Professor Sonja Yung
November 8, 2018
Although jaundice itself is not a disease, it is a term used to describe a demonstrated symptom that presents itself as yellow hue appeared on the skin and occasionally in the eyes. The main cause of jaundice is due to an excessive amount of bilirubin circulating in the body that cannot be properly excreted due to potential impairments from other systems or organs. In the case of the yellow hue that appears on the skin and in the eyes, there is too much built up of unconjugated bilirubin that seeps into the tissues, which in full amount can be toxic if left dispersed in the body. Jaundice is known to mostly affect newborns; about 50% of newborn babies are affected and roughly 80% of premature babies have a chance of showing symptoms of jaundice due to lack to developed liver (Hansen “Neonatal jaundice”). Though most known to affect babies, jaundice can also be a symptom of accompanying conditions in adults. This excess level of unconjugated bilirubin, also known as hyperbilirubinemia, can exacerbate conditions of ill adults whose leading causes range from hepatitis, alcohol related liver disease, blocked bile duct, and to pancreatic cancer. Among newborns, effective treatments include constant observation, phototherapy, or gradual transfusion. For adults, however, due to a wide range of leading cause, treatments do vary depending on acuteness, degree of symptoms, and nature of the root cause. It is important that extended research be applied to learning more about jaundice treatments by the American Academy of Pediatrics in order to ensure safe and appropriate treatments.
Jaundice is a medical term to describe a symptom of yellow hue to skin or eyes as the underlying symptoms to possible root causes. As mentioned in the abstract, jaundice takes place when the unconjugated bilirubin—toxic in large quantity—is not expelled from the body, as it should normally function. When there is an overflowing of unconjugated bilirubin, which is yellow in nature, it can begin to detrimentally impact other organ systems. Bilirubin is a byproduct that happens after hemolysis; it has a yellow pigment that gives urine its yellow color when processed through the kidneys and feces its brown color when the conjugated bilirubin bind to the bile and travel out of the body during excrement. Normally, the liver takes charge in destroying old or damage erythrocytes or red blood cells. When the liver is unable to function properly, the erythrocytes cannot be properly broken down into its normal byproducts that lead to abnormal circulation within the system. In this way, jaundice may indicate malfunctions of organs relating to excreting the bilirubin.
Looking at the cellular level within the bilirubin pathway, when normally functioned bilirubin is formed during hemolysis—the destruction of red blood cells due to damange or old age—that results in the hemoglobin that carries oxygen to be broken down into conjugated and unconjugated bilirubin. It is then carried into the bloodstream to be delivered to liver to be bind to the bile. The bilirubin usually binds to albumin, which is a protein made in the liver to balance the colloid osmotic pressure, in order to be excreted. This is so because when bilirubin is unconjugated, it is lipid-soluble. When bilirubin binds to albumin and bile, however, it becomes water-soluble and is then able to be expelled from the body. Although some is excreted through feces, there is some left over that travels to the kidneys to be excreted along with urine, hence the yellow color.
There are various causes that lead to jaundice in newborn babies; the main cause, though, is the undeveloped function of the premature liver. While the babies are in the mother’s wombs, their bilirubin is excreted through the mother’s umbilical cord. When they are born, the babies will have to let their liver filter through the bilirubin by themselves. Jaundice usually presents itself during the second or third day after delivery and is considered harmless with close observation, encouraged breastfeeding in order to encourage excretion, and phototherapy. Even though it is usually harmless under these circumstances, pathologic jaundice that is caused by an underlying problem may suffer kernicterus, which is brain damage, if left unattended.
Symptoms & Diagnostic Tests
Despite one of the clearest tell tale signs being yellow tint in the skin or the excretion of dark urine and light-colored stool, there are other predominant symptoms of which to be aware. Once again, these changes occur when a blockage or other problem prevents bilirubin from being eliminated in stool, causing more bilirubin to be eliminated in urine. Jaundice is obvious, but identifying its cause requires a doctor’s examination, blood tests, and sometimes other tests such as liver function tests; albumin and total protein; complete blood count; and prothrombin time (Mayo Clinic). Some of the warning signs involve an extensive list of severe abdominal pain and tenderness, drowsiness, agitation, mental confusion, bloody stool, bloody vomit, fever, and being easily bruised or to bled that sometimes lead to tiny reddish purple rash resulted from bleeding of the skin.
Among adults, jaundice is a side symptom that is used to diagnose other disorders, specifically severe liver disease that can cause serious problems to health. These symptoms usually are accompanied by nausea, vomiting and abdominal pain, and visible spiderlike blood vessels in the skin.
In terms of how quickly to seek guidance for these symptoms, people with no warning signs should see a doctor within a few days; however, if people exhibits any of these warning signs, they should see a doctor as soon as possible. The physician usually first ask questions about the person’s symptoms and medical history. They 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 usually ask when the jaundice started and how long it has been presented; this applies mostly to asking when the urine started looking darker. Doctors will then ask about other symptoms such as possible signs of itching, fatigue, or any changes to the excrements. Accompanying diagnosis can include loss of appetite, nausea, vomiting, pain in the abdomen, and fever that possibly points towards hepatitis. It also indicates infection or blockage of bile ducts. In this case, infection of the bile ducts is considered to be an emergency and patient should seek treatment immediately.
