Jaundice - MedFriendly.com

WHAT ARE THE DIFFERENT TYPES OF JAUNDICE AND CAUSES OF JAUNDICE?

There are many different types and causes of jaundice, described below, beginning with hemolytic

jaundice.

In hemolytic jaundice, the amount of bilirubin that is produced is too much for the liver to process. It is

called hemolytic jaundice because it caused by excessive hemolysis. Hemolysis is the breakdown of red

blood cells. Hemoylsis can have many causes, one of which is hemolytic anemia.

Anemia is a condition in which there is an abnormally low amount of hemoglobin in the blood. Hemoglobin

is a substance present in red blood cells that help carry oxygen to cells in the body. Hemolytic anemia is a

condition in which the red blood cells are destroyed earlier than they should be. Since bilirubin is mainly

formed by the breakdown of hemoglobin, too much breakdown of hemoglobin (which happens when red

blood cells are destroyed) leads to too much bilirubin.

One of the most common types of jaundice is known as neonatal jaundice (also called physiological

jaundice). It is called neonatal jaundice because it occurs in newborns (also known as neonates). In fact,

neonatal jaundice occurs in more than half of all newborns. It is usually present 3 to 4 days after birth.

Jaundice in the infant, appears in the head, neck, and upper body at first and then progresses down the

body. In severe cases, jaundice will appear in the toes.

Since infants produce a high number of red blood cells, more red blood are broken down. Also, the red

blood cells of infants do not live as long as the red blood cells of adults. The rapid breakdown of red blood

cells in infants means that more hemoglobin is broken down in infants. This, in turn, leads to more bilirubin

production. In fact, all infants have increased bilirubin levels to a greater or lesser degree in the first week

of life. Only about half of infants, however, are visibly jaundiced.

In other cases, the liver is not yet fully developed when the infant is born and the liver enzymes cannot

break bilirubin down like it will be able to in the future. An enzyme is a type of protein that helps produce

chemical reactions in the body. Premature infants (infants born too early) do not have fully developed

organs, which is why they are more likely to develop neonatal jaundice than full-term babies (babies born

on time). This slow development of the liver has nothing to do with liver disease and the liver will

eventually function as it is supposed to.

Most cases of neonatal jaundice are not serious. Neonatal jaundice usually disappears in a few days,

often without special medical treatment. It is usually always gone in one to two weeks. The bilirubin travels

to the liver, where it is processed and eventually released from the body as waste. Neonatal jaundice

does not have any lasting effects on the infant once it disappears. It should be noted that although

neonatal jaundice is rarely serious (see next paragraph for exceptions), all other types of jaundice indicate

that a serious problem is present, such as a disease process.

Rarely, neonatal jaundice is caused by a serious condition, such as liver disease or other types of organ

damage. There are two blood disorders that can lead to jaundice by causing a rapid breakdown of red

blood cells. These blood disorders are known as Rh incompatibility and ABO incompatibility. When these

blood incompatibility disorders cause jaundice, it is sometimes referred to as incompatibility jaundice.

Jaundice caused by blood group incompatibility is usually observed one to days after birth. Normal

jaundice usually occurs 3 to 10 days after birth.

Rh and ABO are the names of two types of blood groups. Blood groups are systems of classifying blood

according to the presence of absence of certain types of antigens on the surface of red blood cells.

Antigens are substances (usually a protein) that are capable of producing a defensive reaction by the

body, to protect it against foreign invaders. Most antigens come from sources outside of the body, but

some antigens are created naturally by the body (as in the case of antigens on red blood cells).

Rh incompatibility is a mismatch between the blood of a pregnant woman and the blood of her infant,

regarding the Rh (Rhesus) blood group. ABO incompatibility is a mismatch between the blood of a

pregnant woman and the blood of her infant, regarding the ABO blood group.

As an example of Rh incompatibility, if a pregnant mother has the Rh group and the infant does as well,

this would mean the pregnant mother would be exposed to antigens (see last paragraph) that her body

would interpret as a threat. The mother's body may then produce substances known as antibodies that are

designed to fight off antigens. This would mean that the mother's body would be fighting against the

infant's blood. This is what leads to a breakdown of the infant's red blood cells, since the mother's body

has formed antibodies to attack it. Such a situation would not happen if both the infant and the mother had

the RH blood group, or if both did not.

