Jaundice
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Overview
| Jaundice, NOS Classification and external resources | |
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| Yellowing of the skin and sclera caused by Hepatitis A. | |
| ICD-10 | R17. |
| ICD-9 | 782.4 |
| DiseasesDB | 7038 |
| MedlinePlus | 003243 |
| MeSH | D007565 |
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Jaundice, also known as icterus (attributive adjective: "icteric"), is yellowish discoloration of the skin, conjunctiva (a clear covering over the sclera, or whites of the eyes) and mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in red blooded animals). Usually the concentration of bilirubin in the blood must exceed 2–3 mg/dL for the coloration to be easily visible. Jaundice comes from the French word jaune, meaning yellow. Jaundice typically appears in a 'top to bottom' progression (starting with the face, progressing toward the feet), and resolves in a 'bottom to top' manner.
Pathophysiology
- Bilirubin is the major breakdown product of hemoglobin that is released from dying or damaged erythrocytes
- The normal bilirubin range is 0.3-1.0 mg/dL
- Jaundice is visible in conjunctiva, skin and mucosa when the serum bilirubin level rises above 2 mg/dL
Causes
When red blood cells die, the heme in their haemoglobin is converted to bilirubin in the spleen and in the hepatocytes in the liver. The bilirubin is processed by the liver, enters bile and is eventually excreted through feces.
Consequently, there are three different classes of causes for jaundice. Pre-hepatic or hemolytic causes, where too many red blood cells are broken down, hepatic causes where the processing of bilirubin in the liver does not function correctly, and post-hepatic or extrahepatic causes, where the removal of bile is disturbed.
Differential Diagnosis[1][2]
- Abdominal mass
- Acute alcoholic hepatitis
- Alcoholic Hepatitis
- Alpha-1 Antitrypsin Deficiency
- Amyloidosis
- Annular pancreas
- Autoimmune hepatitis
- Autoimmunohemolysis
- Benign recurring cholestasis
- Bile duct tumor
- Biliary atresia
- Biliary tract obstruction
- Cholangitis
- Cholecystitis
- Choledocholithiasis
- Choledochal cyst
- Conditions following hemorrhage
- Congestive Heart Failure
- Crigler-Najjar Syndrome
- Cystic Fibrosis
- Cytomegalovirus (CMV)
- Decompensated cirrhosis
- Dubin-Johnson Syndrome
- Drugs and toxins
- Eclampsia
- Epstein-Barr Virus (EBV)
- Fetal erythroblastosis
- Following hemolytic disease of the newborn syndrome
- Galactosemia
- Gallbladder tumor
- Gilbert's Syndrome
- Glucose-6-phosphate dehydrogenase deficiency
- Graft-versus-host disease
- HELLP Syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count)
- Hepatic trauma
- Hepatitis
- Hepatotoxic liver damage
- Hyperbilirubinemia after heart surgery
- Hyperbilirubinemia after portocaval shunt insertion
- Hyperemesis gravidarum
- Hypermethioninemia
- Hypopituitarism
- Hypothyroidism
- Intrauterine viral infections
- Intrahepatic cholestasis of pregnancy
- Intrahepatic and extrahepatic biliary atresia
- Intravascular hemolysis
- Jaundice of newborn
- Liver abscess
- Liver allograft rejection
- Liver cell carcinoma
- Lucey-Driscoll Syndrome
- Lymphoma
- Malignancy
- Neonatal hepatitis
- Nonalcoholic steatohepatitis or non-alcoholic fatty liver disease
- Pancreatic cancer
- Pancreatitis
- Parasites
- Pernicious anemia
- Polycythemia vera
- Postoperative jaundice
- Primary biliary cirrhosis
- Primary hyperbilirubinemia
- Primary sclerosing cholangitis
- Rotor's Syndrome
- Sarcoidosis
- Sepsis
- Shock
- Sickle Cell Anemia
- Spherocytosis
- Storage diseases
- Strictures
- Thalassemia
- Total parenteral nutrition
- Transfusion reaction
- Trisomy 18
- Tuberculosis
- Tyrosinemia
- Viral hepatitis (A, B, C, D, E)
Diagnosis
History
The caregiver should ask questions regarding
- Alcohol/hepatotoxic medication use
Various Symptoms
- Alcohol Hepatitis
- Aspartate aminotransferase:alanine aminotransferase ratio > 2 (AST:ALT)
- Fever
- Leukocytosis
- Viral Hepatitis
- Anorexia
- Dark urine
- Fatigue
- Hepatomegaly
- Light-colored (acholic) loss stools
- Nausea
- Pruritis
- Right upper quadrant (RUQ) pain
- Nausea and Vomiting
Physical Examination
- Complete physical exam including evidence of:
- Hepatomegaly
- Splenomegaly
- Palpable gallbladder
- Signs of chronic liver disease
Appearance of the Patient
Skin
- Jaundice is visible in conjunctiva, skin and mucosa when the serum bilirubin level rises above 2 mg/dL
Eyes
- Jaundice is usually best seen in the periphery of the ocular conjunctivae
Abdomen
- Hepatomegaly may be present
Neurologic
- A flap may be present
Laboratory Findings
- Total and unconjugated bilirubin
- Aspartate aminotransferase
- Alanine aminotransferase
- Albumin
- Alkaline phosphatase
- HIV serologies
- Hepatitis serologies
- Antinuclear antibody (ANA)
- Antimitochondrial antibodies
