Jaundice: Difference between revisions

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{{CMG}}
__NOTOC__
 
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{{DiseaseDisorder infobox |
{{DiseaseDisorder infobox |
   Name          = Jaundice, NOS |
   Name          = Jaundice, NOS |
   Image          = PHIL 2860 lores.jpg|
   Image          = PHIL 2860 lores.jpg|
   Caption        = Yellowing of the [[skin]] and [[sclera]] caused by [[Hepatitis|Hepatitis A]].|
   Caption        = Yellowing of the [[skin]] and [[sclera]], via Wikimedia Commons<ref>By Photo Credit: Content Providers(s): CDC/Dr. Thomas F. Sellers/Emory University [Public domain], <"https://commons.wikimedia.org/wiki/File%3AJaundice_eye.jpg"></ref>|
  ICD10          = {{ICD10|R|17||r|10}} |
  ICD9          = {{ICD9|782.4}} |
  OMIM          = |
  MedlinePlus    = 003243 |
  eMedicineSubj  = |
  eMedicineTopic = |
  DiseasesDB    = 7038 |
  MeshID        = D007565 |
}}
}}


{{SI}}
'''For patient information, click [[Jaundice (patient information)|here]].'''


==Overview==
'''For the approach to a patient with jaundice, click [[Approach to a patient with jaundice|here]].'''
'''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 membrane]]s caused by hyperbilirubinemia (increased levels of [[bilirubin]] in red blooded animals). Usually the concentration of bilirubin in the [[blood]] must exceed 2–3 [[milligram|mg]]/[[decilitre|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 cell]]s 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.
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{FKH}}, {{FA}}, {{EG}}, {{MJ}}
== Differential Diagnosis<ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:98</ref><ref>Sailer, Christian, Wasner, Susanne.  Differential Diagnosis Pocket.  Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:51-54</ref> ==
* 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]] ('''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelet 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]]
* [[Parasite]]s
* [[Pernicious anemia]]
* [[Polycythemia vera]]
* Postoperative jaundice
* [[Primary biliary cirrhosis]]
* [[Hyperbilirubinemia|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]] ([[Hepatitis A|A]], [[Hepatitis B|B]], [[Hepatitis C|C]], [[Hepatitis D|D]], [[Hepatitis E|E]])


== Diagnosis ==
{{Jaundice}}
=== History ===
The caregiver should ask questions regarding
* Alcohol/hepatotoxic medication use


=== Various Symptoms ===
'''''Synonyms and keywords:''''' Icterus; hyperbilirubinemia, yellow discolouration.
* '''Alcohol Hepatitis'''
*:* Aspartate aminotransferase:alanine aminotransferase ratio > 2 (AST:ALT)
*:* [[Ddx:Fever|Fever]]
*:* [[Leukocytosis]]
* '''Viral Hepatitis'''
*:* [[Anorexia]]
*:* Dark urine
*:* [[Ddx:Fatigue|Fatigue]]
*:* [[Hepatomegaly]]
*:* Light-colored (acholic) loss stools
*:* [[Ddx:Nausea and Vomiting|Nausea]]
*:* [[Ddx:Pruritis|Pruritis]]
*:* [[Abdominal pain|Right upper quadrant (RUQ) pain]]
*:* [[Nausea and Vomiting]]


== Physical Examination ==
==[[Jaundice overview|Overview]]==
* Complete physical exam including evidence of:
*:* [[Ddx:Hepatomegaly|Hepatomegaly]]
*:* [[Ddx:Splenomegaly|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 cell]]s). In tropical countries, [[malaria]] can cause jaundice in this manner. Certain [[Genetic disorder|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
==[[Jaundice historical perspective|Historical Perspective]]==
* Urine: no bilirubin present, urobilirubin > 2 units (except in infants where [[gut flora]] has not developed).
* Serum: increased unconjugated bilirubin.


