Jaundice Symptoms

Neonatal jaundice

Jaundice in babies usually occurs because of a normal increase in red blood cell breakdown and the fact that their immature livers are not efficient at removing bilirubin from the bloodstream.Most jaundice in newborn babies is a normal event and is not serious. In most cases, this jaundice will disappear after a few days, often without any special treatment. Jaundice in the infant appears first in the face and upper body and progresses downward toward the toes. Premature infants are more likely to develop jaundice than full-term babies.Most babies with jaundice have physiologic jaundice. This is the type of jaundice that is caused because of the natural process of breaking down red blood cells.

 what causes jaundice

There are at least two significant processes that predispose normal infants to jaundice:

• The rate of bilirubin production is higher in infants than adults because their red blood cells have a shorter half-life and turn over more rapidly.
• Infants have a relatively limited ability to conjugate bilirubin, and conjugation in the liver is necessary for efficient elimination.

Additionally, there are a number of pathologic conditions that can result in neonatal jaundice. It                   include:

• Conditions that cause accelerated destruction of red cells, which can occur as a result of immune-mediated hemolysis, certain enzyme deficiencies, or structural abnormalities in red cells.
• Increased intestinal absorption of bilirubin, which blunts the infant’s ability to eliminate this waste product. Infants that fail to feed well are often deficient in the types of intestinal bacteria that metabolize bilirubin, and in such cases, significant amounts of bilirubin of reabsorbed into blood.
• Genetic defects in hepatic uptake of bilirubin (e.g. Gilbert’s syndrome) or deficiency in the enzyme necessary for conjugating bilirubin (uridine diphosphate glucuronosyltransferase).

Cholestatic jaundice

Cholestatic jaundice is a condition in which there is a blockage in the flow of bile movement which then causes the overflow  into the bloodstream.  It is a condition where blockage of the flow of bile from the liver causes overspill of bile products into the blood and incomplete bile excretion from the body results.

  Causes of cholestatic jaundice

There are several causes of Cholestatic jaundice, which are given as under

•  caroli’s disease ( congenital disorder characterized by multifocal, segmental dilatation of large intrahepatic bile ducts )
•  cystic fibrosis  (an inherited disease of the mucus glands that affects many body systems causes  progressive damage to the respiratory system and chronic digestive system problems)
•  choledocholithiasis  (presence of at least one gallstone in the common bile duct)
•  hepatic adenoma   (are uncommon benign epithelial liver tumors  frequently located in the right hepatic lobe)
•  primary biliary cirrhosis ( irritation and swelling (inflammation) of the bile ducts of the liver)
•  sarcoidosis (  patches of inflamed cells — called granulomas , usually in the lungs and nearby lymph nodes occurs)
•  liver cancer
•  alveolar hydatid disease (  parasitic disease caused by the larval stage of a microscopic tapeworm Echinococcus multilocularis)
•  combined oral contraceptives
•  gold salts
•  diazepam
•  phenyl butazone
•  para- amino salicylic acid
•  liver metastasis
•  lathosterolosis ( defect of cholesterol biosynthesis due to the deficiency of the enzyme sterol-C5-desaturase) 
•  dubin-johnson syndrome (  rare genetic disorder, in which  a child must get a copy of the defective gene from both parents)
•  pencillamine
•  oxazepam
•  citrullinemia type 2
•  pyritinol
•  primary sclerosing cholangitis (  disease that leads to liver damage and, eventually, liver failure)
•  indomethacin
•  choledochal cyst
•  cholangitis
•  pancreatic cancer
•  lorazepam
•  gall bladder cancer
•  rifampicin
•  mirizzi syndrome ( common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic duct or Hartmann’s pouch of the gallbladder)
•  klatskin tumor(bile duct bifurcation)

  symptoms of  cholestatic jaundice

symptoms mainly include

•  dark coloured urine
•  pale stools
• Yellow colouration of skin and eyes
•  itchy skin
• fever
•  chills
•  rigors
• Episodic right upper abdominal pain
•  weight loss
•  diarrhoea
• Steatorrhoea
•  fatty
• Smelly stools that are difficult to flush away due to fat malabsorption
•  excessive bleeding
•  brusing
• Enlarged liver (tender mass under right rib cage)
• Enlarged spleen (tender mass under left side of rib cage)
•  night sweats
• anorexia
•  malaise
• Xanthelasma/xanthomata (fatty yellow nodules under eyes/on wrists and hands)
•  abdominal distention
•  ascitis

 pathophysiology of jaundice

Jaundice, is characterized by yellow discoloration of the skin, sclera, and mucous membranes, as a result of an increase in bilirubin concentration (hyperbilirubinemia) and subsequent tissue deposition. .When red blood cells have completed their life span of approx. 120 days, and  each red blood cell traverses through the reticuloendothelial system, as its cell membrane ruptures  and become fragile and prone to rupture. Cellular contents, including hemoglobin, are subsequently released into the blood.

