Causes of Jaundice: Signs and Symptoms

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JAUNDICE

Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and whites of the


eyes due to high bilirubin levels.[3][6] It is commonly associated with itchiness.[2] The feces may be pale and the
urine dark.[4] Jaundice in babies occurs in over half in the first week following birth and does not pose a serious
threat in most.[3][6] If bilirubin levels in babies are very high for too long, a type of brain damage, known
as kernicterus,

Signs and symptoms


The main sign of jaundice is a yellowish discoloration of the white area of the eye (sclera) and the skin. Urine is
dark in colour.[12] Slight increases in serum bilirubin are best detected by examining the sclerae, which have a
particular affinity for bilirubin due to their high elastin content. The presence of scleral icterus indicates a serum
bilirubin of at least 3 mg/dL. The conjunctiva of the eye are one of the first tissues to change color as bilirubin
levels rise in jaundice. This is sometimes referred to as scleral icterus. The sclera themselves are not "icteric"
(stained with bile pigment), however, but rather the conjunctival membranes that overlie them. The yellowing of
the "white of the eye" is thus more properly termed conjunctival icterus. The term "icterus" itself is sometimes
incorrectly used to refer to jaundice that is noted in the sclera of the eyes; its more common and more correct
meaning is entirely synonymous with jaundice

 Pale-colored stools
 Dark-colored urine
 Skin itching
 Nausea and vomiting
 Rectal bleeding
 Diarrhea
 Fever and chills
 Weakness
 Weight loss
 Loss of appetite
 Confusion
 Abdominal pain
 Headache
 Swelling of the legs
 Swelling and distension of the abdomen due to the accumulation of fluid (ascites)

Causes of jaundice
Old red blood cells travel to your liver, where they’re broken down. Bilirubin is the
yellow pigment formed by the breakdown of these old cells. Jaundice occurs when
your liver doesn’t metabolize bilirubin the way it’s supposed to.

Your liver might be damaged and unable to perform this process. Sometimes the
bilirubin simply can’t make it to your digestive tract, where it normally would be
removed through your stool. In other cases, there may be too much bilirubin trying to
enter the liver at once or too many red blood cells dying at one time.

Jaundice in adults is indicative of:

 alcohol misuse
 liver cancer
 thalassemia
 cirrhosis (scarring of the liver, usually due to alcohol)
 gallstones (cholesterol stones made of hardened fat material or pigment
stones made of bilirubin)
 hepatitis A
 hepatitis B
 hepatitis C
 hepatitis D
 hepatitis E
 pancreatic cancer
 G6PD deficiency
 biliary (bile duct) obstruction
 sickle cell anemia
 acute pancreatitis
 ABO incompatibility reaction
 drug-induced immune hemolytic anemia
 yellow fever
 Weil’s disease
 other blood disorders such as hemolytic anemia (the rupture or destruction of
red blood cells that leads to a decreased number of red blood cells in your
circulation, which results in fatigue and weakness)
 an adverse reaction to or overdose of a medication, such as an
acetaminophen (Tylenol)

Jaundice is also a frequent occurrence in newborns, especially in babies who are


born prematurely. An excess of bilirubin may develop in newborns because their
livers haven’t fully developed yet. This condition is known as breast milk jaundice

Risk factors

Major risk factors for jaundice, particularly severe jaundice that can cause
complications, include:

 Premature birth. A baby born before 38 weeks of gestation may not be


able to process bilirubin as quickly as full-term babies do. Premature
babies also may feed less and have fewer bowel movements, resulting in
less bilirubin eliminated through stool.

 Significant bruising during birth. Newborns who become bruised during


delivery gets bruises from the delivery may have higher levels of bilirubin
from the breakdown of more red blood cells.

 Blood type. If the mother's blood type is different from her baby's, the
baby may have received antibodies through the placenta that cause
abnormally rapid breakdown of red blood cells.