Tests include liver function test, imaging tests, and sometimes biopsy or laparoscopy. Liver function test is a blood test to evaluate how well the liver is functioning and whether it is damaged. Imaging tests usually involve ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI). Liver function tests, also called liver enzyme tests, involve measuring blood levels of enzymes and other substances produced by the liver. These tests help doctors determine whether the cause is liver malfunction or a blocked bile duct. If a bile duct is blocked, imaging tests, such as ultrasonography, are usually required. Other blood tests are done based on the disorder the doctors suspect and the results of the examination and the initial tests. These may include tests to assess the blood’s ability to clot (prothrombin time and partial thromboplastin time), tests to check for hepatitis viruses or abnormal antibodies (due to autoimmune disorders), a complete blood count, blood cultures to check for infection of the bloodstream, or examination of a blood sample under a microscope to check for excessive destruction of red blood cells
If imaging is needed, ultrasonography of the abdomen is often done first. It can usually detect blockages in the bile ducts. Alternatively, computed tomography (CT) or magnetic resonance imaging (MRI) may be done. If ultrasonography shows a blockage in a bile duct, other tests may be needed to determine the cause. Typically, magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) is used. MRCP is MRI of the bile and pancreatic ducts, done with specialized techniques that make the fluid in the ducts appear bright and the surrounding tissues appear dark. Thus, MRCP provides better images of the ducts than conventional MRI. For ERCP, a flexible viewing tube (endoscope) is inserted through the mouth and into the small intestine, and a radiopaque contrast agent is injected through the tube into the bile and pancreatic ducts. Then x-rays are taken. When available, MRCP is usually preferred because it is just as accurate and is safer. But ERCP may be used because it enables doctors to take a biopsy sample, remove a gallstone, or do other procedures.
Occasionally, liver biopsy is needed. It may be done when certain causes (such as viral hepatitis, use of a drug, or exposure to a toxin) are suspected or when the diagnosis is unclear after doctors have the results of other tests.
Laparoscopy may be done when other tests have not identified why bile flow is blocked. For this procedure, doctors make a small incision just below the navel and insert a viewing tube called a laparoscope to examine the liver and gallbladder directly. Rarely, a larger incision during the laparotomy procedure is needed.
Treatments and Prevention
When a disorder is identified, it is treated if possible. High bilirubin levels themselves may also require treatment. Physiologic jaundice usually does not require treatment and resolves within 1 week. For newborns being fed formula, frequent feedings can help prevent jaundice or reduce its severity. Frequent feedings increase the frequency of bowel movements and thus eliminate more bilirubin in stool. The type of formula does not seem to matter.
Breastfeeding jaundice may also be prevented or reduced by increasing the frequency of feedings. If the bilirubin level continues to increase, rarely, infants may need to be supplemented with formula. In breast milk jaundice, mothers may be advised to stop breastfeeding for only 1 or 2 days and to express breast milk regularly during this break from breastfeeding to keep their milk supply up. Then they can resume breastfeeding as soon as the newborn’s bilirubin level starts to decrease. While breastfeeding, mothers are usually advised not to give the newborn water or water containing sugar because doing so may decrease how much milk the newborn drinks and may disrupt the mother’s milk production. However, breastfed infants who are dehydrated despite efforts to increase breastfeeding may need additional fluids.
Phototherapy or “bili lights” treatment is most commonly used, but it is not effective for all types of hyperbilirubinemia. For example, phototherapy is not used for infants with cholestasis. Phototherapy uses bright light to change bilirubin into a form that can be eliminated rapidly from the body. Blue light is the most effective, and most doctors use special commercial phototherapy units. Newborns are placed under the unit and undressed to expose as much skin as possible. They are turned frequently and left under the lights for variable periods of time (typically about 2 days to a week) depending on how much the bilirubin levels in the blood need to be lowered. Phototherapy can help prevent kernicterus(expand more cellularly under cause). To determine how well the treatment is working, doctors periodically measure bilirubin levels in blood. Skin color is not a reliable guide. Exchange transfusion treatment is used when bilirubin levels are very high and phototherapy is not sufficiently effective. An exchange transfusion can rapidly remove bilirubin from the bloodstream. A small amount of the newborn’s blood is gradually removed (one syringe at a time) and replaced with equal volumes of donor blood. The procedure usually takes about 2 hours. Exchange transfusions may need to be repeated if bilirubin levels remain high. Also, the procedure has risks and complications, such as heart and breathing problems, blood clots, and electrolyte imbalances in the blood. The need for exchange transfusion has decreased since phototherapy has become so effective and since doctors have become better able to prevent problems resulting from incompatible blood types. (insert adults treatment)
Jaundice causes the skin and the eyes to turn yellow. Bilirubin is a yellow chemical in hemoglobin that leads to unconjugated bilirubin circulating in the body if left untreated. As hemolysis takes place, the bone marrow builds new ones to replace them. If the liver or the bone marrow cannot replace the erythrocytes as fast as they are being broken down, bilirubin builds up in the body. Many healthy babies have some jaundice during the first week of life. It usually goes away. Newborn babies and premature babies are more prone to jaundice because their undeveloped liver may not be able to get rid of excess bilirubin. The young liver might not be able to get rid of so much bilirubin. Therefore, a sign of jaundice may be missed in a baby with darker skin color and a bilirubin test should be done if needed.
Figure SEQ Figure * ARABIC 1 (Healthline, https://www.healthline.com/health/jaundice)
Figure SEQ Figure * ARABIC 2 (Medscape, https://emedicine.medscape.com)
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