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JAUNDICE
Definitions
1.​ A medical condition with yellowing of the skin or whites of the eyes, arising
from excess of the pigment bilirubin and typically caused by obstruction of
the bile duct, by liver disease, or by excessive breakdown of red blood cells.
2.​ Clinical marker of defect in metabolism and/or excretion of bilirubin.

Description
●​ Jaundice is yellowing of the skin and eyes. This condition forms when there
is too much bilirubin in your system. Bilirubin is a yellow pigment that is
formed by the breakdown of dead red blood cells in the liver. Normally, the
liver gets rid of bilirubin along with old RBCs. Jaundice can indicate a serious
problem with the function of your liver, gallbladder, or pancreas.

●​ Jaundice (also known as icterus) is a yellowish pigmentation of the skin,

the conjunctival membranes over the sclerae (whites of the eyes), and
other mucous membranes caused by hyperbilirubinemia (increased levels
of bilirubin in the blood). This hyperbilirubinemia subsequently causes
increased levels of bilirubin in the extracellular fluid. Concentration of
bilirubin in blood plasma is normally below 1.2 mg/dL (<25µmol/L). A
concentration higher than 2.5 mg/dL (>50µmol/L) leads to jaundice. The
term jaundice comes from the French word jaune, meaning yellow.

●​ Jaundice is often seen in liver disease such as hepatitis or liver cancer. It

may also indicate leptospirosis or obstruction of the biliary tract, e.g by
gallstones or pancreatic cancer, or less commonly be congenital in origin
(e.g. biliary atresia).
●​ Yellow discoloration of the skin, especially on the palms and the soles, but
not of the sclera and mucous membranes (i.e. oral cavity) is due
to carotenemia- a harmless condition important to differentiate from
jaundice.
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​​ ​​
Normal Eye Sclera​ ​ ​ Jaundiced Eyes​​ ​ Skin Coloration in Jaundice

Bilirubin
Bilirubin is the yellow breakdown product of normal haeme catabolism. Haeme is
found in haemoglobin, a principal component of red blood cells. Bilirubin is
excreted in bile and urine, and elevated levels may indicate certain diseases.

It is responsible for the yellow color of bruises (A bruise, also called a contusion
(medical term), is a type of hematoma of tissue, in which capillaries and
sometimes venules are damaged by trauma, allowing blood to seep, hemorrhage,
or extra vasate into the surrounding interstitial tissues. Not blanching on pressure,
bruises can involve capillaries at the level of skin, subcutaneous tissue, muscle,
or bone ) , the background straw-yellow color of urine (via its reduced breakdown
product, urobilin – the more obvious but variable bright yellow colour of urine is
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due to thiochrome, a breakdown product of thiamine), the brown color

of feces (via its conversion to stercobilin), and the yellow discoloration in jaundice.

Metabolism Of Heme

Blood Levels
The bilirubin level found in the body reflects the balance between production and
excretion. Blood test results should always be interpreted using the reference
range provided by the laboratory that performed the test, but typical reference
ranges for adults are provided:
Total Bilirubin:​ <21 μmol/L​ ​ or​ <1.2 mg/dL
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Direct Bilirubin:​ 1.0 – 5.1 μmol/L​ or​ 0 – 0.3, 0.1 – 0.3, 0.1 – 0.4 mg/dL

Symptoms Of Jaundice

Symptoms of jaundice are given below:

1.​ Yellow-tinted skin and eyes characterize jaundice. In more severe cases, the
whites of your eyes may turn brown.
2.​ You may also have dark urine and pale stools.
3.​ If an underlying health condition such as hepatitis is to blame for jaundice,
you might experience other symptoms, such as excessive fatigue
and vomiting.
4.​ Some people misdiagnose themselves when they experience yellow skin.
According to the National Institutes of Health (NIH), patients who have
jaundice usually have both yellow-colored skin and eyes. If you only have
yellow skin, you may simply have too much beta-carotene in your system
(NIH, 2011).
5.​ Beta-carotene is an antioxidant found in carrots and pumpkin. An overdose
of this antioxidant is not a cause of jaundice.
6.​ 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’. However, the sclera themselves are not "icteric" (stained with bile
pigment) but rather the conjunctival membranes that overlie them.
7.​ 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, however its more
common and more correct meaning is entirely synonymous with jaundice.