Fortunately, blood tests can be done during pregnancy to tell if Rh or ABO incompatibility will be present. If

so, the mother will receive a shot within 72 hours after delivery to avoid any complications. The shot is

called Rh immune globulin and prevents the mother from forming antibodies that may attack the child's red

blood cells.

In infants, jaundice can sometimes be worsened or caused by breastfeeding. When this happens, it is

referred to as breastfeeding jaundice or breastmilk jaundice. This type of jaundice usually occurs between

four to seven days after birth, but it can occur more than 14 days after birth. An underactive thyroid can

also cause jaundice to last for more than 14 days after birth. The thyroid gland is a butterfly-shaped organ

located in the front of the neck that plays an important role in metabolism. Metabolism is the chemical

actions in cells that release energy from nutrients or use energy to create other substances.

What usually happens in breastfeeding jaundice is that the infant is not getting enough breast milk.

Remember that when an infant is born, breast milk is the food that the he/she eats, unless the infant is

given formula. If the infant does not get enough breast milk, the infant does not poop as much. Bilirubin

normally leaves the body when the person poops. If the infant is not pooping as much, not enough bilirubin

leaves the body and bilirubin levels build up.

There is also some evidence that there may be a hormone in the breast milk that interferes with liver

function. Hormones are natural chemicals produced by the body and released into the blood that have a

specific effect on tissues in the body. Breastfeeding jaundice is a diagnosis of exclusion, meaning that it

is only diagnosed when other causes of jaundice have been ruled out. Breastfeeding jaundice can last for

as long as three to ten weeks.

In hepatocellular jaundice, bilirubin levels get too high because there is something preventing it from being

transferred from the liver cells to the bile. This is usually caused by liver failure or acute (sudden)

hepatitis. Hepatitis is inflammation of the liver. In ischemic hepatocellular jaundice, the jaundice is caused

by not enough oxygen or blood reaching the liver, causing it to function improperly.

Rarer causes of increased bilirubin levels are Gilbert's syndrome and Criggler-Najjar syndrome. Gilbert's

syndrome (also known as Gilbert's disease) is a non-harmful, inherited condition that affects the way

bilirubin is processed by the liver, and causes mild jaundice (especially in times of stress). Criggler-Najjar

syndrome is an inherited disorder in which an enzyme, glucuronyl transferase, is deficient or absent. An

enzyme is a type of protein that helps produce chemical reactions in the body. Glucuronyl transferase

helps change bilirubin into bile. If there is not enough of this enzyme present, too much bilirubin will be

present because it cannot be changed into bile. Jaundice due to Criggler-Najjar syndrome usually does not

occur until 14 days (or more) after birth.

Other rare causes of increased bilirubin levels are Dubin-Jonson syndrome and Rotor's syndrome. Dubin-

Johnson syndrome is a disorder that an infant is born with, in which bilirubin levels are high, jaundice is

present, the liver has an abnormal color, and the gallbladder functions abnormally. The gallbladder is a

small, pear shaped sac, located under the liver, which helps store and transport bile to the first part of the

small intestine (known as the duodenum). Rotor's syndrome is another rare liver condition similar to Dubin-

Johnson's syndrome, except that the gallbladder functions normally in Rotor's syndrome and the liver does

not have an abnormal color to it.

In obstructive jaundice, bile is prevented from flowing out of the liver because of blockage in the tubes that

carry bile (known as bile ducts). When the bile ducts become blocked, the bile (and bilirubin) cannot get

where it needs to go and starts to back up, much like a clogged sink. Bilirubin normally flows from the liver,

through the bile ducts, to the gallbladder, and then to the intestines. The gallbladder is a small, pear

shaped sac, located under the liver, which helps store and transport bile to the first part of the small

intestine (known as the duodenum).

When the bile ducts are blocked, the body continues to produce bile and bilirubin. The levels of bile and

bilirubin increase due to the blockage. It should be noted that a narrowing of the bile ducts can also cause

a buildup of bilirubin and lead to jaundice. This narrowing of a tube shaped structure in the body is known

as a stricture.