 Breast-feeding. Breast-fed babies, particularly those who have


difficulty nursing or getting enough nutrition from breast-feeding, are at
higher risk of jaundice. Dehydration or a low caloric intake may
contribute to the onset of jaundice. However, because of the benefits of
breast-feeding, experts still recommend it. It's important to make sure
your baby gets enough to eat and is adequately hydrated.

Complications
High levels of bilirubin that cause severe jaundice can result in serious
complications if not treated.

Acute bilirubin encephalopathy

Bilirubin is toxic to cells of the brain. If a baby has severe jaundice, there's a
risk of bilirubin passing into the brain, a condition called acute bilirubin
encephalopathy. Prompt treatment may prevent significant lasting damage.

Signs of acute bilirubin encephalopathy in a baby with jaundice include:

 Listlessness

 Difficulty waking

 High-pitched crying

 Poor sucking or feeding

 Backward arching of the neck and body

 Fever

Kernicterus

Kernicterus is the syndrome that occurs if acute bilirubin encephalopathy


causes permanent damage to the brain. Kernicterus may result in:

 Involuntary and uncontrolled movements (athetoid cerebral palsy)

 Permanent upward gaze

 Hearing loss

 Improper development of tooth enamel

The goals of testing are to determine the cause of jaundice and to evaluate the severity of the
underlying condition. Initial testing, usually a physical exam conducted by a healthcare
practitioner, is generally focused on the liver. Specific additional tests, such as viral hepatitis
testing and/or testing to evaluate increased red blood cell destruction, may be ordered along
with or following the initial tests based on the clinical findings and the healthcare practitioner's
suspicions of the cause of the jaundice.

Laboratory tests
Some tests are used to detect liver damage and evaluate liver function and may include:

 Liver panel, often comprised of:


 ALT (Alanine aminotransferase)
 ALP (Alkaline phosphatase)
 AST (Aspartate aminotransferase)
 Bilirubin, Total (conjugated and unconjugated), Direct (conjugated) and Indirect
(unconjugated)
 Albumin
 GGT (Gamma-glutamyl transferase)
 Prothrombin time (PT): the liver produces proteins involved in the clotting (coagulation)
of blood; the PT measures clotting function and, if abnormal, may indicate liver damage.
 Urine bilirubin (often as part of a urinalysis)

Some tests may be used to detect infections that affect the liver, such as:

 Hepatitis A
 Hepatitis B
 Hepatitis C
 Hepatitis E
 Cytomegalovirus (CMV)
 Epstein-Barr virus (EBV)

Tests used to detect decreased red blood cell survival may include:

 Complete blood count (CBC)


 Reticulocyte count (if CBC is abnormal)
 Blood smear: to visualize RBCs under a microscope
 Haptoglobin

Non-laboratory tests

Imaging tests and liver biopsies may be used to help evaluate the status and structure of the
liver, gallbladder, and bile ducts. Testing may include:

 Abdominal ultrasound
 CT (computed tomography) scan
 MRI (magnetic resonance imaging) scan, often including MRCP (magnetic resonance
cholangiopancreatogram, to visualize the pancreas and bile ducts)
 Endoscopic retrograde cholangiopancreatography (ERCP, a direct imaging of the
pancreas and bile ducts)
 Liver biopsy

Visit RadiologyInfo.org for more details about imaging tests


Diagnostic tests[24]

Pre-hepatic Jaundice due to the Post-hepatic


Function test
jaundice liver jaundice

Normal /
Total bilirubin Increased
increased

Conjugated bilirubin Normal Increased

Normal /
Unconjugated bilirubin Increased Normal
increased

Normal / Decreased /
Urobilinogen Decreased
increased negative

Dark (urobilinogen + Dark (conjugated


Urine color Normal[25]
conjugated bilirubin) bilirubin)

