include the presence of toxic substances in the tissue (sepsis) causing liver dysfunction, swelling and fluid build-up in the bile duct (cholangitis) or in the pancreas (pancreatitis), degeneration, inflammation, and thickening of the liver tissue (liver cirrhosis), renal and liver failure, etc.

Jaundice Prevention

The liver is a vital organ because it not only serves as an important source of digestive juices but it also helps in producing blood clotting factors, metabolism of medications taken by the patient, excreting toxic substances from the body, etc. Hence it is important to keep it healthy by:

  • Having a balanced diet.
  • Exercising regularly
  • Drinking clean water.
  • Consuming alcohol (if you do) within recommended doses.
  • Avoiding unprotected sexual activities with multiple partners.
Dr. Mahesh Kumar Gupta

Dr. Mahesh Kumar Gupta

गैस्ट्रोएंटरोलॉजी

Dr. Raajeev Hingorani

Dr. Raajeev Hingorani

गैस्ट्रोएंटरोलॉजी

Dr. Vineet Mishra

Dr. Vineet Mishra

गैस्ट्रोएंटरोलॉजी

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