What is Jaundice?

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• Jaundice is a term that is used to describe ‘yellowness’ in the eyes or mucous membranes. It is derived from the Latin term ‘galbinus’ which means ‘yellowish green’. Another term for jaundice is ‘Icterus’. It is an important clinical clue for physicians as it narrows the organ involvement to either blood or the hepatobiliary tree (i.e the Liver and the Biliary Tree). In order to understand jaundice, it is important to discuss the cause, types, and to discuss the implications

• Hemoglobin is a protein in our red blood cells that carries oxygen from the lungs to supply to all parts of our body. It comprises heme and globin, hence the term hemoglobin. The heme is broken down into smaller molecules called bilirubin and biliverdin. In the liver, bilirubin conjugates i.e attach to a molecule called glucuronide which makes it soluble in water making it easier to excrete in the urine. To summarise, heme from hemoglobin (RBC) breaks down to bilirubin(unconjugated), bilirubin carried to the liver, Conjugation i.e attaches to glucuronide, becomes conjugated bilirubin, excreted in the urine.

• A level of 0.2-1.2 mg/dl of bilirubin in the blood is normal. When the levels exceed the upper limit, bilirubin starts depositing in various tissues and produces yellowing of the eyes, mucous membranes, trunk, face, palms, soles, and in severe cases the brain. It is first observed in the eyes which requires a concentration of 3 mg/dl or higher. Levels below 3 mg/dl or lower do not produce ‘yellowness’ but are clinically relevant. They can be observed on routine blood work.

• To evaluate the cause of jaundice in the simplest manner possible, think of red blood cells or the hepatobiliary tree. Since hemoglobin is seen in the RBCs, anything that destroys/breaks down RBCs will elevate the levels of bilirubin. Secondly, if there is any defect in conjugation or post-conjugation excretion, in the hepatobiliary tree, it too will elevate the bilirubin.

Causes of Jaundice

As discussed above, the cause can be due to 1) RBC breakdown or due to 2) hepatobiliary involvement, we shall be emphasizing the latter in the section.

Common causes of Jaundice:-

1. Viral Hepatitis (i.e Hep A, Hep B, Hep C, etc)
2. Alcoholic hepatitis
3. Non-alcoholic hepatitis or fatty liver disease
4. Liver cirrhosis due to any cause
5. Gallstone obstruction
6. Intrinsic enzymatic defects
7. Acute cholangitis

Infrequent causes

1. Primary or secondary biliary cirrhosis
2. Primary or secondary sclerosing cholangitis
3. Auto-immune hepatitis
4. Increased enterohepatic recycling due to any cause

Signs and Symptoms associated with Jaundice

The above causes present with symptoms which include:

1. Darkening of the color of the urine (dark yellow or brownish tinged)
2. Foul-smelling urine
3. Pale stools (whitish-yellow)
4. Abdominal pain or discomfort
5. Back pain in some cases
6. Fatigue or generalized weakness
7. Loss of appetite
8. Generalized itching
9. Sleep disturbances

Approach to management

A detailed history is which includes alcohol use, drug history, diet, lifestyle associated co-morbidities like diabetes, etc.
To evaluate the cause of jaundice in the simplest manner possible, think of red blood cells or the hepatobiliary tree. Since hemoglobin is seen in the RBCs, anything that destroys/breaks down RBCs will elevate the levels of bilirubin. Secondly, if there is any defect in conjugation or post-conjugation excretion, in the hepatobiliary tree, it too will elevate the bilirubin. Therefore, assessment of total bilirubin and its 2 fractions conjugated, and unconjugated bilirubin may provide clues.

Routine tests

1.  Complete blood count
2.  Liver function tests
3.  Serologies for viral causes
4.  Blood sugar level
5.  Lipid profile
6.  Abdominal ultrasonography
7.  Antibodies titers to rule out auto-immune causes (infrequent causes)
8.  In some cases, ERCP and MRCP for the infrequent causes

Once the cause is established, treatment is begun depending on etiology. For viral hepatitis, treatment is mostly supportive. In some instances, anti-viral drugs are given for Hep B and C. For alcoholic hepatitis, reduction and abstinence of alcohol are encouraged. Gallstone obstruction requires immediate intervention with ERCP to prevent cholangitis and subsequent sepsis. Cholecystectomy i.e gall-bladder removal is advised once the condition is stabilized. Infrequent causes are managed with symptomatic treatment.