Jaundice Overview Jaundice is a yellow discoloration of the skin, mucous membranes, and the whites of the eyes caused

by increased amounts of bilirubin in the blood. Jaundice is a sign of an underlying disease process. Bilirubin is a by-product of the daily natural breakdown and destruction of red blood cells in the body. The hemoglobin molecule that is released into the blood by this process is split, with the heme portion undergoing a chemical conversio n to bilirubin. Normally, the liver metabolizes and excretes the bilirubin in th e form of bile. However, if there is a disruption in this normal metabolism and/ or production of bilirubin, jaundice may result. Jaundice Causes Jaundice may be caused by several different disease processes. It is helpful to understand the different causes of jaundice by identifying the problems that dis rupt the normal bilirubin metabolism and/or excretion. Pre-hepatic (before bile is made in the liver) Jaundice in these cases is caused by rapid increase in the breakdown and destruc tion of the red blood cells (hemolysis), overwhelming the liver's ability to ade quately remove the increased levels of bilirubin from the blood. Examples of conditions with increased breakdown of red blood cells include: malaria, sickle cell crisis, spherocytosis, thalassemia, glucose-6-phosphate dehydrogenase deficiency (G6PD), drugs or other toxins, and autoimmune disorders. Hepatic (the problem arises within the liver) Jaundice in these cases is caused by the liver's inability to properly metaboliz e and excrete bilirubin. Examples include: hepatitis (commonly viral or alcohol related), cirrhosis, drugs or other toxins, Crigler-Najjar syndrome, Gilbert's syndrome, and cancer. Post-hepatic (after bile has been made in the liver) Jaundice in these cases, also termed obstructive jaundice, is caused by conditio ns which interrupt the normal drainage of conjugated bilirubin in the form of bi le from the liver into the intestines. Causes of obstructive jaundice include: gallstones in the bile ducts, cancer (pancreatic and gallbladder/bile duct carcinoma), strictures of the bile ducts, cholangitis, congenital malformations, pancreatitis, parasites, pregnancy, and newborn jaundice. Jaundice in newborn babies can be caused by several different conditions, althou gh it is often a normal physiological consequence of the newborn's immature live r. Even though it is usually harmless under these circumstances, newborns with e xcessively elevated levels of bilirubin from other medical conditions (pathologi c jaundice) may suffer devastating brain damage (kernicterus) if the underlying problem is not addressed. Newborn jaundice is the most common condition requirin g medical evaluation in newborns. The following are some common causes of newborn jaundice: Physiological jaundice This form of jaundice is usually evident on the second or third day of life. It is the most common cause of newborn jaundice and is usually a transient and harm

less condition. Jaundice is caused by the inability of the newborn's immature li ver to process bilirubin from the accelerated breakdown of red blood cells that occurs at this age. As the newborn's liver matures, the jaundice eventually disa ppears. Maternal-fetal blood group incompatibility (Rh, ABO) This form of jaundice occurs when there is incompatibility between the blood typ es of the mother and the fetus. This leads to increased bilirubin levels from th e breakdown of the fetus' red blood cells (hemolysis). Breast milk jaundice This form of jaundice occurs in breastfed newborns and usually appears at the en d of the first week of life. Certain chemicals in breast milk are thought to be responsible. It is usually a harmless condition that resolves spontaneously. Mot hers typically do not have to discontinue breastfeeding. Breastfeeding jaundice This form of jaundice occurs when the breastfed newborn does not receive adequat e breast milk intake. This may occur because of delayed or insufficient milk pro duction by the mother or because of poor feeding by the newborn. This inadequate intake results in dehydration and fewer bowel movements for the newborn, with s ubsequent decreased bilirubin excretion from the body. Cephalohematoma (a collection of blood under the scalp) Sometimes during the birthing process, the newborn may sustain a bruise or injur y to the head, resulting in a blood collection/blood clot under the scalp. As th is blood is naturally broken down, sudden elevated levels of bilirubin may overw helm the processing capability of the newborn's immature liver, resulting in jau ndice. Jaundice Symptoms Jaundice is a sign of an underlying disease process. . Common signs and symptoms seen in individuals with jaundice include: yellow discoloration of the skin, mucous membranes, and the whites of the eyes, light-colored stools, dark-colored urine, and itching of the skin. The underlying disease process may result in additional signs and symptoms. Thes e may include: nausea and vomiting, abdominal pain, fever, weakness, loss of appetite, headache, confusion, swelling of the legs and abdomen, and newborn jaundice. In newborns, as the bilirubin level rises, jaundice will typically progress from the head to the trunk, and then to the hands and feet. Additional signs and sym ptoms that may be seen in the newborn include: poor feeding, lethargy, changes in muscle tone, high-pitched crying, and seizures. Exams and Tests The health care pracitioner will need to take a detailed history of the patient' s illness, and he or she will also be examined to see if there are any findings that indicate the cause of the patient's jaundice. However, additional testing i s usually required to clearly determine the underlying cause of jaundice. The fo llowing tests and imaging studies may be obtained: Blood tests These may initially include a complete blood count (CBC), liver function tests ( including a bilirubin level), lipase/amylase level to detect inflammation of the

