BRIEF NOTES ON JAUNDICE

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JAUNDICE
INTRODUCTION:
Jaundice, or icterus, is yellowish discoloration of the skin, mucous membranes, sclerae, and body
fluids resulting from excess accumulation and deposition of bilirubin in the body in the presence
of serum hyperbilirubinemia. The yellow hue may be mimicked by carotenemia, but in the latter
condition, no scleral icterus is present and bilirubin levels are normal.1
DEFINATION:
Jaundice, also known as icterus, is a yellowish or greenish pigmentation of the skin and whites of
the eyes due to high bilirubin levels. It is commonly associated with itchiness. The feces may be
pale and the urine dark.2
EPIDEMEOLOGY:
The prevalence of jaundice varies with age and sex; newborns and older adults are most often
affected. Figure 1 shows the age and sex distribution of jaundice in family practice, based on a
study of more than 526,000 diagnoses among 88,000 patients.
The causes of jaundice also vary with age. Approximately 20 percent of term newborns develop
jaundice in the first week of life, primarily because of immaturity of the hepatic conjugation
process. Congenital abnormalities, hemolytic or bilirubin uptake disorders, and conjugation
defects are also responsible for jaundice in infancy or childhood. Viral hepatitis A is the most
frequent cause of jaundice among school-age children. Common duct stones, alcoholic liver
disease and neoplastic jaundice occur in middle-aged and older patients.
Jaundice in men is most likely to be due to cirrhosis, chronic hepatitis B, hepatoma, pancreatic
cancer or sclerosing cholangitis. In contrast, women tend to have higher rates of common duct
stones, primary biliary cirrhosis and carcinoma of the gallbladder.3
ETIOLOGY:
Jaundice most often occurs as a result of an underlying disorder that either causes overproduction
of bilirubin or prevents the liver from disposing of it, both of which result in bilirubin being
deposited in tissues.
Some underlying conditions that may cause jaundice are:
 Acute inflammation of the liver - may impair the ability of the liver to conjugate and secrete
bilirubin, resulting in a buildup.
 Inflammation of the bile duct - may prevent the secretion of bile and removal of bilirubin,
causing jaundice.
 Obstruction of the bile duct - prevents the liver from disposing of bilirubin.

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 Hemolytic anemia - production of bilirubin increases when large quantities of red blood cells
are broken down.
 Gilbert's syndrome - an inherited condition that impairs the ability of enzymes to process the
excretion of bile.
 Cholestasis - a condition where the flow of bile from the liver is interrupted. The bile
containing conjugated bilirubin remains in the liver instead of being excreted.
More rare conditions that may cause jaundice include:
 Crigler-Najjar syndrome - an inherited condition that impairs the specific enzyme responsible
for processing bilirubin
 Dubin-Johnson syndrome - an inherited form of chronic jaundice that prevents conjugated
bilirubin from being secreted out of the liver's cells
 Pseudojaundice - a harmless form of jaundice in which the yellowing of the skin results from
an excess of beta-carotene, not from an excess of bilirubin; usually from eating lots of
carrots, pumpkin, or melon4
CLINICAL PRESENTATION:5
Common signs and symptoms seen in individuals with jaundice include:
 yellow discoloration of the skin, mucous membranes, and the whites of the eyes,
 light-colored stools,
 dark-colored urine, and
 itching of the skin.
The underlying disease process may result in additional signs and symptoms. These may include:
 nausea and vomiting,
 abdominal pain,
 fever,
 weakness,
 loss of appetite,
 headache,
 confusion,
 swelling of the legs and abdomen, and
 newborn jaundice.
In newborns, as the bilirubin level rises, jaundice will typically progress from the head to the
trunk, and then to the hands and feet. Additional signs and symptoms that may be seen in the
newborn include:
 poor feeding,
 lethargy,
 changes in muscle tone,
 high-pitched crying, and

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 seizures.
RISK FACTORS:
There are a number of risk factors associated with the development of jaundice:
Certain rare conditions
There are a number of rare conditions which have jaundice as a distinguishing symptom of the
disorder. Some of these rare conditions are: Crigler-Najjar syndrome, Dubin-Johnson syndrome,
Gilbert's syndrome, Lucey-Driscoll syndrome, Niemann-Pick disease, Rotor's syndrome.
Haemolytic anaemia
People with haemolytic anaemia, a condition which causes destruction of the haemolytic blood
cells, are at risk of developing anaemia. This is due to the body's inability to recycle the bilirubin
from the red blood cells in the liver and this causes a build-up in the body and jaundice ensues.
Hepatitis
People with hepatitis (especially autoimmune or viral hepatitis) are highly at risk of developing
jaundice as a symptom of their condition. This is due to the liver being unable to recycle the
bilirubin as it is not functioning properly, so the bilirubin builds up in the body and jaundice
ensues.6
PATHOPHYSIOLOGY:-
COMPLICATIONS:
The complications associated with neonatal jaundice occur when bilirubin levels reach toxic
levels, and the bilirubin gets into the central nervous system and damages the brain. The brain

