In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia.
Bilirubin is formed when hemoglobin (the part of red blood cells that carries oxygen) is broken down as part of the normal process of recycling old or damaged red blood cells. Bilirubin is carried in the bloodstream to the liver, where it binds with bile. Bilirubin is then moved through the bile ducts into the digestive tract, so that it can be eliminated from the body. Most bilirubin is eliminated in stool, but a small amount is eliminated in urine. If bilirubin cannot be moved through the liver and bile ducts quickly enough, it builds up in the blood and is deposited in the skin. The result is jaundice.
Many people with jaundice also have dark urine and light-colored stool. These changes occur when a blockage or other problem prevents bilirubin from being eliminated in stool, causing more bilirubin to be eliminated in urine.
If bilirubin levels are high, substances formed when bile is broken down may accumulate, causing itching all over the body. But jaundice itself causes few other symptoms in adults. However, in newborns with jaundice high bilirubin levels (hyperbilirubinemia) can cause a form of brain damage called kernicterus.
Also, many disorders that cause jaundice, particularly severe liver disease, cause other symptoms or serious problems. In people with liver disease, these symptoms may include nausea, vomiting and abdominal pain, and small spiderlike blood vessels that are visible in the skin (spider angiomas). Men may have enlarged breasts, shrunken testes, and pubic hair that grows as it does in women.
Serious problems caused by liver disease can include
If people eat large amounts of food rich in beta-carotene (such as carrots, squash, and some melons), their skin may look slightly yellow, but their eyes do not turn yellow. This condition is not jaundice and is unrelated to liver disease.
Jaundice has many causes. Most causes involve disorders and drugs that
The portal vein receives blood from the entire intestine and from the spleen, pancreas, and gallbladder and carries that blood to the liver. After entering the liver, the portal vein divides into right and left branches and then into tiny channels that run through the liver. When blood leaves the liver, it flows back into the general circulation through the hepatic vein.
The most common causes of jaundice are
Hepatitis damages the liver, making it less able to move bilirubin into the bile ducts. Hepatitis may be acute (short-lived) or chronic (lasting at least 6 months). It is usually caused by a virus. Acute viral hepatitis is a common cause of jaundice, particularly jaundice that occurs in young and otherwise healthy people. Sometimes hepatitis is caused by an autoimmune disorder or use of certain drugs. When hepatitis is caused by an autoimmune disorder or a drug, it cannot be spread from person to person.
Drinking large amounts of alcohol over a long period of time damages the liver. The amount of alcohol and time required to cause damage varies, but typically, people must drink heavily for at least 8 to 10 years. Other drugs, toxins, and some herbal products can also damage the liver (see Table: Some Causes and Features of Jaundice).
If the bile ducts are blocked, bilirubin can build up in the blood. Most blockages are caused by a gallstone, but some are caused by cancer (such as cancer in the pancreas or bile ducts) or rare liver disorders (such as primary biliary cholangitis or primary sclerosing cholangitis).
Less common causes of jaundice include hereditary disorders that interfere with how the body processes bilirubin. They include Gilbert syndrome and other, less common disorders such as Dubin-Johnson syndrome. In Gilbert syndrome, bilirubin levels are slightly increased but usually not enough to cause jaundice. This disorder is most often detected during routine screening tests in young adults. It causes no other symptoms and no problems.
Disorders that cause excessive breakdown of red blood cells (hemolysis) often cause jaundice (see Autoimmune Hemolytic Anemia and Hemolytic Disease of the Newborn).
Jaundice is obvious, but identifying its cause requires a doctor”s examination, blood tests, and sometimes other tests.
In people with jaundice, the following symptoms are cause for concern:
If people have any warning signs, they should see a doctor as soon as possible. People with no warning signs should see a doctor within a few days.
Doctors first ask questions about the person”s symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see Table: Some Causes and Features of Jaundice).
Doctors ask when the jaundice started and how long it has been present. They also ask when urine started to look dark (which usually occurs before jaundice develops). People are asked about other symptoms, such as itching, fatigue, changes in stool, and abdominal pain. Doctors are particularly interested in symptoms that suggest a serious cause. For example, sudden loss of appetite, nausea, vomiting, pain in the abdomen, and fever suggest hepatitis, particularly in young people and people with risk factors for hepatitis. Fever and severe, constant pain in the upper right part of the abdomen suggest acute cholangitis (infection of the bile ducts), usually in people with a blockage in a bile duct. Acute cholangitis is considered a medical emergency.
