Hepatic Jaundice Causes

In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia.

Bilirubin is formed when hemoglobin (the part of red blood cells that carries oxygen) is broken down as part of the normal process of recycling old or damaged red blood cells. Bilirubin is carried in the bloodstream to the liver, where it binds with bile.

Bilirubin is then moved through the bile ducts into the digestive tract, so that it can be eliminated from the body. Most bilirubin is eliminated in stool, but a small amount is eliminated in urine. If bilirubin cannot be moved through the liver and bile ducts quickly enough, it builds up in the blood and is deposited in the skin. The result is jaundice.

Many people with jaundice also have dark urine and light-colored stool. These changes occur when a blockage or other problem prevents bilirubin from being eliminated in stool, causing more bilirubin to be eliminated in urine.

High bilirubin levels may cause people to itch all over, but jaundice itself causes few other symptoms in adults. However in newborns, high bilirubin levels (see Jaundice in Newborns) can cause a form of brain damage called kernicterus. Also, many disorders that cause jaundice cause other symptoms or serious problems.

These symptoms may include nausea, vomiting and abdominal pain, and small spiderlike blood vessels that are visible in the skin (spider angiomas). Men may have enlarged breasts, shrunken testes, and pubic hair that grows as it does in women.

Serious problems can include

  • Ascites: Accumulation of fluid within the abdomen
  • Coagulopathy: A tendency to bleed or bruise
  • Hepatic encephalopathy: Deterioration of brain function because the liver malfunctions, allowing toxic substances to build up in the blood, reach the brain, and cause changes in mental function (such as confusion and drowsiness)
  • Portal hypertension: High blood pressure in the veins that bring blood to the liver, which can lead to bleeding in the esophagus and sometimes stomach
  • If people eat large amounts of food rich in beta-carotene (such as carrots, squash, and some melons), their skin may look slightly yellow, but their eyes do not turn yellow. This condition is not jaundice and is unrelated to liver disease.

Causes of jaundice

Jaundice is caused by a build-up of a substance called bilirubin in the blood and tissues of the body.
Any condition that disrupts the movement of bilirubin from the blood to the liver and out of the body can cause jaundice.

What is bilirubin?

Bilirubin is a waste product that’s produced when red blood cells break down. It is transported in the bloodstream to the liver, where specialised cells help to combine it with a digestive fluid called bile.

The bile and bilirubin is converted into a substance called urobilinogen by bacteria inside the digestive system, which is passed out of the body in urine or stools. It is bilirubin that gives urine its light yellow colour and stools their dark brown colour.

Types of jaundice

There are three types of jaundice, depending on what is affecting the movement of bilirubin out of the body.

  • Pre-hepatic jaundice occurs when a condition or infection speeds up the breakdown of red blood cells. This results in an increase in bilirubin levels in the blood and triggers the symptoms of jaundice.
  • Intra-hepatic jaundice occurs when a problem in the liver, for example damage as the result of infection or exposure to a harmful substance (such as alcohol), disrupts the liver’s ability to process bilirubin.
  • Post-hepatic jaundice is triggered when the bile duct system is damaged, inflamed or obstructed, which results in the gallbladder being unable to move bile into the digestive system.

The causes of each type of jaundice are described below.

Pre-hepatic jaundice

Causes of pre-hepatic jaundice include:

  • malaria – a blood-borne infection spread by mosquitoes and common in tropical areas of the world
  • sickle cell anaemia – a genetic condition that causes red blood cells to develop abnormally; it is most common among black Caribbean, black African and black British people
  • thalassaemia – a similar genetic condition to sickle cell anaemia in that it affects the production of red blood cells; it is most common in people of Mediterranean, Middle Eastern and, in particular, South Asian descent
  • Crigler-Najjar syndrome – a rare genetic condition where an enzyme that’s needed to help move bilirubin out of the blood and into the liver is missing
  • hereditary spherocytosis – an uncommon genetic condition that causes red blood cells to have a much shorter life span than normal

Intra-hepatic jaundice

Causes of intra-hepatic jaundice include:

  • the viral hepatitis group of infections – hepatitis A, hepatitis B and hepatitis C
    alcoholic liver disease – where the liver is damaged as a result of alcohol misuse
  • leptospirosis – a bacterial infection that’s spread by animals, particularly rats; it’s common in tropical areas of the world and uncommon in the UK
  • glandular fever – a viral infection caused by the Epstein-Barr virus
  • drug misuse – two leading causes are the recreational drug ecstasy and overdoses of paracetamol
  • primary biliary cirrhosis – a rare and poorly understood condition that causes progressive liver damage
  • Gilbert’s syndrome – a common genetic condition where the liver has problems breaking down bilirubin at a normal rate
  • liver cancer – a rare and usually incurable cancer that develops inside the liver
  • exposure to substances known to be harmful to the liver, such as phenol (used in the manufacture of plastic) or carbon tetrachloride (widely used in the past in processes such as refrigeration, although now its use is strictly controlled)
  • autoimmune hepatitis – a rare condition where the immune system starts to attack the liver
  • primary sclerosing cholangitis – a rare type of liver disease that causes chronic (long-lasting) inflammation of the liver
  • Dubin-Johnson syndrome – a rare genetic condition where the liver is unable to combine bilirubin with bile and move it out of the liver

Post-hepatic jaundice

Causes of post-hepatic jaundice include:

  • gallstones obstructing the bile duct system
  • pancreatic cancer – an uncommon type of cancer that develops inside the pancreas (a gland that helps with the digestion of food)
  • gallbladder cancer or bile duct cancer, which are both relatively rare types of cancer
  • pancreatitis – inflammation of the pancreas, which can either be acute pancreatitis (the inflammation onlylasts for a few days) or chronic pancreatitis (the inflammation lasts for many years)

Evaluation

Jaundice is obvious, but identifying its cause requires a doctor’s examination, blood tests, and sometimes other tests.