===Hepatic===
==[[Jaundice classification scheme|Classification]]==


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 [[metastasis|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..
==[[Jaundice pathophysiology|Pathophysiology]]==


Laboratory Findings: Urine: bilirubin present, Urobilirubin > 2 units but variable (Except in children)
==[[Jaundice causes|Causes]]==


===Post-hepatic===
==[[Jaundice differential diagnosis|Differentiating Jaundice from other Conditions]]==
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 [[gallstone]]s in the [[common bile duct]], and [[pancreatic cancer]] in the head of the [[pancreas]].  Also, a group of parasites known as "[[liver fluke]]s" 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 pseudocyst]]s. 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 pigment]]s. 
==[[Jaundice epidemiology and demographics|Epidemiology and Demographics]]==


Patients also can present with elevated serum cholesterol.
==[[Jaundice risk factors|Risk Factors]]==


Patients often complain of severe itching or "pruritus".
==[[Jaundice screening|Screening]]==


==[[Neonatal jaundice]]==
==[[Jaundice natural history|Natural History, Complications and Prognosis]]==


==Diagnosis==
{{main|Neonatal jaundice}}
[[Jaundice history & symptoms|History and Symptoms]] | [[Jaundice physical examination|Physical Examination]] | [[Jaundice lab tests|Laboratory Findings]] | [[Jaundice chest x ray|Chest X Ray]] | [[Jaundice CT|CT]] | [[Jaundice MRI|MRI]] | [[Jaundice echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Jaundice other imaging findings|Other Imaging Findings]] | [[Jaundice other diagnostic studies|Other Diagnostic Studies]]
'''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 birth]]s. 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.<ref>{{cite web |url=http://aapnews.aappublications.org/cgi/content/full/18/5/231 |title=Increased vigilance needed to prevent kernicterus in newborns -- O�Keefe 18 (5): 231 -- AAP News |accessdate=2007-06-27 |format= |work=}}</ref>


==Jaundiced eye==
== Treatment ==
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." <ref name=eye>From "The Dictionary of Cliches" by James Rogers (Ballantine Books, New York, 1985).</ref>
[[Jaundice medical therapy|Medical Therapy]] | [[Jaundice surgery|Surgery]] | [[Jaundice primary prevention|Primary Prevention]] | [[Jaundice secondary prevention|Secondary Prevention]] | [[Jaundice cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Jaundice future or investigational therapies|Future or Investigational Therapies]]


==External links==
==Case Studies==


[http://www.childliverdisease.org/education/yellowalert - Children's Liver Disease Foundation: information on jaundice in infants]
[[Jaundice case study one|Case #1]]


==See also==
==Related Chapters==
*[[Cholestasis]]
*[[Cholestasis]]
 
*[[Bilirubin]]
==External Links==
* [http://www.bidmc.org/YourHealth/ConditionsAZ.aspx?ChunkID=11737 Beth Israel Deaconess Medical Center: Jaundice]
 
==References==
==References==
{{Reflist|2}}
{{SIB}}
{{Symptoms and signs}}
[[ar:يرقان]]
[[bs:Žutica]]
[[ca:Icterícia]]
[[cs:Žloutenka]]
[[da:Gulsot]]
[[de:Ikterus]]
[[es:Ictericia]]
[[eo:Iktero]]
[[fr:Ictère]]
[[it:Ittero]]
[[he:צהבת]]
[[la:Icterus]]
[[lt:Gelta]]
[[ml:മഞ്ഞപ്പിത്തം]]
[[ms:Demam kuning jaundis]]
[[nl:Geelzucht]]
[[ja:黄疸]]
[[no:Gulsott]]
[[nn:Gulsot]]
[[pl:Żółtaczka (medycyna)]]
[[pt:Icterícia]]
[[sk:Žltačka]]
[[sl:Zlatenica]]
[[fi:Keltaisuus]]
[[sv:Gulsot]]
[[te:పచ్చకామెర్లు]]
[[tr:Sarılık]]
[[zh:黄疸]]
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Digestive system]]
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[[Category:Hepatology]]
[[Category:Hepatology]]

Latest revision as of 22:26, 29 July 2020

Template:DiseaseDisorder infobox

For patient information, click here.

For the approach to a patient with jaundice, click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Farnaz Khalighinejad, MD [2], Fatima Shaukat, MD [3], Eiman Ghaffarpasand, M.D. [4], Mehrian Jafarizade, M.D [5]

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Synonyms and keywords: Icterus; hyperbilirubinemia, yellow discolouration.

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Jaundice from other Conditions

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Chest X Ray | CT | MRI | Echocardiography or Ultrasound | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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Case #1

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