Family doctor

What is it?

Jaundice is not actually a disease itself. Rather, it is a manifestation of an underlying problem.

The word jaundice is derived from the French word for yellow: "jaune" and refers to a yellowish colour of the skin and eyes. It is caused by a build-up of bilirubin in the body tissues. Bilirubin is a pigment which is formed as a natural process when haemoglobin (the oxygen-carrying component of blood) is metabolised. Any disease affecting the liver, the bile ducts or the breakdown of red blood cells, can cause an accumulation of bilirubin and lead to jaundice.

What are the causes?

There is a multitude of possible causes of jaundice. In all cases, a person with jaundice should be seen by a doctor who will need to take a history of the illness, examine the patient and request some tests in order to make an accurate diagnosis.

Some of the more common and more important causes of jaundice are described below:

1. Neonatal Jaundice

Jaundice in newborn babies is very common and is mostly a normal event. It can occur for two reasons:

1. Newborn babies have too many red blood cells which contain haemoglobin. It is normal for the baby's body to break down these excess red blood cells and thus form a large amount of bilirubin.
2. A newborn's liver is underdeveloped or immature and therefore cannot process the bilirubin as quickly as an adult.

In most cases, an infant's jaundice will resolve within a few days, often without the need for any treatment.

Occasionally, jaundice in an infant is caused by blood group incompatibility (ABO or Rhesus Incompatibility) which causes a very fast breakdown of red blood cells. If it is not the mother's first pregnancy, the possibility of this problem is usually picked up in the antenatal period.

A rare cause of neonatal jaundice is a physical defect in the liver or bile duct system.

Treatment of jaundice in a newborn may be required if the blood level of bilirubin is very high. This will usually entail placing the infant under fluorescent lights for a few days, which speeds up the metabolism of the excess bilirubin.

2. Viral Hepatitis

Hepatitis means inflammation of the liver and is often associated with jaundice. Hepatitis can be caused by several viruses, but the most common ones are: hepatitis A, hepatitis B and hepatitis C. More recently, other viruses causing hepatitis have been discovered, but less is known about them.

Symptoms

The severity of symptoms of viral hepatitis varies widely, but the symptoms in each of the different viruses are similar. Apart from jaundice, viral hepatitis can cause flu-like symptoms: fever, headache, aching limbs, tiredness, loss of appetite, nausea and vomiting. Skin rashes and joint pains can also occur in hepatitis B. A tender and enlarged liver is also commonly present.

Hepatitis A is transmitted through contaminated food or water. The virus is excreted in the faeces of an infected person and can survive for 3-4 hours outside of the body. Transmission of the virus is thus enhanced in conditions of poor hygiene and overcrowding. Generally, hepatitis A is a self-limiting illness and does not persist in the bloodstream nor in the stools after the illness has resolved. A vaccine against hep A is available and will prevent 90% of people from getting the disease.

Hepatitis B and C are transmitted in blood and other body fluids (e.g. semen, breast milk). Hepatitis B is particularly infectious and is frequently spread by sexual contact. It can also be transmitted by hep B positive mothers to their infants at the time of delivery, in which case the risk of chronic hepatitis in the baby is as high as 90%. Other groups at high risk of getting hepatitis B include intravenous drug abusers, homosexuals and health care workers.

Most people who get hepatitis B will become ill and their immune system will fight off the infection. However, 5-10% of people will go on to develop chronic hepatitis. Another 5-10% will become carriers, in which case they will be asymptomatic but able to infect others.

The hep B vaccine consists of 3 separate injections over a period of 7 months and is also 90% effective.

Hepatitis C is less likely to be transmitted by sexual contact or from mother-to-neonate, and is more likely to be transmitted in blood (e.g. intravenous drug use or blood transfusion). Both hepatitis B and C are now screened for in blood donors and the risk of getting these viruses from blood transfusions is nowadays negligible.

Treatment of viral hepatitis

There is no specific medication to treat viral hepatitis. Treatment during the acute illness is generally "supportive" e.g. bed rest, avoidance of alcohol.