The hemoglobin is phagocytosed by macrophages , and split into its heme and globin portions.The remainder comes from prematurely destroyed erythroid cells in the bone marrow and form  hemoproteins such as myoglobin and cytochrome.  Due to imbalance in bilrubin formation and clearance there  results in Elevated serum bilirubin occurs. Elimination of bilirubin requires conversion to water-soluble conjugates by the hepatocytes through the action of uridine diphosphate (UDP)-glucuronyl transferase (glucuronidation) and secretion into the bile. Conjugated bilirubin, along with bile salts, is then excreted via the biliary system into the duodenum and deconjugated by bacterial enzymes in the terminal ileum and colon. Approximately 20% of deconjugated bilirubin (urobilinogen) is reabsorbed and re- excreted in bile. Unconjugated bilirubin is mostly bound to albumin and is not filtered by the kidney; conjugated bilirubin, however, may be filtered and reabsorbed in the kidney, with a small fraction excreted in the urine. A significant amount of conjugated bilirubin in the urine suggests cholestasis and hepatobiliary dysfunction. The majority of this bilirubin comes from the breakdown of heme from expired red blood cells.

urobilinogen can take two pathways. It can either be further converted into stercobilinogen, which is then oxidized to stercobilin and passed out in the feces, or it can be reabsorbed by the intestinal cells, transported in the blood to the kidneys, and passed out in the urine as the oxidised product urobilin. Stercobilin and urobilin are the products responsible for the coloration of faeces and urine, respectively.

 common signs and symptoms  of jaundice

Jaundice is  not a disease,  it is a sign of an underlying disease process. The best way to check for infant jaundice is to press your finger gently on your baby’s forehead or nose. If the skin looks yellow where you pressed, it’s likely  that baby has jaundice. If  baby doesn’t have jaundice, the skin color should simply look slightly lighter than its normal color for a moment.   Premature babies  are more likely to develop jaundice than full-term babies.Common signs and symptoms seen in individuals with jaundice include:

•  there is yellow discoloration of the skin, mucous membranes, and the white portion of the eyes,
• light-colored stools may be present,
•  there is  itching of the skin.
•  nausea vomiting are common
• abdominal pain may be present
• fever
•  body weakness
•  there is loss of appetite,
• headache,
• confusion,
• swelling of the legs and abdomen,
• poor feeding occurs in infants,
• lethargy,
•  there is change in muscle tone,
• high-pitched crying occurs in infants,
•  seizures
•   there may be dull pain in the liver region.
•  baby seems listless, sick or difficult to wake
• Sometimes, infants with significant jaundice have extreme tiredness and poor feeding.
• Bitter taste felt in mouth
• Occurrence of severe constipation and nausea, which might lead to undue weakness
• There is a pale tinge seen in the urine
• The pulse rate also is hampered once this disease sets in; the affected person experiences slower pulse rate
• The stools would be foul-smelling and also pale
• The tongue also turns pale or yellowish and is also referred to as ‘ furry tongue’
• The back of the baby is arch-shaped
• Conditions called apnea and disapnea are also witnessed in such babies

General classification of jaundice

Jaundice is a term  which is mainly used to describe an increase in the amount of bilirubin in the body, which results in the  yellow colouration of white area of eye, and skin . jaundice can be categorize into three different types; each results in yellowing pigmentation but for different reasons.

Physiologic Jaundice

Physiologic jaundice is common in newborns whose livers have not fully developed the ability to process bilirubin. This period of jaundice usually resolves itself within two to three days. A type of exaggerated physiologic jaundice is referred to as “breastfeeding jaundice,” which usually appears during the first week of a newborn’s life., breastfeeding jaundice is believed to be a result of inadequate breast milk intake, leading to dehydration or low caloric intake. Breastfeeding jaundice usually peaks during an infant’s second or third week of life, and providing the infant is ingesting sufficient calories usually resolves itself without causing any medical problems. .

