Jaundice is a yellow discoloration of the skin, mucous membranes, or sclera, reflecting elevated conjugated or unconjugated bilirubin in the blood. In fair-skinned patients, it is most noticeable on the face, trunk, and sclera; in dark-skinned patients, on the hard palate, sclera, and conjunctiva. Jaundice is most apparent in natural sunlight and may be accompanied by pruritus, dark urine, and clay-colored stools. It can result from prehepatic, hepatic, or posthepatic causes and may be the only initial sign of serious disorders, such as pancreatic cancer.

History and physical examination

• Document onset, duration, and progression of jaundice.

• Assess associated symptoms: pruritus, clay-colored stools, dark urine, fatigue, fever, chills, abdominal pain, anorexia, weight loss, nausea, vomiting, and cardiopulmonary complaints (palpitations, dyspnea).

• Obtain history of alcohol use, prior liver/gallbladder/pancreatic disease, hepatitis, gallstones, cancer, and medications.

• Evaluate family history of jaundice.

• Physical examination should be in natural light to distinguish jaundice from hypercarotenemia.

• Inspect skin for dryness, texture, hyperpigmentation, xanthomas, spider angiomas, petechiae, clubbing, and gynecomastia.

• Assess cardiovascular status: auscultate for murmurs, gallops, crackles; palpate lymph nodes, abdomen, liver, and spleen; test for ascites.

• Assess mental status for early signs of hepatic dysfunction.

Medical causes

Other Causes

• Drugs: Acetaminophen, isoniazid, tetracyclines, sulfonamides, hormonal contraceptives, erythromycin, niacin, androgenic steroids, statins, ethanol, phenytoin, rifampin, phenothiazines, etc.

• Treatments: Upper abdominal surgery, portacaval shunts, prolonged halothane anesthesia, shock, blood loss, transfusions.

Jaundice: Impaired Bilirubin Metabolism

• Prehepatic: Massive hemolysis (e.g., transfusion reactions, sickle cell anemia); unconjugated bilirubin rises; increased urobilinogen in urine/stools.

• Hepatic: Liver cannot conjugate/excrete bilirubin (e.g., hepatitis, cirrhosis, metastatic cancer, hepatotoxic drugs); both conjugated and unconjugated bilirubin increase.

• Posthepatic: Biliary obstruction prevents excretion of conjugated bilirubin (e.g., stones, tumors, strictures).

Special considerations

• Manage pruritus: frequent bathing, calamine lotion, diphenhydramine, hydroxyzine.

• Prepare for laboratory studies: serum bilirubin, liver enzymes, cholesterol, urine/fecal urobilinogen, prothrombin time, CBC.

• Imaging: ultrasonography, cholangiography; liver biopsy; exploratory laparotomy if needed.

Patient counseling

• Educate on dietary modifications and ways to reduce pruritus.

• Encourage monitoring and reporting of new symptoms.

Pediatric pointers

• Physiologic jaundice: common in neonates, appears 3–5 days after birth.

• Obstructive jaundice: congenital biliary atresia, choledochal cyst (notably in Japanese children).

• Other pediatric causes: Crigler-Najjar, Gilbert’s disease, Rotor syndrome, hereditary spherocytosis, thalassemia major, erythroblastosis fetalis, Hodgkin’s disease, infectious mononucleosis, Wilson’s disease, amyloidosis, Reye’s syndrome.

Geriatric pointers

In patients >60 years, jaundice usually results from cholestasis due to extrahepatic obstruction.

References

1. Liebel, F., Kaur, S., Ruvolo, E., Kollias, N., & Southall, M. D. (2012). Irradiation of skin with visible light induces reactive oxygen species and matrix-degrading enzymes. Journal of Investigative Dermatology, 132, 1901–1907.

2. Stokowski, L. A. (2011). Fundamentals of phototherapy for neonatal jaundice. Advances in Neonatal Care, 11, 10–21.