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toxicity can either be reversible (early acute bilirubin encephalopathy) or the damage may be
permanent and irreversible (kernicterus). Permanent damage may lead to cerebral palsy,
deafness, and intellectual impairment.7
DIAGNOSIS:
Medical history and examination
It's likely your GP or hospital doctor will take a detailed medical history to try to determine why
you have jaundice.
You may be asked whether:
 you had any flu-like symptoms before jaundice (this may indicate hepatitis)
 you're currently experiencing other symptoms, such as abdominal pain, itchy skin or
weight loss
 you've recently travelled to a country where conditions such as malaria or hepatitis A are
widespread
 you've noticed a change of colour in your urine and stools
 you have a history of alcohol misuse
 you're currently taking drugs or have taken them in the past
 your occupation could have exposed you to harmful substances
It's likely you'll also have a physical examination to check for signs of an underlying condition,
such as swelling of the legs, ankles and feet (a possible sign of cirrhosis), or a noticeable
swelling of your liver (a possible sign of hepatitis)
Urine test
A urine test can be used to measure levels of a substance called urobilinogen. It's produced when
bacteria break down bilirubin inside the digestive system.
Higher-than-expected levels of urobilinogen in your urine may suggest pre-hepatic jaundice or
intra-hepatic jaundice. Lower levels could suggest post-hepatic jaundice.
Liver function and blood tests
A liver function test is a type of blood test used to help diagnose certain liver conditions
including:
 hepatitis
 cirrhosis
 alcoholic liver disease
When the liver is damaged it releases enzymes into the blood. At the same time, levels of
proteins that the liver produces to keep the body healthy begin to fall.
By measuring the levels of these enzymes and proteins, it's possible to build up a picture of how
well the liver is functioning. In addition, your blood can be tested for infections known to trigger
jaundice, such as malaria and hepatitis C.

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Imaging tests
If intra-hepatic jaundice or post-hepatic jaundice is suspected, imaging tests can be used to check
for abnormalities inside the liver or bile duct systems. These include:
 ultrasound scan
 computerised tomography (CT) scan
 magnetic resonance imaging (MRI) scan
 endoscopic retrograde cholangiopancreatography (ERCP) – a small, flexible fibreoptic
camera (endoscope) is used to inject a special dye into the bile ducts; the dye shows up
on X-ray and is useful in helping to confirm a diagnosis of pre-hepatic jaundice
Liver biopsy
A biopsy may be recommended to assess the condition of the liver tissue if it may have been
damaged by a condition such as cirrhosis or liver cancer.
During a liver biopsy, your tummy is numbed with a local anaesthetic, and a fine needle is
inserted so that a small sample of liver cells can be taken and sent to a laboratory for examination
under a microscope.8
MANAGEMENT:
NON PHARMACOLOGICAL THERAPY:
 Radish Leaves: You can extract the juice from green radish leaves and drink daily. It helps to
regulate abdominal discomfort and also improves appetite. This treatment may be continued for
8 to 10 days.
 Tomatoes: Add some pepper and salt to fresh tomato juice and drink every morning. Lycopene
from tomatoes can help to reduce damage to the liver and even facilitate recovery.
 Snake Gourd Leaves: Add some dry snake gourd leaves to boiling water. Then boil coriander
seeds in water until it reduces to one third the amount. Combine both decoctions and drink
thrice every day.
 Almonds: Soak 7 to 8 almond kernels in water and keep overnight. Peel the almonds, grind
into a paste and consume. You can also consume almonds along with dried dates and
cardamoms. The dates and cardamoms should also be soaked in water for the night.
 Pigeon Pea Leaves: The juice obtained from pigeon pea leaves are known to be helpful in
treating jaundice. Extract the juice and drink in small doses daily.
 Sugarcane Juice: Squeeze half a lime into a glass of sugarcane juice and drink twice or thrice
daily. This is a popular remedy for jaundice which is known to quicken recovery. Make sure
that the juice is not contaminated in any way. It is better to prepare the juice at home after
cleaning the sugarcane thoroughly.
 Lemon Juice: Dilute lemon juice with water and drink frequently during the day. This will
help in protecting the liver cells.