Causes Of Jaundice

Old red blood cells travel to your liver, where they’re broken down. Bilirubin is the
yellow pigment formed by the liver’s breakdown of these old cells. Jaundice
occurs when your liver doesn’t break down bilirubin the way it is supposed to.
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Your liver might be damaged and unable to perform this process. Sometimes, the
bilirubin simply can’t make it to your digestive tract to be eventually 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 often indicative of:

o​ Alcohol abuse
o​ Infections
o​ Liver cancer
o​ Cirrhosis (scarring of the liver)
o​ Gallstones (cholesterol stones made of hardened fat (lipid) material or
pigment Stones made of bilirubin)
o​ Hepatitis (swelling of the liver that decreases its ability to function)
o​ Pancreatic cancer
o​ Parasites in the liver
o​ Blood disorders, such as hemolytic anemia (a decreased amount of red
blood cells in the body, which leads to fatigue and weakness).
o​ An adverse reaction to or overdose of a medication, such as acetaminophen

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

born prematurely. An excess of bilirubin may develop in these newborns because
their livers haven’t fully developed yet.

Types Of jaundice

There are three types of jaundice, depending on what is affecting the movement
of bilirubin out of the body.
1.​ Pre-hepatic jaundice occurs when a condition or infection speeds up the
breakdown of red blood cells. This results in an increase in bilirubin levels
in the blood and triggers the symptoms of jaundice.
2.​ Intra-hepatic jaundice occurs when damage to the liver, either as the
result of infection or exposure to a harmful substance such as alcohol
disrupts the liver's ability to process bilirubin.
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3.​ Post-hepatic jaundice is triggered when the bile duct system is damaged,
inflamed or obstructed, which results in the gallbladder being unable to
move bile into the digestive system.

The causes of each type of jaundice are described below:

Pre-hepatic jaundice:
Causes of pre-hepatic jaundice include:
●​ Malaria – a blood-borne infection spread by mosquitoes and common in
tropical areas of the world.
●​ Sickle cell anaemia – a genetic condition that causes red blood cells to
develop abnormally; it is most common among black Caribbean, black
African and black British people
●​ Thalassaemia – a similar genetic condition to sickle cell anaemia in that it
affects the production of red blood cells; it is most common in people of
Mediterranean, Middle Eastern and, in particular, South Asian descent.
●​ Gilbert's syndrome – a common genetic condition where the
transportation of bilirubin from the blood to the liver is slower than it
should be, leading to a build-up of bilirubin in the blood.
●​ Crigler-Najjar syndrome – a rare genetic condition where an enzyme
that's needed to help move bilirubin out of the blood and into the liver is
missing.
●​ hereditary spherocytosis – an uncommon genetic condition that causes
red blood cells to have a much shorter life span than normal.

Intra-hepatic jaundice:
Causes of intra-hepatic jaundice include:
●​ The viral hepatitis group of infections – hepatitis A, hepatitis
B and hepatitis C
●​ Alcoholic liver disease – where the liver is damaged as a result
of alcohol misuse
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●​ Leptospirosis – a bacterial infection that's spread by animals,

particularly rats; it's common in tropical areas of the world and
uncommon in the UK
●​ Glandular fever – a viral infection caused by the Epstein-Barr virus
●​ Drug misuse – two leading causes are the recreational drug ecstasy
and overdoses of paracetamol
●​ Primary biliary cirrhosis – a rare and poorly understood condition
that causes progressive liver damage
●​ Liver cancer – a rare and usually incurable cancer that develops inside
the liver
●​ Exposure to substances known to be harmful to the liver, such as
phenol (used in the manufacture of plastic) or carbon tetrachloride
(widely used in the past in processes such as refrigeration, although
now its use is strictly controlled)
●​ Autoimmune hepatitis – a rare condition where the immune system
starts to attack the liver
●​ Primary sclerosing cholangitis – a rare type of liver disease that
causes chronic (long-lasting) inflammation of the liver
●​ Dubin-Johnson syndrome – a rare genetic condition where the liver is
unable to combine bilirubin with bile and move it out of the liver
Post-hepatic jaundice:
Causes of post-hepatic jaundice include:
●​ Gallstones obstructing the bile duct system
●​ Pancreatic cancer – an uncommon type of cancer that develops inside the
pancreas (a gland that helps with the digestion of food)
●​ Gallbladder cancer or bile duct cancer, which are both relatively rare
types of cancer
●​ Pancreatitis – inflammation of the pancreas, which can either be acute
pancreatitis (the inflammation only lasts for a few days) or chronic
pancreatitis (the inflammation lasts for many years)
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Tests And Diagnosis