Stool color Brown Slightly pale Pale

Alkaline phosphatase levels Increased

Normal
Alanine transferase and
Increased
aspartate transferase levels

Conjugated bilirubin in urine Not present Present

Large spleen

Pathophysiology[edit]
Jaundice itself is not a disease, but rather a medical sign of one of many possible underlying pathological
processes that occur at some point along the normal physiological pathway of the metabolism of bilirubin in
blood.
When red blood cells have completed their life span of approximately 120 days, or when they are damaged,
their membranes become fragile and prone to rupture. As each red blood cell traverses through
the reticuloendothelial system, its cell membrane ruptures when its membrane is fragile enough to allow this.
Cellular contents, including hemoglobin, are subsequently released into the blood. The hemoglobin
is phagocytosed by macrophages, and split into its heme and globin portions. The globin portion, a protein, is
degraded into amino acids and plays no role in jaundice. Two reactions then take place with the heme
molecule. The first oxidation reaction is catalyzed by the microsomal enzyme heme oxygenase and results
in biliverdin (green color pigment), iron, and carbon monoxide. The next step is the reduction of biliverdin to a
yellow color tetrapyrrole pigment called bilirubin by cytosolic enzyme biliverdin reductase. This bilirubin is
"unconjugated," "free" or "indirect" bilirubin. Approximately 4 milligrams of bilirubin per kilogram of blood is
produced each day.[33] The majority of this bilirubin comes from the breakdown of heme from expired red blood
cells in the process just described. Approximately twenty percent comes from other heme sources, however,
including ineffective erythropoiesis, and the breakdown of other heme-containing proteins, such as
muscle myoglobin and cytochromes.[33]

Liver events[edit]
The unconjugated bilirubin then travels to the liver through the bloodstream. Because this bilirubin is not
soluble, however, it is transported through the blood bound to serum albumin. Once it arrives at the liver, it is
conjugated with glucuronic acid (to form bilirubin diglucuronide, or just "conjugated bilirubin") to become more
water-soluble. The reaction is catalyzed by the enzyme UDP-glucuronyl transferase.
This conjugated bilirubin is excreted from the liver into the biliary and cystic ducts as part of bile. Intestinal
bacteria convert some bilirubin into urobilinogen. From there, urobilinogen can take two pathways. It can either
be further converted into stercobilinogen, which is then oxidized to stercobilin and passed out in the feces, or it
can be reabsorbed by the intestinal cells, transported in the blood to the kidneys, and passed out in
the urine as the oxidised product urobilin. Stercobilin and urobilin are the products responsible for the coloration
of feces and urine, respectively

reatment

Mild infant jaundice often disappears on its own within two or three weeks.
For moderate or severe jaundice, your baby may need to stay longer in the
newborn nursery or be readmitted to the hospital.

Treatments to lower the level of bilirubin in your baby's blood may include:

 Light therapy (phototherapy). Your baby may be placed under a special


lamp that emits light in the blue-green spectrum. The light changes the
shape and structure of bilirubin molecules in such a way that they can be
excreted in both the urine and stool. During treatment, your baby will
wear only a diaper and protective eye patches. Light therapy may be
supplemented with the use of a light-emitting pad or mattress.

 Intravenous immunoglobulin (IVIg). Jaundice may be related to blood


type differences between mother and baby. This condition results in the
baby carrying antibodies from the mother that contribute to the rapid
breakdown of the baby's red blood cells. Intravenous transfusion of an
immunoglobulin — a blood protein that can reduce levels of antibodies —
may decrease jaundice and lessen the need for an exchange transfusion.

 Exchange transfusion. Rarely, when severe jaundice doesn't respond


to other treatments, a baby may need an exchange transfusion of blood.
This involves repeatedly withdrawing small amounts of blood and
replacing it with donor blood, thereby diluting the bilirubin and maternal
antibodies — a procedure that's performed in a newborn intensive care
unit.

What Medications and Procedures Treat Jaundice?

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).

Is Surgery Necessary to Treat Jaundice?

 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.

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