Pathologic Jaundice

Pathologic jaundice can occur in children and adults and is diagnosed when jaundice presents a health risk. In infants, pathologic jaundice can occur when physiologic jaundice becomes exacerbated by dehydration or a premature or complicated birth. In adults, there are several causes of pathological jaundice, including blood incompatibilities and diseases, and hereditary syndromes. Several forms of hepatitis, cirrhosis of the liver and other liver diseases, bile duct blockage, along with infections and medications, can also cause pathological jaundice

Gilbert Syndrome

Gilbert’s syndrome is a harmless hereditary condition that results in mild jaundice. During times of illness or stress, people with Gilbert’s syndrome will experience low levels of some bilirubin-processing enzymes in their livers.

the other  types of jaundice are:

• Hemolytic Jaundice: Hemo means ‘blood’ and lytic means ‘breakdown of cells’; together ‘hemolytic’ means breakdown of red blood cells. In hemolytic jaundice or pre-hepatic jaundice, the bilirubin level is raised due to excess breakdown of red blood cells.In this form, overproduction of bilirubin results from excessive breakdown of red blood cells (hemolysis). For this process to cause jaundice, the degree of hemolysis usually has to be severe enough to produce a degree of anemia as well.

  Causes  include defects in the structure of the hemoglobin (thalassemia), faulty red blood cell membranes (spherocytosis) and infection in the blood cells (malaria). Each of these make the red blood cells more fragile and susceptible to hemolysis.

• Obstructive Jaundice: Also known as post-hepatic jaundice is caused by obstruction of bile flow from the liver. This increases the level of bilirubin in the blood, thereby causing obstructive jaundice. Obstructive Jaundice can cause extreme pruritus (itching) due to build up of salt and other biles constituents.When the bile duct is blocked, bilirubin builds up in the liver. As it no longer being excreted from the body the level in the bloodstream then rises and produces jaundice. The most common cause of obstructive jaundice is a gallstone leaving the gall bladder and becoming lodged in the bile duct. In older people, cancers of the gall bladder and pancreas may also obstruct the duct.

• Hepatocellular Jaundice: This type of jaundice is very common and occurs due to inability of the liver to metabolize and remove bilirubin from the biliary system.Damaged liver cells cannot remove and conjugate the normal quantity of bilirubin circulating in the blood, thus causing the level of bilirubin in the blood to rise. Viral hepatitis  is the most common liver disease that causes jaundice. Liver inflammation caused by certain toxic chemicals, alcohol (alcoholic hepatitis), and glandular fever may also be associated with jaundice.

• Neonatal Jaundice:. Neontal jaundice is marked by yellow discoloration of skin and other tissues of a newborn. The symptoms generally become apparent on the second or fourth day after the baby is born and disappear on it own within two to three weeks.

Interesting facts about jaundice

Jaundice is a yellow discoloration of the  skin and eyes.  During pregnancy, the mother’s liver removes bilirubin for the baby, but after birth the baby’s liver must remove the bilirubin. In some babies, the liver might not be developed enough to efficiently get rid of bilirubin. When too much bilirubin builds up in a new baby’s body, the skin and whites of the eyes might look yellow and this yellow coloring is called jaundice.Jaundice usually goes away without treatment. most of the newborns will have normal jaundice ,one day or more after birth. Jaundice that usually  appears within the first 24 hours of life, or after the first week, is not considered normal.Abnormal jaundice may be caused by the baby’s blood type (ABO or RH factor incompatibility) or one of many other causes. The yellow color is first seen in the eyes and head,  then it moves down the baby’s body. A blood test is usually done if the yellow is seen below the baby’s chest.  As  bilirubin is flushed from the body through the stool, jaundice may persist until a baby experiences more regular bowel movements; this typically happens between the first 5 and 10 days of life

