What is Jaundice Jaundice   refers   to   yellowish   discolouration   of   the   skin   and   eyes.   It   occurs when   the   bilirubin   levels   in   the   blood   increase.   One   of   the   main   functions   of the    liver    is    to    get    rid    of    toxins    whether    ingested    with    or    without    our knowledge.    They    also    get    rid    of    waste    products    produced    by    the    body. Bilirubin is one such product. What is Bilirubin Red   blood   cells   (RBC)   have   a   life   span   of   around   120   days.   Throughout   life they   are   continuously   replaced.   During   the   recycling   process   the   old   and damaged    RBCs    are    broken    down    and    bilirubin    is    an    end    product.    The bilirubin   thus   formed   is   carried   in   the   bloodstream   to   the   liver   where   it   mixes with    bile    in    a    process    called    conjugation.    This    conjugated    bilirubin    is transported   with   the   bile   to   the   gut   where   it   is   degraded   further   and   eliminated   in   the   stools. A   small   amount   is   also   excreted   in   the urine. Normally   the   level   of   bilirubin   in   the   blood   is   about   1.2   milligrams   per   deciliter   (mg/dL)   for   adults   and   about   1   mg/dL   for   children. When the level in the blood rises to about 3 mg/dL the skin and eyes (conjunctiva) become yellow and jaundice results. Significance of Jaundice: If   your   bilirubin   levels   are   higher   than   normal,   it’s   a   sign   that   either significantly   larger   number   of   red   blood   cells   are   breaking   down   or that   your   liver   isn’t   functioning   properly   to   clear   the   bilirubin   from your blood. Another   reason   could   be   that   the   excretory   pathway   from   the   liver is   being   blocked   so   no   bilirubin   is   conjugated   or   is   transported   by bile to the gut. Types of Jaundice: • Hemolytic jaundice • Hepatocellular jaundice • Obstructive or post-hepatic jaundice Hemolytic jaundice When   there   is   excessive   destruction   of   RBCs   haemolytic   jaundice results.   This   can   happen   in   Sickle   cell   anaemia,   Thalassemia   and certain drugs that can cause destruction of red blood cells. Hepatocellular jaundice In hepatocellular jaundice, the liver cells are affected hence conjugation of bilirubin is impaired. The liver cells may be affected in: • Viral infections (Hepatitis A B and C) • Alcohol abuse • Cirrhosis of liver • Autoimmune liver disease • Gilbert syndrome • Drugs eg acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) • Mushroom poisoning Obstructive (Cholestatic) jaundice In    obstructive    jaundice,    the    transport    of    bilirubin    to    the intestines   is   affected   due   to   a   blockage   of   the   bile   ducts.   If blockage    is    within    the    liver    it    is    termed    intrahepatic cholestasis.   If   outside   (bile   duct)   it   is   termed   extrahepatic cholestasis.   The   accumulated   bilirubin   spills   over   into   the blood. The causes include: Tumor or inflammation in the bile ducts or gallbladder Stones in the gallbladder or bile ducts Pancreatic cancer Congenital disorders of bile ducts Infection It   should   be   emphasised   that   jaundice   is   in   itself   a   symptom of   an   underlying   disease.   Except   Haemolytic   Jaundice   all other   types   indicate   pathology   in   and   around   the   liver.   The clinical features will therefore depend on the disease. Symptoms: Fever Tiredness and lethargy Abdominal pain Loss of appetite Nausea Severe itching How is Jaundice Evaluated? A   complete   and   thorough   history   and   physical   examination   is   essential   to give   a   clue   to   the   possible   cause. The   doctor   will   ask   you   about   the   onset   and duration    of    symptoms,    history    of    weight    loss,    family    history,    history    of blood   transfusion,   and   history   of   drug   ingestion   or   IV   drug   use.   During physical   examination,   he   will   look   for   signs   of   anaemia,   fever,   presence   of liver   enlargement,   enlarged   lymph   nodes   etc   to   rule   in   or   rule   out   certain causes. Blood tests : • Bilirubin level in blood (total, conjugated & unconjugated bilirubin) • Blood test to rule out haemolytic anaemia • Blood test to check function of liver: Serum transaminases (ALT and AST) Serum alkaline phosphatase, gamma-GT level. • Viral serology for hepatitis B and C • Blood culture to check for infectious causes. Urine Test:   Urine is checked for presence of bile salts and bile pigments Diagnostic imaging: This is done to visualize the gall bladder, the pancreas and the liver: Ultrasound CT-scan MRI scan ERCP - Occasionally specialised tests such as endoscopic retrograde cholangiopancreatography Liver   Biopsy    –   Only   done   when   other   tests   are   not   helpful   or   further   information   is   needed.   A   liver   biopsy   carries   some   risk   of bleeding and infection. How is Jaundice Treated? The treatment of jaundice involves management of the underlying cause and providing symptomatic relief. Analgesics and antipyretics to relieve symptoms of pain and fever Cholestyramine for relief of itching Liver supplements in hepatocellular jaundice to improve liver function (viral hepatitis A which is usually self-limiting). Anti-viral medication for Hepatitis B and C Management of haemolytic anaemia Surgery to remove gallstone or stone in bile duct. Appropriate management of tumor in the liver, gallbladder, biliary tree or pancreas How can Jaundice be Prevented? Not all causes of jaundice can be prevented. However infectious and drug induced causes can be prevented. Proper hygienic practices such as regular handwashing before eating and after emptying bowels Avoid sharing personal items such as razors and toothbrushes Blood and blood components should be checked thoroughly for Hepatitis B and C before transfusion. Hepatitis B vaccination in high risk individuals such as doctors and lab personnel who handle blood and blood products Practising safe sex Avoid sharing IV needles Ensure clean and sterile needles are used while getting tattooed Avoid alcohol abuse Avoid abuse of painkillers such as NSAIDs and acetaminophen How long will it take to recover from jaundice? The   duration   depends   on   the   cause   of   jaundice.   Usually   hepatitis A   infection   is   self-limiting   and   the   patient   recovers   in   4-6   weeks.   In cases   of   obstruction,   the   jaundice   disappears   once   the   obstruction   is   relieved   eg   removing   bile   duct   stones.   In   malignancy   the   course of   disease   may   be   prolonged   and   difficult   to   predict.   In   liver   failure   eg   alcoholism   and   cirrhosis   jaundice   may   be   progressively worse. Diet recommended in jaundice. A   diet   filled   with   fresh   fruits   and   green   vegetables   is   essential. Avoid   oily   and   spicy   foods. Alcohol   intake   should   be   avoided.   Liver supplements will help. Can jaundice be fatal? Most cases of jaundice recover completely. In instances of liver failure or incurable cancer, it could be life-threatening. Jaundice   may   indicate   a   serious   underlying   pathology.   Consult   a   doctor   without   delay   for   a   full   check   up   if   you   or   someone close to you is affected. NB: This topic is discussed in greater detail in the “ Medical Forum” under Gastroenterology . Lakshmi Venkataraman. MD

Signs you may see with Jaundice: Anaemia (haemolytic jaundice) Liver enlargement Weight loss Serious Signs: Swelling abdomen (ascites), visible blood vessels on skin (spider naevi), enlarged breast tissue in men (gynaecomastia) and tremor