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

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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