pancreas (pancreatitis), and an electrolytes panel. In women, a pregnancy test may be obtained. Additional blood tests may be required depending upon the initi al results and the history provided to the practitioner. Urinalysis: Urinalysis is an analysis of the urine and is a very useful test in the diagnosis of screening many diseases. Imaging Studies Ultrasound: This is a safe, painless imaging study that uses sound waves to exam ine the liver, gallbladder, and pancreas. It is very useful for detecting gallst ones and dilated bile ducts. It can also detect abnormalities of the liver and t he pancreas. Computerized tomography (CT) scan: A CT scan is imaging study similar to an X-ra y that provides more details of all the abdominal organs. Though not as good as ultrasound at detecting gallstones, it can identify various other abnormalities of the liver, pancreas, and other abdominal organs as well. Cholescintigraphy (HIDA scan): A HIDA scan is an imaging study that uses a radio active substance to evaluate the gallbladder and the bile ducts. Magnetic resonance imaging (MRI): MRI is an imaging study that uses a magnetic f ield to examine the organs of the abdomen. It can be useful for detailed imaging of the bile ducts. Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is a procedure that involves the introduction of an endoscope (a tube with a camera at the end) thro ugh the mouth and into the small intestine. A dye is then injected into the bile ducts while X-rays are taken. It can be useful for identifying stones, tumors, or narrowing of the bile ducts. Liver Biopsy In this procedure, a needle is inserted into the liver after a local anesthetic has been administered. Often ultrasound will be used to guide placement of the n eedle. The small sample of liver tissue which is obtained is sent to a laborator y for examination by a pathologist (a physician who specializes in diagnosis of tissue samples). Among other things, a liver biopsy can be useful for diagnosing inflammation of the liver, cirrhosis, and cancer. Jaundice Treatment Treatment depends on the cause of the underlying condition leading to jaundice a nd any potential complications related to it. Once a diagnosis is made, treatmen t can then be directed to address that particular condition, and it may or may n ot require hospitalization. Treatment may consist of expectant management (watchful waiting) at home with re st. Medical treatment with intravenous fluids, medications, antibiotics, or blood tr ansfusions may be required. If a drug/toxin is the cause, these must be discontinued. In certain cases of newborn jaundice, exposing the baby to special colored light s (phototherapy) or exchange blood transfusions may be required to decrease elev ated bilirubin levels. Surgical treatment may be required. Medical Treatment Treatment varies based on the medical condition responsible for causing jaundice , and the associated symptoms and complications. Treatments may include the foll owing: 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). Medications Medications may or may not be necessary. After diagnosing the cause of the patie

nt's jaundice, the health care practitioner will direct the patient's treatment and prescribe medications if they are necessary. As outlined above, various medi cation options exist depending on the underlying cause of the jaundice. Surgery Surgical treatment may be necessary in certain cases of cancer, congenital malfo rmations, conditions that obstruct the bile ducts, gallstones, and abnormalities of the spleen. Sometimes, a liver transplant may be necessary. Next Steps Follow-up The patient should closely follow the health care practitioner's recommendations and treatment regimen. Once the diagnosis has been established, the health care practitioner will determine whether or not the patient requires a specialist (f or example, gastroenterologist, hematologist/oncologist, general surgeon, etc.) to address their particular underlying medical condition. Additional blood testi ng and imaging studies may be required. Depending on the cause of the patient's jaundice, he or she may require only a s hort-term follow-up with visits to the health care practitioner, or the patient may require lifelong close supervision by a physician. The patient should discus s the potential complications of thier condition with your health care practitio ner, and always seek medical attention if the symptoms recur or worsen. Prevention The underlying medical condition causing jaundice can in some cases be prevented . Some preventive measures include the following: Avoid heavy alcohol use (alcoholic hepatitis, cirrhosis, and pancreatitis). Vaccines for hepatitis (hepatitis A, hepatitis B) Take medications which prevent malaria before travelling to high-risk regions. Avoid high-risk behaviors such as intravenous drug use or unprotected intercours e (hepatitis B). Avoid potentially contaminated food/water and maintain good hygiene (hepatitis A ). Avoid medications that can cause hemolysis in susceptible individuals (such as t hose with G6PD deficiency, a condition that leads to red blood cell breakdown af ter consumption of certain substances). Avoid medications and toxins which can cause hemolysis or directly damage the li ver. Outlook The prognosis depends on the underlying cause. Some conditions are easily manage d and carry an excellent prognosis, while others may become chronic and require lifelong physician supervision. Unfortunately, some conditions causing jaundice may be fatal despite medical or surgical intervention. Discuss the prognosis wit h a health care practitioner once a diagnosis has been established.