Doctors ask people whether they have had liver disorders, whether they have had surgery that involved the bile ducts, and whether they take any drugs that can cause jaundice (eg, the prescription drugs amoxicillin/clavulanate, chlorpromazine, azathioprine, and oral contraceptives; alcohol; over-the-counter drugs; medicinal herbs; and other herbal products such as teas). Knowing whether family members have also had jaundice or other liver disorders can help doctors identify hereditary liver disorders.
Because hepatitis is a common cause, doctors ask particularly about conditions that increase the risk of hepatitis, such as
During the physical examination, doctors look for signs of serious disorders (such as fever, very low blood pressure, and a rapid heart rate) and for signs that liver function is greatly impaired (such as easy bruising, a rash of tiny dots or splotches, or changes in mental function). They gently press on the abdomen to check for lumps, tenderness, swelling, and other abnormalities, such as an enlarged liver or spleen.
Tests include the following:
Liver function tests (also called liver enzyme tests) involve measuring blood levels of enzymes and other substances produced by the liver. These tests help doctors determine whether the cause is liver malfunction or a blocked bile duct. If a bile duct is blocked, imaging tests, such as ultrasonography, are usually required.
Other blood tests are done based on the disorder doctors suspect and the results of the examination and the initial tests. They may include
If imaging is needed, ultrasonography of the abdomen is often done first. It can usually detect blockages in the bile ducts. Alternatively, computed tomography (CT) or magnetic resonance imaging (MRI) may be done.
If ultrasonography shows a blockage in a bile duct, other tests may be needed to determine the cause. Typically, magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) is used. MRCP is MRI of the bile and pancreatic ducts, done with specialized techniques that make the fluid in the ducts appear bright and the surrounding tissues appear dark. Thus, MRCP provides better images of the ducts than conventional MRI. For ERCP, a flexible viewing tube (endoscope) is inserted through the mouth and into the small intestine, and a radiopaque contrast agent is injected through the tube into the bile and pancreatic ducts. Then x-rays are taken. When available, MRCP is usually preferred because it is just as accurate and is safer. But ERCP may be used because it enables doctors to take a biopsy sample, remove a gallstone, or do other procedures.
Occasionally, liver biopsy is needed. It may be done when certain causes (such as viral hepatitis, use of a drug, or exposure to a toxin) are suspected or when the diagnosis is unclear after doctors have the results of other tests.
Laparoscopy may be done when other tests have not identified why bile flow is blocked. For this procedure, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to examine the liver and gallbladder directly. Rarely, a larger incision is needed (a procedure called laparotomy).
The underlying disorder and any problems it causes are treated as needed. If jaundice is due to acute viral hepatitis, it may disappear gradually, without treatment, as the condition of the liver improves. However, hepatitis may become chronic, even if the jaundice disappears. Jaundice itself requires no treatment in adults
Usually, itching gradually disappears as the liver”s condition improves. If itching is bothersome, taking cholestyramine by mouth may help. However, cholestyramine is ineffective when a bile duct is completely blocked.
If the cause is a blocked bile duct, a procedure may be done to open the bile duct. This procedure can usually be done during ERCP, using instruments threaded through the endoscope.
In older people, the disorder causing jaundice may not cause the same symptoms as it typically does in younger people, or the symptoms may be milder or harder to recognize. For example, if older people have acute viral hepatitis, they often have much less abdominal pain than younger people. When older people become confused, doctors may mistakenly diagnose dementia and not realize that the cause is hepatic encephalopathy. That is, doctors may not realize that brain function is deteriorating because the liver is unable to remove toxic substances from the blood (as it usually does) and, thus, the toxic substances can reach the brain.
In older people, jaundice usually results from a blockage in the bile ducts, and the blockage is more likely to be cancer. Doctors suspect that the blockage is cancer when older people have lost weight, have only mild itching, have no abdominal pain, and have a lump in the abdomen.