Jaundice
What is it?
The word jaundice describes a yellow pigmentation of the skin and eyes. This clinical sign is associated with diseases of the liver and/or the biliary tract. Jaundice may be caused by any of a large number of diseases and the condition in isolation is not a diagnosis, but a sign of the underlying disease. The yellow pigmentation is due to abnormal levels of bilirubin (bile pigment) in the blood.
How does it occur?
One of the main functions of the liver is to produce bile, a yellow liquid containing the pigment bilirubin and other chemicals. Bile aids the digestion of fats in the small intestine. Bile made in the cells of the liver is secreted into small bile ducts within the liver substance (intrahepatic ducts). These drain into a larger network of ducts, which carry the bile out of the liver (extra hepatic ducts) into the common bile duct. The common bile duct conveys the bile to the duodenum, which is the first part of the small intestine. The gall bladder is a reservoir attached to the common bile duct where the bile is concentrated.
Abnormal accumulation of bilirubin occurs when pathological processes affect the normal structure and/or functioning of the substance of the liver itself – for example viral infection, toxins. In addition any disease process that affects the drainage of the bile away from the liver to the gut will cause bilirubin to accumulate. Examples of this include a gallstone blocking the common bile duct, cancerous deposits encircling the duct or narrowing of the duct due to inflammation (stricture).
Causes
Diseases that commonly cause jaundice in the UK include: -
- Gallstones,
- Viral hepatitis A, B or C,
- Drugs and toxins, including alcohol,
- Malignant deposits in the liver from primary cancers elsewhere in the body,
- Cirrhosis,
- Cancer of the pancreas,
- Others as listed in the tables below
Diseases that affect the liver itself (intra hepatic causes)
| Infections |
Viral - hepatitis A, B, or C, yellow fever Bacterial: sepsis, tuberculosis, leptospirosis. Neonatal hepatitis syndrome. |
| Toxins |
Alcohol. Drugs e.g. oestrogens, contraceptive pill. Pregnancy. |
| Infiltration |
Carcinoma: metastases. Lymphoma. Adenocarcinoma of kidney (non-metastatic). Sarcoidosis. |
| Familial |
Benign recurrent (Gilberts Disease). Neonatal cholestatic syndromes. |
| Reduced blood flow |
Perioperative hypo perfusion/shock. Sickle Cell Anaemia. |
| Intrahepatic ducts |
Biliary atresia. Primary Biliary Cirrhosis. Sclerosing cholangitis. Malignant infiltration of ducts. |
| Autoimmune |
Chronic active hepatitis. |
Diseases outside the liver (extra hepatic causes)
- Stones in the common bile duct,
- Pancreatic and biliary tree cancers,
- Pressure on the common bile duct from enlarged lymph nodes,
- Stricture of the common bile duct.
Clinical Features
The yellow discoloration of the skin and the whites of the eyes are usually accompanied by production of dark urine and pale faeces. Jaundice causes itching (pruritus) that can be a very distressing symptom as the jaundice increases in intensity. Non-specific symptoms of jaundice include tiredness, malaise, nausea, fever, muscle pains and poor appetite. In long standing jaundice skin lesions such as spider naevi telangiectases may develop. Depending on the cause the liver and spleen may be enlarged on examination, and complications such as muscle wasting, osteoporosis, ascites (abnormal accumulation of fluid in the abdominal cavity), portal hypertension and liver failure occur.
Treatment
The type of treatment is entirely dependent on the cause of the jaundice. In some cases it will be curative e.g. surgical removal of a gallstone blocking the common bile duct. Viral infections e.g. hepatitis A, may recover spontaneously. In other cases treatments will modify the disease process and the jaundice will improve or disappear. Treatment may be purely symptomatic e.g., drugs to relieve itching or palliative as in malignant disease. Some types of advanced liver disease causing jaundice may be treated by liver transplantation.