Liver cancer is a type of disease that can cause the bile ducts to be blocked. Cancer is an abnormal

growth of new tissue characterized by uncontrolled growth of abnormally structured that have a more

primitive form. Gallstones (stones in the gallbladder) can also block the bile ducts and cause jaundice.

Other causes of obstructive jaundice are the absence of bile ducts (known as biliary atresia) or the

destruction of bile ducts. Destruction of bile ducts can be caused by cirrhosis, a type of disease that

destroys the liver. When either of these two things happen, bile stays still in the liver (a condition known

as cholestasis) and bilirubin is forced back into the blood. Bilirubin is forced back into the blood because

the bile is not moving. Since the bile is not moving, the bilirubin cannot be passed out with the bile and

goes back to the blood. When the bilirubin goes back to the blood, bilirubin levels increase. Cholestasis

can also be caused by the effects of certain medications. It can also be caused by pregnancy, due to the

pressure that builds up in the belly.

Malaria has been known to cause jaundice. Malaria is a serious disease caused by parasites that is

spread by mosquitoes. A parasite is any organism that lives in or on another living being, gains an

advantage by doing so, but causes disadvantage to the being it is living on. Malaria can cause jaundice

by causing liver damage. Other types of parasites, such as tapeworms, may also lead to jaundice.

Tapeworms are ribbon-shaped worms that live inside the intestines of humans or of animals that have a

spine.

CAN EXCESS BILIRUBIN CAUSE BRAIN DAMAGE?

Yes. Bilirubin can cause serious damage, such as brain damage and deafness, but only if the levels of

bilirubin are extremely high. A rare form of brain damage that can be caused in infants due to high bilirubin

levels is known as kernicterus. Kernicterus is especially likely to occur in premature infants and results on

a form of mental retardation and seizures. Seizures are involuntary muscle movements and/or decreased

awareness of the environment due to overexcitement of nerve cells in the brain. Infants with kernicterus

usually have muscles that are very tense.

Other problems that can be caused by kernicterus include hearing loss, deafness, and cerebral palsy.

Cerebral palsy is a type of brain damage that occurs during pregnancy, during birth, during infancy, or

during early childhood that causes the child to have difficulties with movement and posture. Cerebral palsy

does not get worse as time progresses.

Kernicterus can lead to death. When the brains of children with kernicterus are examined, it is often found

that the basal ganglia has been stained with bilirubin. The basal ganglia are paired groups of nerve cells

located deep within the brain that play an important part in smooth, continuous muscle movements and in

starting and stopping movements.

It is important to have bilirubin levels checked regularly if jaundice is occurring so as to prevent significant

problems from occurring. If an infant develops severe jaundice, the risk of developing kernicterus is

increased by acidosis (too much acid in the blood) Acidosis increases the risk of bilirubin being deposited

in the brain. Acidosis can be treated with sodium bicarbonate. Sodium bicarbonate is a substance in the

blood that prevents it from becoming too acidic or too alkaline (non-acidic). Assisted breathing is also

used when acidosis is present because the condition may cause breathing difficulties.

Decreased levels of albumin in the blood also increase the risk for jaundice. Albumin is the most abundant

protein in the body. It is produced in the liver. Albumin binds to certain substances (such as bilirubin) and

helps retain them in the body so they are not all filtered out. Drugs that displace bilirubin form albumin can

also lead to kernicterus.

IS JAUNDICE MORE LIKELY TO OCCUR IN CERTAIN RACES?

Yes. Jaundice is more likely to occur in Asians (especially the Chinese).

WHAT ARE RISK FACTORS FOR JAUNDICE?

Risk factors for jaundice include premature birth (being born too early), being Asian (especially Chinese),

bruising, and a cephalohematoma. A cephalohematoma is an extensive, soft swelling on the scalp of

newborn infants that is caused by bleeding in the space between the skull and covering over the skull.

Another risk factor for jaundice is polycythemia vera. Polycythemia vera is a condition of unknown cause

in which there is a long-term increase in red blood cells and other types of cells. Whenever more red

blood cells are present, this means that more bilirubin will be produced when the red blood cells are broken

down, leading to jaundice. Breastfeeding can also be a risk factor for jaundice.

WHEN DOES JAUNDICE IN THE INFANT NORMALLY OCCUR?

