Jaundice

Published on 23/05/2015 by admin

Last modified 22/04/2025

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Jaundice

Jaundice is yellow discoloration of the tissues, noticed especially in the skin and sclera (Figs 28, 37), due to accumulation of bilirubin. For jaundice to be clinically apparent, the circulating bilirubin levels should be in excess of 35 μmol/L. Jaundice may be prehepatic (due to haemolysis), hepatic (due to intrinsic liver disease) or cholestatic (due to either intrahepatic cholestasis or post-hepatic biliary tract obstruction).

Figure 37 Jaundiced sclera in a patient with hepatitis.
Mild jaundice is evident in the sclera. There is no obvious jaundice in the skin. Jaundice in the sclera is usually clinically apparent when the circulating bilirubin levels are in excess of 35 μmol/L.

Causes

Prehepatic (Unconjugated Hyperbilirubinaemia)

Congenital Defects

• Gilbert’s disease

• Crigler–Najjar syndrome

Haemolysis

Congenital red cell defects

• Hereditary spherocytosis (congenital acholuric jaundice)

• Sickle cell disease

• G6PD deficiency

• Thalassaemia

Acquired

• Malaria • (common where malaria is endemic)

• Incompatible blood transfusion

• Autoimmune

• Haemolytic disease of the newborn

• Absorbing large haematoma

• Hypersplenism

Hepatic

Acute Hepatocellular Disease

• Viral hepatitis

• Hepatitis A, B, C

• EBV

• CMV

• Drugs, e.g. paracetamol, halothane

• Other infections

• Leptospirosis

• Toxins, e.g. carbon tetrachloride

• Autoimmune

Chronic hepatocellular disease

• Chronic viral hepatitis

• Chronic autoimmune hepatitis

• End-stage liver disease

• Alcohol

• Cirrhosis

• Haemochromatosis

• Wilson’s disease

Cholestatic

Intrahepatic

• Drugs, e.g. chlorpromazine

• TPN

• Viral hepatitis

• Primary biliary cirrhosis

• Pregnancy

Extrahepatic (Obstructive)

In the lumen

• Gallstones

• Infestation

• Clonorchiasis (liver fluke)

• Schistosomiasis

In the wall

• Stricture, e.g. inflammatory, postoperative

• Cholangitis

• Congenital biliary atresia

• Cholangiocarcinoma

• Sclerosing cholangitis

• Choledochal cyst

Outside the wall

• Carcinoma of the head of the pancreas

• Carcinoma of the ampulla of Vater

• Malignant nodes in the porta hepatis

• Chronic pancreatitis

• Mirizzi syndrome

History

General

Fever, malaise, weight loss, dark urine, pale stools, itching.

Newborn

Biliary atresia presents as deepening jaundice within 2–3 days of birth. Liver failure develops over 3–6 months. Physiological jaundice is common and is due to immaturity of liver function. It usually settles within the first week of life.

Prehepatic

Ask about family history, racial origin, drugs, haematuria, history of anaemia. Gilbert’s disease is inherited as an autosomal dominant. There is a failure of uptake of unconjugated bilirubin by the hepatocyte. Crigler–Najjar syndrome is a failure of conjugation within the hepatocyte.

Hepatocellular

Occupation. Contact with jaundice. Travel. Alcohol. Sexual activity. Drugs (tablets, injections, anaesthetic agents, drug abuse). Exposure to industrial solvents. Previous episodes of jaundice. Infection. Influenza-like symptoms. Rashes. Joint pains. Blood transfusions.

Cholestatic

Drugs, e.g. chlorpromazine. Travel abroad. Severe upper abdominal pain preceding jaundice (biliary colic followed by impaction of stone in common bile duct). Insidious onset of painless jaundice (malignancy). Dark urine, pale stools, itching.

Examination

Prehepatic (haemolytic)

Often the jaundice is not intense, with only a mild lemon tinge. Anaemia. Splenomegaly.

Hepatic

Tender liver in hepatitis. Signs of liver failure: spider naevi, palmar erythema, leuconychia, clubbing, gynaecomastia, testicular atrophy, ascites, peripheral oedema, bruising, Dupuytren’s contracture, caput medusae, liver flap. Haematemesis may have occurred from bleeding oesophageal varices.

Cholestatic

Hepatomegaly – usually smooth liver with ‘sharp’ edge. Palpable gall bladder (Courvoisier’s law – in the presence of obstructive jaundice if the gall bladder is palpable, the cause is unlikely to be due to gallstones). Epigastric mass, e.g. carcinoma of the pancreas. Other abdominal masses, e.g. carcinoma of the stomach and carcinoma of the colon with secondary deposits in the porta hepatis. Recent surgical scars. Scratch marks on abdomen from itching.