Jaundice is the yellow discoloration of the skin, sclerae (whites of the eyes), and mucous membranes due to elevated serum bilirubin levels. Clinically visible jaundice typically occurs when total serum bilirubin >2–2.5 mg/dL (≈34–43 µmol/L).
Bilirubin Metabolism Overview
- Bilirubin is a yellow pigment derived from the breakdown of heme in red blood cells.
- Unconjugated (indirect) bilirubin is insoluble in water and bound to albumin for transport to the liver, where it is:
- Taken up by hepatocytes
- Conjugated with glucuronic acid (becomes water-soluble)
- Excreted into bile → reaches intestine → converted to urobilinogen and stercobilin (gives stool its brown color)
- Some urobilinogen is reabsorbed and excreted in urine.
Types of Hyperbilirubinemia
- Pre-hepatic (Hemolytic) Jaundice
- Caused by increased RBC breakdown
- Excess unconjugated bilirubin
- Common causes:
- Hemolytic anemias (e.g., sickle cell disease, thalassemia, malaria)
- Autoimmune hemolysis
- Hepatic (Hepatocellular) Jaundice
- Due to hepatocyte dysfunction (impaired uptake, conjugation, or excretion)
- Mixed conjugated and unconjugated hyperbilirubinemia
- Causes:
- Viral hepatitis, drug-induced liver injury (e.g., isoniazid, acetaminophen), alcoholic hepatitis, cirrhosis, hepatoma
- Post-hepatic (Obstructive/Cholestatic) Jaundice
- Impaired bile flow due to obstruction
- Predominantly conjugated bilirubin
- Causes:
- Gallstones, bile duct strictures, pancreatic cancer, cholangiocarcinoma, primary sclerosing cholangitis
Common Causes of Jaundice
| Category | Common Causes |
|---|---|
| Infectious | Viral hepatitis (A, B, C), Malaria, Leptospirosis, Typhoid, CMV |
| Hematologic | Hemolytic anemias (SCD, G6PD), autoimmune hemolysis, malaria |
| Hepatic | Alcoholic liver disease, Drug-induced liver injury, Cirrhosis |
| Obstructive | Biliary atresia (infants), Gallstones, Pancreatic tumor |
| Neoplastic | Hepatocellular carcinoma, Cholangiocarcinoma |
| Congenital | Gilbert’s syndrome, Crigler-Najjar, Dubin-Johnson, Rotor |
Clinical Features of Jaundice
History
- Fatigue, nausea, anorexia, RUQ pain
- Dark urine, pale stools, pruritus (obstructive pattern)
- Smoking aversion may point to hepatitis
- Drug use, alcohol history, transfusion, and travel history
Physical Examination
- Scleral icterus, skin jaundice
- Hepatomegaly, splenomegaly (e.g., in hemolytic anemia)
- Stigmata of chronic liver disease: spider angiomas, gynecomastia, ascites
- Lymphadenopathy (e.g., lymphoma, viral infection)
- Asterixis, confusion → hepatic encephalopathy
Investigations
Basic Labs
- CBC with Reticulocyte Count – Elevated in hemolysis
- Peripheral smear – Sickle cells, schistocytes
- Liver Function Tests (LFTs):
- ALT/AST: Hepatocellular damage
- ALP/GGT: Cholestasis or obstruction
- Total and Direct Bilirubin
- Albumin – ↓ in chronic liver disease
- PT/INR – Liver synthetic function
Urinalysis
- Bilirubin present – conjugated hyperbilirubinemia
- Urobilinogen – Absent in obstructive jaundice
Serologic Tests
- HBsAg, Anti-HCV, Anti-HAV IgM, EBV/CMV serologies
- TORCH panel in neonates
Imaging
- Abdominal Ultrasound – First-line in obstructive jaundice
- CT/MRI/MRCP – For detailed liver and biliary tract evaluation
Specialized Tests
- Alpha-fetoprotein (AFP) – Elevated in hepatocellular carcinoma
- Liver biopsy – Chronic hepatitis, cirrhosis, tumor
- Paracentesis – Ascitic fluid analysis if ascites present
Management Principles
🚨 Jaundice is a symptom, not a disease. Management targets the underlying cause.
| Cause | Management |
|---|---|
| Hemolytic anemia | Treat underlying hemolysis, transfusions if necessary |
| Viral hepatitis | Supportive care, antivirals (e.g., HBV, HCV), avoid hepatotoxins |
| Drug-induced liver injury | Discontinue offending drug (e.g., isoniazid, acetaminophen), consider N-acetylcysteine |
| Obstructive jaundice | ERCP or surgery to relieve obstruction |
| Cirrhosis with complications | Diuretics, paracentesis, liver transplant evaluation |
| Neonatal jaundice | Phototherapy or exchange transfusion (if severe) |
| Unknown cause | Admit for further workup |
Nursing Considerations (NCLEX Focus)
- Monitor I&O, skin integrity, and neuro status (risk of encephalopathy)
- Teach patient to avoid alcohol and hepatotoxic meds
- Encourage nutritional support – high-calorie, moderate-protein, low-sodium diet (if cirrhotic)
- Ensure infection prevention in immunocompromised or liver failure patients
- Educate on medication adherence and follow-up labs
Key High-Yield Pearls
- ✅ Dark urine + pale stool + pruritus → think obstructive jaundice
- ✅ ALT > AST → viral hepatitis; AST > ALT → alcoholic hepatitis
- ✅ Hemolysis signs + isolated unconjugated bilirubin → pre-hepatic jaundice
- ✅ Always screen for viral hepatitis in liver disease
- ✅ Sudden jaundice + abdominal mass → consider malignancy