jaundice can be easily seen in in fair-skinned infants .  It can be seen by taking baby into a well-lit room, applying gentle  pressure to  chest, and looking for a yellowish skin as the pressure subsides. This technique may not work on children with darker skin, so in that case jaundice can be seen  in their gums(yellowing of gums). When severe jaundice leaves  untreated , it can cause a condition called kernicterus. Kernicterus is a type of brain damage that can result from high levels of bilirubin in a baby’s blood. It can cause athetoid cerebral palsy and hearing loss. Kernicterus also causes problems with vision and teeth and sometimes can cause intellectual disabilities. A blood test is usually done if the yellow is seen below the baby’s chest. feeding every 1-3 hours with breast milk is important so the bowel movements can pass the bilirubin.Phototherapy (light) with a special lamp or lighted blanket may be used . The high-intensity lights used during phototherapy break down bilirubin into, less toxic substance that is easier to flush from the body.Baby needs to stay in light therapy at all times except during feeding.. Only breast milk  helps pass bilirubin. Make sure baby has at least three bowel movements and 4-5 wet diapers a day. Severe, abnormal jaundice may require baby to have a blood transfusion.Frequent feeding can help prevent severe jaundice. A breastfed baby needs to nurse every one to three hours (at least eight to 12 times a day).

           what are the common diseases that cause jaundice

There are several uncommon conditions that give rise to jaundice. It mainly includes

a) increased or over-production of bilirubin

Certain conditions that elevate the level of   bilirubin in the blood results in either mild or moderate jaundice that is difficult to detect.These conditions include:

1) rapid destruction of red blood cells ( hemolysis),

2) a defect in the formation of red blood cells that leads to the over-production of hemoglobin in the bone marrow ( ineffective erythropoiesis),

3) absorption of large amounts of hemoglobin when there has been much bleeding into tissue( from hematomas, collections of blood in the tissues)

b) Acute inflammation of the liver

sometimes, liver becomes inflamed that reduce the ability of the liver to conjugate (attach glucuronic acid to) and secrete bilirubin. It include acute viral hepatitis, alcoholic hepatitis, and Tylenol-induced liver toxicity.

   c)Chronic liver diseases

Chronic inflammation of the liver can lead to scarring and cirrhosis, and can ultimately result in jaundice. Common examples include chronic hepatitis-B and C, alcoholic liver disease with cirrhosis, and autoimmune hepatitis

   d) Infiltrative diseases of the liver

It refer to diseases in which the liver is filled with cells or substances that don’t belong there. The most common example would be metastatic cancer to the liver , usually from cancers within the abdomen.

    e) Inflammation of the bile ducts

some  diseases causing inflammation of the bile ducts, for example, primary biliary cirrhosis or sclerosing cholangitis and some drugs, that  can stop the flow of bile and elimination of bilirubin and lead to jaundice.

   f) Blockage of the bile ducts

The most common causes of blockage of the bile ducts are gallstones and pancreatic cancer. Less common causes include cancers of the liver and bile ducts.

g)  Genetic disorders

There are several rare genetic disorders present from birth that give rise to jaundice. Crigler-Najjar syndrome is caused by a defect in the conjugation of bilirubin in the liver due to a reduction or absence of the enzyme responsible for conjugating the glucuronic acid to bilirubin.
The only common genetic disorder that may cause jaundice is Gilbert’s syndrome . It is caused by a mild reduction in the activity of the enzyme responsible for conjugating the glucuronic acid to bilirubin. The increase in bilirubin in the blood usually is mild and infrequently reaches levels that cause jaundice.

    h) Developmental abnormalities of bile ducts

sometimes bile ducts do not develop normally and the flow of bile is interrupted. Jaundice frequently occurs. These diseases usually are present from birth . Cysts of the bile duct (choledochal cysts) are an example of such a developmental abnormality. Another example is Caroli’s disease.

    i)Jaundice of pregnancy

there are some additional causes of jaundice that are unique to pregnancy.

1) Cholestasis of pregnancy. Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis is often accompanied by itching but infrequently causes jaundice.