- Haptoglobin
- Reticulocyte count
- Lactic dehydrogenase (LDH)
MRI and CT
- Abdominal CT scan may be helpful
Echocardiography or Ultrasound
- Abdominal ultrasound
Other Diagnostic Studies
- Endoscopic retrograde cholangio-pancreatography (ERCP)
Treatment
- Discontinue (and avoid) use of hepatotoxic medications
- Rehydrate
- Treat underlying etiologies
Acute Pharmacotherapies
- Steroids
Surgery and Device Based Therapy
- Cholecystectomy or ERCP
Pre-hepatic
'Pre-hepatic' -(or hemolytic) jaundice is caused by anything which causes an increased rate of hemolysis (breakdown of red blood cells). In tropical countries, malaria can cause jaundice in this manner. Certain genetic diseases, such as sickle cell anemia and glucose 6-phosphate dehydrogenase deficiency can lead to increased red cell lysis and therefore hemolytic jaundice. Commonly, diseases of the kidney, such as hemolytic uremic syndrome, can also lead to coloration. Defects in bilirubin metabolism also present as jaundice. Jaundice usually comes with high fevers.
The laboratory findings include
- Urine: no bilirubin present, urobilirubin > 2 units (except in infants where gut flora has not developed).
- Serum: increased unconjugated bilirubin.
Hepatic
Hepatic causes include acute hepatitis, hepatotoxicity and alcoholic liver disease, whereby cell necrosis reduces the liver's ability to metabolise and excrete bilirubin leading to a buildup in the blood. Less common causes include primary biliary cirrhosis, Gilbert's syndrome (a genetic disorder of bilirubin metabolism which can result in mild jaundice, which is found in about 5% of the population) and metastatic carcinoma. Jaundice seen in the newborn, known as neonatal jaundice, is common, occurring in almost every newborn as hepatic machinery for the conjugation and excretion of bilirubin does not fully mature until approximately two weeks of age..
Laboratory Findings: Urine: bilirubin present, Urobilirubin > 2 units but variable (Except in children)
Post-hepatic
Post-hepatic (or obstructive) jaundice, also called cholestasis, is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct, and pancreatic cancer in the head of the pancreas. Also, a group of parasites known as "liver flukes" live in the common bile duct, causing obstructive jaundice. Other causes include strictures of the common bile duct, biliary atresia, ductal carcinoma, pancreatitis and pancreatic pseudocysts. A rare cause of obstructive jaundice is Mirizzi's syndrome.
The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause as normal feces get their color from bile pigments.
Patients also can present with elevated serum cholesterol.
Patients often complain of severe itching or "pruritus".
Neonatal jaundice
Neonatal jaundice is usually harmless: this condition is often seen in infants around the second day after birth, lasting until day 8 in normal births, or to around day 14 in premature births. Serum bilirubin normally drops to a low level without any intervention required: the jaundice is presumably a consequence of metabolic and physiological adjustments after birth. In extreme cases, a brain-damaging condition known as kernicterus can occur; there are concerns that this condition has been rising in recent years due to inadequate detection and treatment of neonatal hyperbilirubinemia. Neonatal jaundice is a risk factor for hearing loss.[3]
Jaundiced eye
It was once believed persons suffering from the medical condition jaundice saw everything as yellow. By extension, the jaundiced eye came to mean a prejudiced view, usually rather negative or critical. Alexander Pope, in 'An Essay on Criticism' (1711), wrote: "All seems infected that the infected spy, As all looks yellow to the jaundiced eye." [4]
External links
- Children's Liver Disease Foundation: information on jaundice in infants
See also
References
- ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:98
- ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:51-54
- ↑ Increased vigilance needed to prevent kernicterus in newborns -- O�Keefe 18 (5): 231 -- AAP News. Retrieved on 2007-06-27.
- ↑ From "The Dictionary of Cliches" by James Rogers (Ballantine Books, New York, 1985).
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Acknowledgement and Attribution Regarding Sources of Content
Some of the initial content on this page may be incorporated in part from copyleft sources in the public domain including wikis such as Wikipedia and AskDrWiki. Drug information for patients came from the The National Library of Medicine. Infectious disease information may have come from the Centers for Disease Control (CDC). Differential Diagnoses are drawn from clinicians as well as an amalgamation of 3 sources: 1.The Disease Database; 2. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:3; 3. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:7 .