Jaundice in the infant normally occurs between 3 to 10 days after birth. Jaundice that occurs within 24

hours after birth or lasts after 14 days past birth is a potentially serious condition that should be evaluated

by a doctor.

WHAT ARE COMMON SIGNS AND SYMPTOMS OF JAUNDICE?

The main sign in jaundice is yellow colored skin. Besides this sign, symptoms of jaundice include nausea,

vomiting, itching, pain in the belly, dark urine (pee), and pale feces (poop). The itching is caused by

bilirubin being deposited in the skin. Jaundice can be one of several signs or symptoms of a disease or it

may be the only sign or symptom.

In obstructive jaundice (see above), dark urine and pale feces usually accompany the jaundice. The urine

is dark because high amounts of bilirubin are filtered into it from the blood. The feces is pale because the

bilirubin, which normally colors it brown, cannot reach the intestine, which is where the feces is. The

intestine is a tube shaped structure that is part of the digestive tract. It stretches from an opening in the

stomach to the anus (the area that poop comes out of) and occupies most of the lower parts of the belly.

In hemolytic jaundice the urine and feces are normal in color. In hepatocellular jaundice, the urine may be

dark but the feces is normal. See the previous section for a description of hemolytic and hepatocellular

types of jaundice.

HOW IS JAUNDICE DIAGNOSED?

Sometimes, jaundice does not occur until the baby leaves the hospital. One technique that doctors

recommend to parents is to apply gentle pressure to the infant's chest. If after releasing the pressure a

yellow color is found, jaundice may be present. This technique works best for infants without pale skin. For

children without pale skin, it is recommended by doctors to check for yellowing of the gums.

To diagnose jaundice, the doctor will naturally need to see the patient. In addition to a routine history and

physical examination, the doctor will want to check the level of bilirubin in the blood to determine if the

levels are too high. A normal level of bilirubin is .1 to 1.2 milligrams. A milligram is a thousandth of a gram,

which is a very small unit of weight.

Blood tests known as liver function tests (abbreviated as LFTs) will also be done to assess how the liver

is functioning. A blood smear can be performed, which involves placing a drop of blood under a glass side,

which is then inspected under a microscope. A blood smear will help tell if large numbers of immature red

blood cells are present. If so, hemolysis (the breakdown of red blood cells) is suspected to be causing the

jaundice.

A urine and fecal urobilinogen test may also be performed. Urobilinogen is a colorless substance that is

formed in the intestine after the breakdown of bilirubin. Some of this substance is passed out from the

body in the urine (pee) or feces (poop). Thus, testing the amount of urobilinogen in the urine and feces

can help diagnose jaundice.

Other tests that may be performed in the diagnosis of jaundice are the prothrombin time (PT) test and the

complete blood count (CBC) test. The PT test works by taking a blood sample and determining how quickly

it clots (when the blood comes together as a solid). The CBC test shows the number of various types of

red and white blood cells. White blood cells help the body fight against infections.

Techniques to visualize internal organs such as the liver may also be performed. The most common of

such tests is a CT (computerized tomography) scan. CT scanning is an advanced imaging technique that

uses x-rays and computer technology to produces very clear and detailed pictures. An ultrasound can also

be used, which is a procedure that uses types of sound waves to produce images of the body. Another

viewing technique used requires surgery to explore the inner organs such as the liver. An example of such

a surgery is endoscopy, which uses a flexible viewing tube inserted into the body to get a close look at a

particular body part.

Taking a tissue sample from an organ, such as the liver, for laboratory analysis is another test that may

be performed in patients with jaundice. Taking a tissue sample for analysis is known as a biopsy. This is

what is needed to diagnose hepatocellular jaundice (see above). If a disease or blockage of the tubes that

transport bile are suspected of causing the jaundice, ultrasound tests, liver function tests, and a

cholangiography is performed to assist with the diagnosis. A cholangiography is a technique in which x-

rays take pictures of the tubes that transport bile after those tubes have been filled with a contrast

material. Contrast material is a liquid substance that x-rays cannot pass through.

