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Jaundice or icterus is a yellow colouration of skin and whites of the eye or mucous membranes due to excess bilirubin. Serum bilirubin more than 2mg% (34.2µmol/L).

Bilirubin is a yellow-coloured waste material that remains in the bloodstream after iron is removed from the blood.

Bilirubin is a waste product that is found in the blood after the iron has been removed from the blood. It is filtered by the liver out from blood and when it reaches the liver it is conjugated forming conjugated bilirubin. Once bilirubin has been conjugated it is released to bile and excreted to faeces.

Hyperbilirubinemia occurs when there is excessive leakage of bilirubin to the tissues.

Jaundice usually occurs as a result of an underlying disorder that either causes the production of too much bilirubin or prevents the liver from getting rid of bilirubin.

In general terms, hyperbilirubinaemia may be pre-hepatic, hepatic, or post-hepatic.

• Pre-hepatic hyperbilirubinemia occurs due to excess intravascular release of bilirubin by haemolysis.
• Hepatic hyperbilirubinemia is due to hepatocyte dysfunction (faulty uptake, metabolism or excretion of bilirubin) and
• Post-hepatic hyperbilirubinemia is due to impaired removal of bilirubin from the biliary system (e.g., common bile duct obstruction, intrahepatic cholestasis)

Causes of Jaundice

The table below gives you the most common causes of jaundice:

The most common ones that you have or likely to encounter with are viral hepatitis, haemolytic anaemia (e.g., sickle cell, malaria), cirrhosis, biliary obstruction, hepatoma, drug-induced (e.g., alcohol, isoniazid).

Types of Jaundice

There are three main types of jaundice:

• Hepatocellular jaundice occurs as a result of liver disease or injury.
• Hemolytic jaundice occurs as a result of hemolysis, or an accelerated breakdown of red blood cells, leading to an increase in production of bilirubin.
• Obstructive jaundice occurs as a result of an obstruction in the bile duct. This prevents bilirubin from leaving the liver

Clinical Features of jaundice

Before ordering investigations, a meticulous clinical examination and history taking are key.

History should include exposure to hepatotoxic drugs pre-existing known as a haematological disorder. History of anorexia, nausea, and aversion to smoking is suggestive of viral hepatitis, while the history of dark urine, pale stool, and pruritus is suggestive of obstructive jaundice.

Physical examination should include observation for the presence of spider naevi, gynecomastia, loss of axillary hair, parotid gland enlargement, and ascites, which is suggestive of cirrhosis.

A yellow tinge to the skin and the whites of the eyes,

Splenomegaly is suggestive of parenchymal liver disease or haemolytic jaundice.

Investigations

After you've carried out your physical examination you may need to order investigation tests to confirm your diagnosis or rule out some. The tests that you are likely to order are:

• Blood slide for malaria.  
  Jaundice in a patient with malaria is a medical emergency.
• Urine bilirubin levels.
  Absence of bilirubin in a patient suggests haemolytic jaundice and presence of bilirubin suggests hepatobiliary jaundice.
• Urine urobilinogen levels
  Excessive urobilinogen suggests Urobilinogen is absent in obstructive jaundice.
• Liver function tests:
  • Gamma globulin transaminase levels – Elevated levels suggest alcohol abuse.
  • Alkaline phosphatase – Elevated levels suggest obstruction.
  • SGOT (AST) – Elevated levels suggest hepatocellular damage.
  • SGPT (ALT) – Elevated levels suggest hepatocellular damage.
• Serum proteins:
  • Albumin – Low levels in chronic liver disease such as cirrhosis.
  • Globulins – Hyperglobulinaemia is found in chronic active hepatitis,
• Full haemoglobin
  Polymorphonuclear leukocytosis is found in Sickle cells may be seen in the peripheral blood smear.
• Reticulocyte count
  Increased reticulocyte count indicates a haemolytic anaemia
• If the above investigations are not diagnostic consider performing:
  • HBs Ag, HAV – TORCHES (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis) in young infants.
  • Ultrasound: 
    Ultrasound is useful in obstructive jaundice, gallstones, differentiating between abscess and obstruction.
  • Alpha-foetoproteins: 
    Substantial elevations of alpha-foetoproteins are found in hepatocellular carcinoma.
  • Paracentesis of ascitic fluid: 
    Protein content <3g% is found in cirrhosis, tuberculosis, peritoneal tumours, peritoneal infection, or hepatic venous obstruction.
    Bloodstained ascites usually indicates a malignant disease – cytology is mandatory
• Liver biopsy is important in the diagnosis of chronic hepatitis and cirrhosis and hepatocellular carcinoma.

Management of a patient with jaundice

Treatment of jaundice is by treating the underlying cause since jaundice isn't a diagnosis by itself but just "a face" of an underlying disorder.

Anaemia-induced jaundice may be treated by boosting the amount of iron in the blood by either taking iron supplements or eating more iron-rich foods.

Patients with history and physical findings suggestive of viral hepatitis can be managed with bed rest, avoidance of alcohol and prescribe multivitamin tablets, steroids and antivirals.

Obstructive jaundice is treated by surgery.

If the jaundice is drug-induced, treatment for involves changing to an alternative medication

If the cause is not apparent you should admit the patient for investigations.

In any patient who has jaundice and mental complaint, you should consider hepatic encephalopathy.

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