Your doctor will first conduct blood tests to determine the cause of your jaundice.
A blood test can not only determine the total amount of bilirubin in your body, but
it can also help detect indicators of other diseases such as hepatitis.
Other diagnostic tests may be used, including:

●​ Liver Function Tests: A series of blood tests that measure levels of

certain proteins and enzymes that the liver produces when it is healthy and
when it is damaged.

●​ SGPT(ALT): Level of Serum glutamate pyruvate transaminase (SGPT) now

called Alanine transaminase (ALT) is raised in acute liver damage. On injury
to liver cells in which it is present in large amount, this enzyme leaks into
the blood stream. Liver damage may because of the jaundice.

●​ Imaging Tests: Includes abdominal ultrasounds (using high-frequency sound

waves to generate images of your internal organs), computed tomography
(CT) scan, and/or magnetic resonance imaging (MRI) tests.

●​ Liver Biopsies: A small piece of liver tissue is removed for testing and
microscopic examination.

The severity of jaundice in newborns is generally diagnosed with a blood test. A

small blood sample is taken by pricking the infant’s toe. Your pediatrician will
recommend treatment if the results indicate moderate to severe jaundice.

Preventing Jaundice
Because of the wide range of potential causes, it's not possible to prevent all cases
of jaundice. However, you can take precautions to minimise your risk of
developing the condition.
These precautions include:
●​ Ensuring that you stick to the recommended daily amount (RDA) for
alcohol consumption
●​ Maintaining a healthy weight for your height and build
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●​ If appropriate, ensuring that you're vaccinated againsthepatitis

A or hepatitis B, which are more common in certain parts of the world –
vaccination is usually only recommended depending on where in the
world you're travelling
●​ Minimising your risk of exposure to hepatitis C, as there's currently no
vaccine for the condition – in England, the most effective way of
preventing hepatitis C is by not injecting illegal drugs such as heroin, or
making sure that you don't share drug injecting equipment if you do
More information about each precaution is provided below:
Alcohol: Giving up drinking alcohol altogether is the most effective way of
reducing your risk of developing jaundice, particularly if you've been drinking for
many years. As a minimum preventative measure, stick to the recommended daily
amounts for alcohol consumption. The recommended daily amounts are:

●​ 3-4 units a day for men.

●​ 2-3 units a day for women.
A unit of alcohol is approximately equal to half a pint of normal strength lager, a
small glass of wine or a single measure (25ml) of spirits.
Many experts would recommend that as well as sticking to the recommended
daily amounts, you also spend two to three days a week not drinking any alcohol.
Visit your GP if you're finding it difficult to moderate your alcohol consumption.
Counselling services and medication are available to help you reduce your alcohol
intake.
Maintaining a healthy weight: Obesity and the resulting damage it can
sometimes cause to the liver (non-alcoholic fatty liver disease) is an often
overlooked cause of cirrhosis (scarring of the liver) and jaundice. Achieving and
maintaining a healthy weight is therefore an effective way of preventing jaundice.

In addition, a high-fat diet can increase your blood cholesterol level, which in turn
will also raise your risk of developing gallstones.
The most successful weight loss programmes include at least 150 minutes (2 hours
and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast
walking, every week, eating smaller portions and only having healthy snacks in
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between meals. A gradual weight loss of around 0.5kg (1.1lbs) a week is usually
recommended.
avoiding sharing any object that could be contaminated with blood, such as razors
and toothbrushes.
There's less risk of developing hepatitis C by having sex with someone who is
infected, but as a precaution it's recommended that you use a barrier method of
contraception, such as a condom.
It may also be possible to get hepatitis C by sharing banknotes or "snorting tubes"
to snort drugs, such as cocaine or amphetamine. These types of drugs can irritate
the lining of the nose, and small particles of contaminated blood could be passed
on to the note or tube, which you could then inhale.