Jaundice

Synonyms : icterus, Yellow skin

Type of Jaundice: Haemolytic Jaundice, Hepatocellular Jaundice, Cholestatic Jaundice

Clinical features, Diagnosis, Management, Prognosis, Nutrition, Herbs,

Jaundice (icterus) refers to the yellow appearance of the skin, sclerae and mucous membranes resulting from the increased bilirubin concentration in body fluids. Internal tissues are coloured yellow except the brain, as bilirubin does not cross the blood-brain barrier, other than in the immediate period after birth when it can cause brain damage. Jaundice can be caused by increased bilirubin production (e.g., haemolysis) or by impaired bilirubin metabolism and decreased bilirubin clearance.

Haemolytic Jaundice 

This results from increased destruction of red blood cells in the spleen or circulation, or their precursors in the bone marrow, causing increased bilirubin production through metabolism of the haem component of haemoglobin. Common causes are hereditary spherocytosis, sickle cell disease and various forms of thalassaemia. Jaundice due to haemolysis is usually mild because a healthy liver can increase uptake and metabolism of unconjugated bilirubin, which is conjugated and then excretex Hyperbilirubinaemia in haemolytic jaundice is unconjugated in type, reflecting increased delivery of unconjugated bilirubin to the liver.

Clinical features:  < BACK TO TOP >

       There is usually only mild jaundice.

       Darker stools due to increased delivery of pigments into the intestine can be noticed, as well as darker urine due to increased excretion of urobilinogen that is converted to urobilin (recall that unconjugated bilirubin is not excreted in the urine).

       Signs and symptoms of anaemia are present (lassitude, fatigue, breathlessness on exertion, palpitations, throbbing in the head and ears, dizziness, headaches, dimness of vision, pallor of skin and mucous membranes).

       Enlargement of spleen (splenomegaly) may be found if excessive erythrocyte destruction takes place in the spleen.

       Chronic overproduction of bilirubin may result in the formation of gallstones composed predominantly of bilirubin (‘pigment stones? due to oversaturation of bile with bilirubin.

Diagnosis:  < BACK TO TOP >

       The plasma bilirubin is elevated but is usually less than 100 mmol/L (normal is up to 17 mmol/L); hyperbilirubinaemia is dominantly unconjugated (indirect).

       There is no bilirubinuria because unconjugated bilirubin can not pass into the urine, but there is increased amount of urobilinogen in the urine.

       The liver function tests are normal because there is no liver damage.

       Full blood count shows reduced haemoglobin and red blood cell count with increased number of reticulocytes (young red blood cells that still have some residual ribosomal material).

       The peripheral blood shows signs of haemolytic anaemia (a moderate macrocytosis and polychromasia due to reticulocytosis, with red cell abnormalities specific for the type of haemolytic disease, e.g., round spherical erythrocytes in hereditary spherocytosis, or banana-shaped ones in sickle cell disease).

Management  < BACK TO TOP >

       The management varies and is specific to the haemolytic disease (further discussion in the section about haemolytic anaemia)

Prognosis  < BACK TO TOP >

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Hepatocellular Jaundice

This type of jaundice results from inability of the liver to metabolise and transport bilirubin into the bile as a result of liver cell damage. Concentration in the blood of both unconjugated and conjugated bilirubin is increased since swelling of hepatocytes leads to compression of tiny intrahepatic bile ducts and impaired bile drainage. Acute parenchymal liver diseases, usually due to the hepatic viruses or to drugs, are common causes. Prolonged alcohol abuse is a very important cause as well. 

Clinical features: < BACK TO TOP >

       Jaundice is of various intensity depending on the severity of the underlying condition.

       Other features also vary with the underlying disease (discussed later). 

Diagnosis/Management: < BACK TO TOP >

       Vary with the underlying disease (e.g., hepatitis or cirrhosis) and are discussed later. 

Cholestatic Jaundice 

Cholestasis is a failure of bile flow, and its cause may lie anywhere between the liver cell (hepatocyte) and the duodenum. Cholestasis may be due to failure of the hepatocytes to generate bile flow (certain rare inherited defects such as Dubin-Johnson syndrome where the main problem appears to be impaired transport of bilirubin across the cell membrane), obstruction to bile flow in the intrahepatic bile ducts (a rare condition of unknown cause called primary biliary cirrhosis), or obstruction to bile flow in the extrahepatic bile ducts (stones, tumours especially of the pancreas, strictures). The last one is the most important cause of cholestatic jaundice. Hyperbilirubinaemia is conjugated in type since conjugation of bilirubin proceeds undisturbed but the bile returns into the blood. 

Clinical features: < BACK TO TOP >

       There is jaundice of various intensity, static or fluctuating, reflecting the mechanism and severity of cholestasis.

       Stools are pale or clay-coloured due to deficiency of pigments (bilirubin is not delivered into the gut).

       There is dark urine from the renal excretion of conjugated bilirubin.

       Generalised pruritus (itch), probably due to skin deposition of bile salts is commonly reported; sometimes scratch marks are visible.

       White-yellowish hard lipid deposits in the skin over joints and tendons (xanthomas) and around the eyes (xanthelasmas) develop due to protracted elevation of serum cholesterol (bile cholesterol is returned to blood).

       There can be weight loss due to marked malabsorption (bile salts are required for fat digestion and indirectly for absorption of lipid soluble vitamins).

       Bleeding tendency (easy bruising) is sometimes noted due to vitamin K deficiency (vitamin K is a lipid soluble vitamin).

       Dystrophy of the bones due to vitamin D deficiency (vitamin D is also a lipid soluble vitamin) can also be a problem. 

Diagnosis: < BACK TO TOP >

       Investigations in individual patients are determined by the clinical findings. It is usual to find elevated levels of conjugated bilirubin in blood together with raised alkaline phosphatase.

       Where there is no obvious cause for cholestasis, initial efforts are directed to identifying a large biliary duct obstruction, and ultrasound should be carried out initially.

       ERCP (endoscopic retrograde cholangiopancreatography) is the best investigation if the biliary tract is dilated, as demonstrated on ultrasound.

      Liver biopsy is performed when there is strong evidence of liver damage such as in biliary cirrhosis or inherited abnormalities of bilirubin transport into intrahepatic bile ducts. 

Management: < BACK TO TOP >

      This depends on the underlying cause of the cholestasis.   

 The summary of findings in different types of jaundice

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Nutrition < BACK TO TOP >

Nutrition that alleviate or prevent Jaundice :-
Lemon, Grapefruit, limes to alkalise the system

Herbs < BACK TO TOP >

Herbs that alleviate or prevent Jaundice :-
Berberis vulgaris (barberry), Gentiana lutea (Gentian), Silybum marinum (st mart's thistle), Taraxacum officinale (dandelion),  Trifolium pratense (Red Clover),  Verbascum thapsus (mullein)

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