Warning signs:

In people with jaundice, the following symptoms are cause for concern:

  • Severe abdominal pain and tenderness
  • Changes in mental function, such as drowsiness, agitation, or confusion
  • Blood in stool or tarry black stool
  • Blood in vomit
  • Fever
  • A tendency to bruise or to bleed easily, sometimes resulting in a reddish purple rash of tiny dots or larger splotches (which indicate bleeding in the skin)

When to see a doctor

If people have any warning signs, they should see a doctor as soon as possible. People with no warning signs should see a doctor within a few days.

What the doctor does

Doctors first ask questions about the person’s symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done.

Doctors ask when the jaundice started and how long it has been present. They also ask when urine started to look dark (which usually occurs before jaundice develops).

People are asked about other symptoms, such as itching, fatigue, changes in stool, and abdominal pain. Doctors are particularly interested in symptoms that suggest a serious cause.

For example, sudden loss of appetite, nausea, vomiting, pain in the abdomen, and fever suggest hepatitis, particularly in young people and people with risk factors for hepatitis.

Fever and severe, constant pain in the upper right part of the abdomen suggest acute cholangitis (infection of the bile ducts), usually in people with a blockage in a bile duct. Acute cholangitis is considered a medical emergency.

Doctors ask people whether they have had liver disorders, whether they have had surgery that involved the bile ducts, and whether they take any drugs that can cause jaundice (including alcohol, over-the-counter drugs, medicinal herbs, and other herbal products such as teas).

Knowing whether family members have also had jaundice or other liver disorders can help doctors identify hereditary liver disorders.

Because hepatitis is a common cause, doctors ask particularly about conditions that increase the risk of hepatitis, such as

  • Working at a day care center
  • Living in or working at an institution with long-term residents, such as a mental health care facility, prison, or long-term care facility
  • Living in or traveling to an area where hepatitis is widespread
  • Participating in anal sex
  • Eating raw shellfish
  • Injecting illegal or recreational drugs
  • Having hemodialysis
  • Sharing razor blades or toothbrushes
  • Getting a tattoo or body piercing
  • Working in a health care facility without being vaccinated against hepatitis
  • Having had a blood transfusion before 1992
  • Having sex with someone who has hepatitis

During the physical examination, doctors look for signs of serious disorders (such as fever, very low blood pressure, and a rapid heart rate) and for signs that liver function is greatly impaired (such as easy bruising, a rash of tiny dots or splotches, or changes in mental function).

They gently press on the abdomen to check for lumps, tenderness, swelling, and other abnormalities, such as an enlarged liver or spleen.

Treatment

The underlying disorder and any problems it causes are treated as needed. If jaundice is due to acute viral hepatitis, it may disappear gradually, without treatment, as the condition of the liver improves.

However, hepatitis may become chronic, even if the jaundice disappears. Jaundice itself requires no treatment in adults (unlike in newborns—see Jaundice in Newborns).

Usually, itching gradually disappears as the liver’s condition improves. If itching is bothersome, taking cholestyramine

by mouth may help. However, cholestyramine

is ineffective when a bile duct is completely blocked.

If the cause is a blocked bile duct, a procedure may be done to open the bile duct. This procedure can usually be done during ERCP, using instruments threaded through the endoscope (see Endoscopy).

Essentials for Older People

In older people, the disorder causing jaundice may not cause the same symptoms as it typically does in younger people, or the symptoms may be milder or harder to recognize.

For example, if older people have acute viral hepatitis, they often have much less abdominal pain than younger people. When older people become confused, doctors may mistakenly diagnose dementia and not realize that the cause is hepatic encephalopathy.

That is, doctors may not realize that brain function is deteriorating because the liver is unable to remove toxic substances from the blood (as it usually does) and, thus, the toxic substances can reach the brain.

In older people, jaundice usually results from a blockage in the bile ducts, and the blockage is more likely to be cancer. Doctors suspect that the blockage is cancer when older people have lost weight, have only mild itching, have no abdominal pain, and have a lump in the abdomen.

Key Points

If damage to the liver is severe, jaundice may be accompanied by serious problems, such as deterioration of brain function and a tendency to bleed or bruise.

Acute viral hepatitis is a common cause of jaundice, particularly in young and otherwise healthy people.

People should see a doctor promptly if they have jaundice so that the doctor can check for serious causes.
Cholestyramine may help relieve itching.

Source & More Info: Merck Manuals and nhs.uk

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