It is important to remember that many people with naturally dark skin have yellowing of the whites of the

eyes. This is why the roof of the mouth is often one of the best places to look for jaundice because it is

unaffected by a person's skin color. The mucous membranes covering the roof of the mouth are what turn

yellow in people with jaundice, whether they naturally have dark skin or not.

HOW IS JAUNDICE TREATED?

Jaundice is always treated by treating the underlying cause of the high bilirubin levels. For example, if the

cause of the high bilirubin level is liver cancer, then treatment will be aimed at the liver cancer. In infants,

jaundice is usually treated with phototherapy, meaning that they are placed under special lights known as

billilights. The lights may be blue, green, or white. The baby is placed under the lights completely naked.

However, the infant's eyes are covered with soft protective pads when placed under the lights and a cloth

is placed over the infant's private parts. The baby is kept in a warmer so that it does not get cold. The

baby can be removed from the lights for short periods of time to interact with the parents.

The infant may also be placed under a blanket that produces light, known as a biliblanket. Lights are used

because light helps to break down bilirubin. Protective eye pads are not used when the blanket is the only

treatment. Biliblankets are not very effective on a low power setting. Each day, the bilirubin levels in the

blood will be checked to see how much they are decreasing.

Phototherapy is a safe and effective treatment that has been used since the 1970s. Phototherapy can

also be done at home after talking with the doctor and renting the proper equipment. If the jaundice is not

significant enough for medical treatment, doctors have often recommended that parents give their children

a bit of sun exposure early in the morning or late in the afternoon. However, avoiding the midday sun is

important so that sunburn does not occur.

Infants with jaundice that were born full-term usually need phototherapy for a few days, and sometimes for

more than a week. Premature infants usually develop neonatal jaundice between the fifth and seventh day

after delivery, but usually goes away within two months. It should be noted that most doctors will not begin

treatment unless the bilirubin level is over 20 milligrams. However, other factors that will influence whether

treatment should occur is whether or not the baby is premature, if blood group incompatibility is present

(see above), and if the baby is sick. In such cases, the doctor may start treatment if the bilirubin level is

under 20 milligrams.

Most doctors do not recommend stopping breastfeeding in infants that have jaundice (although some do).

Rather, increased breastfeeding is often recommended since the problem is due to the child not getting

enough breast milk. The potential harm of stopping breastfeeding usually outweighs the risk of mild to

moderate increased bilirubin levels. Stopping breastfeeding can interfere with the flow of the mother's

breast milk, for example, and can decrease her confidence in the ability to breastfeed.

It is very unusual for infants (even premature infants) to need any other treatment for jaundice, other than

phototherapy. Some doctors, however, will also administer immunoglobulins (also known as antibodies)

through the infant's veins to decrease the bilirubin level. Immunoglobulins are proteins that bind to

substances in the body that are recognized as foreign. This binding process leads to the destruction of the

substances they bind to. Some doctors prescribe the calming medication, Phenobarbital, for severe

jaundice because it helps the liver enzymes process bilirubin.

In rare cases, if the bilirubin levels get too high, a blood exchange transfusion can be done, in which the

infant's blood is exchanged with donated blood that does not contain a high level of bilirubin. Blood

exchange transfusions can also be done if the mother's body has formed substances known as antibodies

that are attacking the infant's red blood cells, causing more bilirubin to form. Extremely premature infants

may need an urgent blood exchange transfusion if their bilirubin levels get dangerously high. However,

premature infants tend to respond very well to phototherapy.

WHAT IS THE DIFFERENCE BETWEEN JAUNDICE AND HYPERCAROTENEMIA?

In hypercarotenemia (also known as carotenemia), the skin has a yellow-orange color, but the eyes do

not. In jaundice, both the eyes and skin have a yellowish color. Hypercarotenemia is an abnormally

increased level of beta carotene in the blood. Beta carotene is a yellow rid pigment (a naturally colored

substance) that is found is some foods such as carrots or carrot juice. People who eat large amounts of

foods that contain beta carotene (or who take a large number of beta carotene pills) may develop too high

of a level of beta carotene in their blood, leading to skin color changes.

WHAT ELSE IS JAUNDICE KNOWN AS?

Jaundice is also known as icterus.

WHAT IS THE ORIGIN OF THE TERM, JAUNDICE?

Jaundice comes from the French word "jaune" meaning "yellow."