2) Acute fatty liver of pregnancy. Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but not always present in AFLP. Treatment usually involves delivery of the fetus as soon as possible.

what is jaundice

Jaundice is the  yellowish colouring of the skin and sclerae (the white portion of the eyes) that is caused by high levels in blood of the chemical bilirubin( hyperbilirubinemia). It  is not a disease but rather a sign that can occur due to manydiseases.  Jaundice can occur in babies, children, and adults.  The excess bilirubin  level causes the skin, eyes, and mucus membranes in the mouth to turn a yellowish color. Jaundice is often seen in liver disease such as hepatitis or liver cancer . It may also indicate obstruction of the  biliary tract, for example by gallstones or pancreatic cancer , or less commonly  may be congenital  The color of the skin and sclerae vary depending on the level of bilirubin. When the bilirubin level is mildly elevated, they are yellowish and when the bilirubin level is high, they tend to be brown.

what causes jaundice

Jaundice  is mainly caused by an increase in the amount of bilirubin in the blood. Bilirubin is a yellowish pigment that is produced from the breakdown of heme (blood), primarily from hemoglobin and red blood cells (RBCs).  When red blood cells get old, they are destroyed. Hemoglobin , the iron-containing chemical in red blood cells that carries oxygen, is released from the destroyed red blood cells after the iron it contains is removed. The chemical that remains in the blood after the iron is removed becomes bilirubin. liver  remove toxic chemicals or waste products from the blood, and bilirubin is a waste product. The liver removes bilirubin from the blood. After the bilirubin has entered the liver cells, the cells conjugate (attaching other chemicals, primarily glucuronic acid) to the bilirubin, and then secrete the bilirubinglucuronic acid complex into bile. The complex that is secreted in bile is called conjugated bilirubin. The conjugated bilirubin is eliminated in the feces, due to the presesnce of bilrubin in the feces it appears to be yellow in colour.

Jaundice occurs when there is

1)   large amount of  bilirubin is  being produced for the liver to remove from the blood . It commonly occurs in patients with  hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood

2)  There is  defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin glucuronic acid (conjugated) or secreted in bile

3) There is  blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. The bile ducts can be blocked by cancers gall stones, or inflammation of the bile ducts. The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

Talking about jaundice, the question that one needs to ask is that what  is pathological jaundice? What is the link between jaundice in newborn babies and adults based on the bilirubin levels in the blood? In the newly born, jaundice is not harmful mostly and is classified as neonatal type. Regarding pathological jaundice, whether it is in newborns or adults, this is a condition that poses a risk to health and sometimes it may be harmful. In the neonatal jaundice, it takes few days for liver to adjust and work properly after birth. Until the liver adjusts, the bilirubin is not removed effectively, so, it builds up in the body and causes symptoms like yellowish tone of skin and yellow eyes.

If one suffers from the pathological jaundice, then this condition can follow through his entire life. In this condition, bilirubin level is not being handled correctly and it builds up in the body. This condition can result due to blood transfusion incompatibilities, viral infections, Hepatitis, blood diseases, genetic disorders, infections, blocked bile duct and drug and medications. The link between jaundice and every age group is the excessive level of bilirubin in the blood. Bilirubin is pigment produced in body by liver when red blood cells are recycled. The normal level of the bilirubin in blood is one milligram per deciliter (1mg/dl) but if it exceeds this amount the one may see yellowing of skin and eyes. Unlike neonatal type of jaundice, pathological jaundice will take time to get better.

The link between neonatal type of jaundice and pathological jaundice is that there is something wrong with the body in handling the bilirubin and body cannot effectively remove it due to some disease or any underlying condition. Conditions like Hepatitis and damage to liver by virus are life threatening conditions. If the cause of jaundice occurs in childhood and cannot be corrected, then it follows the person in the adulthood as well.

In a new baby born, the first diagnosis will be done according to how the child looks. However, it will be hard to know the extent of the problem without further tests. The level of the bilirubin in the blood will help the doctor to know the treatment that he will give to your child.

The tests will be physical exam, laboratory tests of the blood sample and the skin test. If the doctor thinks that there is any other cause of the disorder, then he can order extra tests for urine and blood.

In case the child is suffering mild jaundice, it can disappear  in just few days or weeks. However if the jaundice is severe, then he can need to stay in the nursery or to get admitted into a hospital.

The treatment in new baby born can include the following.

Light therapy also known as phototherapy. This will require placing the baby under a special light which emits blue green spectrum. The light will change the bilirubin molecules into the way that will make it easier to be excreted into the stool or in the urine.

Intravenous immunoglobulin, this is the treatment that is given to the baby in case the jaundice was caused by a difference in blood type of the baby and the mother. The antibodies in the blood of the baby will cause the breakdown of the blood cells into the baby’s system. The child can also need transfusion. This  happens when the baby’s jaundice is not responding to other treatment given.