The Facts

Jaundice is a symptom of many medical problems but it is most often associated with conditions of the liver or the gallbladder. Jaundice causes yellow skin and eyes because of an excess amount of the bile pigment bilirubin in the fat layer under the skin. Either the body is producing too much, or it's not getting rid of it fast enough.

In addition to being caused by problems with the liver, jaundice can also occur among newborns, particularly premature babies. Jaundice that occurs at the time of birth generally disappears within days, but some babies require phototherapy treatment (special lights that help break down bilirubin). In this case, the yellowing of the skin is not due to liver or gallbladder disease.

Instead, jaundice is caused by the fact that fetuses have a different kind of red blood cell than adults. They are just getting rid of these cells around the time of birth, which releases a lot of bilirubin. Newborns also temporarily lack sufficient amounts of the enzymes that break down bilirubin. With time, the liver cells mature and are able to rid the body of excess bilirubin, and the jaundice will disappear.

Causes

Normally, large amounts of blood flow each minute through the liver, which may be thought of as the body's chemical processing plant. The liver breaks down old, inefficient red blood cells in a process called hemolysis. This releases large amounts of bilirubin. The liver also manufactures the other components of bile.
Bile is a greenish-yellow fluid secreted by the liver that contains cholesterol, bile salts, and waste products such as bilirubin. The bilirubin leaves the liver via the bile ducts to be stored in the gallbladder directly underneath. It's then slowly released into the intestine from the gallbladder. It helps digest food in the intestine and exits the body in the stool.

Too much bilirubin can be toxic and can cause jaundice. Therefore, it's important to eliminate it from the body as fast as it's produced. There are three basic ways this process can go wrong:

• The liver itself can be temporarily or permanently damaged, reducing its ability to break down bilirubin (mix it with bile) and move it into the gallbladder.
• The gallbladder or its bile ducts can become blocked, preventing excretion of bilirubin into the intestine. Bilirubin will then back up into the liver and then into the bloodstream.
• Any condition that leads to very rapid destruction of red blood cells can create too much bilirubin for even a healthy liver to handle. Again, the excess is carried into the bloodstream.

Some causes of jaundice due to poor liver function include:

• viral hepatitis: Hepatitis A, B, C, D, and E can all cause temporary liver inflammation. Types B and C can also cause chronic, lifelong inflammation.
• medication-induced hepatitis: This may be caused by alcohol, erythromycin*, methotrexate, amiodarone, statins (e.g., lovastatin, pravastatin, rosuvastatin), nitrofurantoin, testosterone, oral contraceptives, acetaminophen, and many other medications.
• autoimmune hepatitis: In this condition, the body's immune system attacks its own liver cells. Autoimmune hepatitis is more common in people and families with other autoimmune diseases, such as lupus, thyroid disease, diabetes, or ulcerative colitis. Primary biliary cirrhosis is another autoimmune condition of the liver and involves inflammation of the bile ducts.
• alcoholic liver disease: This involves damage to the liver caused by excessive, long-term consumption of alcohol.
• Gilbert's syndrome: This harmless inherited condition is quite common, affecting about 2% of the population. Minor defects in the liver's metabolism of bilirubin cause jaundice to appear in times of stress, exercise, hunger, or infection.

Some causes of jaundice due to obstruction (blockage) include:

• gallstones: Formed in the gallbladder, gallstones can block the bile ducts, preventing bile (and bilirubin) from reaching the intestine. Sometimes, the bile ducts may become infected and inflamed.
• cholestasis of pregnancy:  This problem can be caused by genetic or hormonal factors. It usually causes severe itching and rarely, jaundice.
• tumours: These may be in the liver, pancreas, or gallbladder. They are occasionally responsible for obstruction.

Some causes due to excessive red blood cell destruction (hemolysis):

• malaria: The liver destroys red blood cells infected with the parasite.
• Hemolytic anemia: This includes conditions such as sickle cell disease and thalassemia. It may also be an autoimmune condition.
• newborn jaundice: This condition is found in many newborn babies.

Symptoms and Complications



When you are jaundiced, your skin and the whites of your eyes are yellow. Sometimes, people who eat a lot of carrots or beta-carotene tablets take on a yellowish colour. This is called carotenemia, and can be easily distinguished from jaundice because the whites of the eyes don't turn yellow.

Other symptoms depend on the cause of jaundice. If a fever or flu-like illness comes before jaundice, it's usually a sign of a viral hepatitis infection. Brown urine, common in hepatitis, is generally a sign of poor liver function or increased red blood cell destruction. The body is trying to get rid of excess bilirubin in the urine. Pale, white, or clay-coloured stool, on the other hand, is an indicator of obstruction in the gallbladder or bile ducts. Many people with obstruction due to gallstones experience abdominal pain, while those with obstruction due to tumours usually have painless jaundice.

Jaundice itself is unlikely to hurt you unless the bilirubin reaches very high concentrations. It is a sign, however, of an underlying problem. There are too many possible causes of jaundice to attempt diagnosis at home. You should see a doctor if you think you have jaundice, especially if you have pain or tenderness in your abdomen, changes in mental status, or any bleeding from your digestive system.

Making the Diagnosis



Your doctor will take a medical history and perform a physical exam. Your doctor will ask how suddenly the jaundice came on, what other symptoms accompanied it, and how the stool and urine look. A blood sample will also be taken and checked for hepatitis virus antibodies, abnormal red blood cells, bilirubin levels, and various other substances that give clues about liver function. Your doctor may also order other tests such as an ultrasound or biopsy to determine the cause of jaundice.

Treatment and Prevention



There's no treatment for jaundice as such, since it's not a disease but a sign of a medical problem. The approach is to treat the underlying cause, if possible. Some of the medical problems that cause jaundice are curable, like malaria. Others, like thalassemia, are treatable. Many, like hepatitis A, newborn jaundice, or cholestasis of pregnancy, aren't curable but go away on their own. Usually treatment is unnecessary. Conditions like cirrhosis and chronic hepatitis are lifelong problems that may cause permanent or recurring jaundice. Some types of cancer can cause jaundice and should be investigated by a physician as early as possible, since early detection and treatment can improve survival.

Many of these diseases are inherited or autoimmune conditions that we don't know how to prevent. People can, however, do something about the two most common causes of jaundice - viral hepatitis and alcoholic liver disease. There are vaccines against hepatitis A and B (although, unfortunately, not against type C). The hepatitis B vaccine can protect you against lifelong complications of this disease. People suffering from alcoholism can help reduce their risk of alcoholic liver disease by seeking treatment for their condition.



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