As is the case in all viruses, prevention is a more effective way of controlling the disease.

If a person knows they have been in contact with someone with hepatitis B, they should see a doctor quickly, as immune globulin can be given to lower the risk of getting hepatitis B themselves.

3. Gallstones

Gallstones are a common problem in adults. Although they more commonly cause intermittent abdominal pain, they can sometimes cause jaundice. This occurs when gallstones get stuck in gallbladder or bile duct system, blocking bilirubin from being excreted via the intestine. Usually, the acute problem will resolve spontaneously and the gallbladder can be taken out non-urgently. However, sometimes, gallstones can lead to infection of the gallbladder or bile duct and/or septicaemia, which also may be associated with jaundice. This can be a serious condition and requires urgent treatment with appropriate antibiotics.

4. Alcoholic Hepatitis

Alcoholic hepatitis can be an acute or chronic illness that occurs as a result of liver cell damage caused by excessive alcohol. It is usually a reversible disease, but can go on to cause cirrhosis.

It usually occurs after a recent binge of heavy drinking. The symptoms can include jaundice, nausea, loss of appetite, abdominal pain, an enlarged tender liver, fever and mental confusion. It can be a mild illness which resolves after stopping alcohol, or it can lead to serious complications, causing critical illness and even death.

5) Malignancy

Cancer is a possible cause of jaundice, particularly in older people and in cases where there are few other symptoms besides the jaundice.

In these cases the jaundice is usually caused by a blockage in the excretion of bilirubin. A tumour causing the blockage may be in the liver, in the bile duct system or in the pancreas and pressing on the bile duct.

In cases where the jaundice is caused by excessive breakdown of red blood cells, there might be a malignancy of the blood, or involving the spleen. (The spleen is largely responsible for the breakdown of 'old' blood cells).

6. Medications

Several medications can cause hepatitis as a possible side effect. This may or may not result in a visible jaundice and sometimes it only causes a blood test abnormality. The jaundice is usually mild and the illness nearly always resolves once the drug has been stopped.

7. Pregnancy

A rare cause of jaundice is pregnancy. Sometimes, this is associated with excessive 'morning sickness' (hyperemesis gravidarum). The reason why some women get jaundice with pregnancy and the mechanism behind it are unclear, but it is usually a mild illness with an excellent prognosis.

What tests might the doctor order to diagnose the cause of jaundice?

1. Blood tests

Blood tests are very useful in a case of jaundice. These will usually show raised 'liver enzymes' as well as a high bilirubin level. Depending on exactly which enzymes are raised, further tests may be necessary to make an accurate diagnosis.

A 'full blood count" is also useful to look for infection or any blood cell abnormality.

2. Imaging

A doctor may request an ultrasound scan or a CT scan of the abdomen to check for gallstones or other structural abnormalities of the liver, gallbladder or bile ducts.

3. ERCP

ERCP (endoscopic retrograde cholangiopancreatography) is an invasive test requiring sedation or anaesthetic. It involves passing a 'scope' into the bile and pancreatic ducts via the small intestine and can be useful to demonstrate a site of blockage or to perform delicate surgery, including gallstone removal.

4. Liver Biopsy

Sometimes, a sample of liver tissue is required to make a definitive diagnosis. Liver biopsy is usually done under local anaesthetic and involves a long biopsy needle being passed through the skin to get a small sample of liver. Sometimes, it is done under ultrasound or CT guidance.

Treatment of jaundice

Treatment, if possible, would be of the underlying cause. As mentioned above, not all of the causes of jaundice are treatable.

In cases where there is a very high level of bilirubin, usually from a bile outflow obstruction, a patient may experience severe generalised itching. There are drugs which can help the itching (e.g. cholestyramine), and topical treatments (e.g. calamine lotion) may help, but this problem can be very difficult to treat.

Anyone experiencing a yellow change in skin colour should see a doctor for a diagnosis to be made as a specific treatment might be indicated.