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 Barley Water: Another hugely popular natural jaundice cure is barley water. Add a cup of
barley to about three liters of water and simmer for a couple of hours. Drink this frequently
during the day for relief from jaundice.
 Berberis Vultaris: This herb is also known as jaundice berry and is often recommended to
those suffering from jaundice. The juice or extract of the herb may be consumed daily.
 Turmeric: Add a quarter teaspoon of turmeric powder to warm water and drink twice daily.
 Papaya Leaves: Grind some tender papaya leaves into a paste. Combine the paste with half a
teaspoon of honey and consume.
 Ginger: Extract the juice from a piece of ginger, combine with lime juice and mint juice and
consume several times a day.
 Buttermilk: Add a pinch of roasted cumin seeds powder and some salt to buttermilk and
consume. This aids in proper digestion and is beneficial for the liver.
 Indian Gooseberry: A useful natural treatment for jaundice, Indian gooseberry may be
consumed along with water daily.
 Oregano: Add a couple of teaspoons of oregano to a cup of water and bring to a boil. Simmer
for about ten minutes and then strain. Consume this regularly for relieving jaundice symptoms.
PHARMACOLOGICAL THERAPY:
Jaundice treatment depends upon the basic condition leading to jaundice and complications
associated with it. Treatment may be directed towards attacking the underlying cause and
providing symptomatic relief, and may or may not require hospitalization.
• Medical treatment may include administration of intravenous fluids (IV Fluids) in case
of dehydration, medications for nausea/vomiting and / or pain, antibiotics, anti-viral medications,
and blood transfusions, depending on the patient condition. In certain cases, medications may not
be necessary also, and could be managed by rest. Medications are used depending upon the
underlying cause of the jaundice.
If a drug was found to be the cause, it is discontinued.
• In certain cases of newborn jaundice, phototherapy or exchange blood transfusions is used to
decrease elevated bilirubin levels.
• Surgical treatment may be required in cases such as cirrhosis or liver cancer. It may also be
necessary in conditions such as gallstones, congenital malformationsand other conditions that
obstruct the bile ducts. Sometimes, a liver transplant is possibly needed.8
PREVENTIONS:
vaccination, alcohol consumption, maintaining weight, having a healthy and balanced diet, avoid
junk food, having washing habits, drink loads of water, avoid using illegal drugs, avoid stress,
body cleaning, proper exposure to sunlight

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CONCLUSION
Careful assessment of the risk factors involved, a systematic approach to the detection and
follow-up of jaundice with the appropriate laboratory investigations, along with judicious
phototherapy and exchange transfusion when indicated, are all essential to avoid these
complications.
1- Every newborn should be assessed for the risks of developing sever hyperbilirubinemia
postnattaly.
2- Early prediction of neonatal hyperbilirubinemia by predischarge TCB or TSB and/or
assessment of clinical risk factors are important to avoid the hazards of sever hyperbilirubinemia
and its threat of brain damage.
3- The predischarge bilirubin measurement is more accurate and generates wider risk
stratification than a clinical risk factor.
4- TCB measurements had demonstrated a strong positive linear correlation with TSB.
5- Exclusive breastfeeding decrease the incidence of neonatal jaundice compared to bottle
feeding, but if these infants are starved or dehydrated, they could probably be at higher risk of
bilirubin encephalopathy.
6- There is no effect of oxytocin used for labor induction in the incidence of neonatal jaundice.

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REFERENCES:
1. Moseley RH. Approach to the patient with jaundice. In: {L-End}Kelley’s Textbook of Internal
Medicine. 4th ed. Lippincott, Williams and Wilkins; 2000: chapter 103.
2. Roger Jones (2004). Oxford Textbook of Primary Medical Care. Oxford University Press.
p. 758.
3. Author: Jerry T. McKnight, Jerry E. Jones Date: March, 1992.
4. Last updated Fri 16 December 2016 By Caroline Gillott Reviewed by University of Illinois-
Chicago, School of Medicine
5. http://www.emedicinehealth.com/jaundice/page5_em.htm
6.http://www.vitalhealthzone.com/health/conditions/j/jaundice/05_risk_factors_for_jaundice.htm
l#1
7. "Jaundice." MedscapeReference.com. Updated Mar. 4, 2016. Medically Reviewed by a Doctor
on 9/6/2016
8. Written by Avinash Ramani | Medically Reviewed by Dr. Simi Paknikar on Oct 21, 2013