Jaundice

What jaundice is

Jaundice, also called icterus, is a yellow discolouration of the skin and sclera (the whites of the eyes) caused by a build-up of bilirubin, the yellow pigment produced when haemoglobin breaks down. Jaundice is a sign rather than a diagnosis in itself, and it always warrants medical investigation in adults.

How bilirubin metabolism works

Red blood cells break down naturally over time, releasing a substance called unconjugated bilirubin. The liver then processes, or conjugates, this bilirubin so that it can be excreted in bile, which passes into the gut and gives stool its normal brown colour. Jaundice develops when too much bilirubin is produced through excessive breakdown of red blood cells, when the liver fails to process bilirubin properly because of liver disease, or when bile cannot drain normally because of an obstruction somewhere in the system.

Symptoms of jaundice

Yellowing of the sclera is often the first visible sign of jaundice, and yellowing of the skin tends to be more obvious in good light. Itching can also occur, particularly with obstructive causes of jaundice. Dark, tea-coloured urine reflects conjugated bilirubin being excreted through the kidneys, while pale, clay-coloured stools occur because bilirubin is not reaching the gut. It can be easier to spot jaundice by checking the sclera in a mirror than by looking at the skin alone, especially in some skin tones.

Causes of jaundice

Jaundice is generally grouped by where the problem lies in the bilirubin pathway. Pre-hepatic causes involve excess bilirubin production and include haemolytic anaemia, sickle cell crisis, and Gilbert’s syndrome, a benign condition that causes mild jaundice during fasting or illness. Hepatic causes involve damage to liver cells themselves and include viral hepatitis A, B, C and E, alcohol-related liver disease, advanced fatty liver disease, drug-induced liver injury such as a paracetamol overdose (which is a medical emergency), autoimmune hepatitis, and cirrhosis from any cause. Post-hepatic causes involve obstruction of the bile duct and include gallstones in the common bile duct, pancreatic cancer (which classically causes painless jaundice and needs urgent assessment), cholangiocarcinoma, pancreatitis compressing the bile duct, and strictures following previous surgery.

Associated symptoms that point to a cause

Certain accompanying symptoms can help point towards the underlying cause of jaundice. Gallstone obstruction typically causes pain in the right upper abdomen, along with fever if the bile duct becomes infected (cholangitis). Hepatitis often causes flu-like symptoms, a tender liver, and raised liver enzymes on blood tests. Alcohol-related liver disease is usually associated with a history of heavy drinking and can cause fluid build-up in the abdomen (ascites). Pancreatic cancer classically causes weight loss alongside painless, progressively worsening jaundice. Jaundice from haemolysis tends to occur alongside anaemia, dark urine, and normal ALP levels on blood tests.

When jaundice is a medical emergency

You should go to A&E if jaundice occurs alongside fever and shaking, since this combination can indicate cholangitis, an infection that carries a risk of sepsis. Severe abdominal pain, confusion (which can indicate hepatic encephalopathy), and vomiting blood alongside jaundice are also emergencies, as is any jaundice following a paracetamol overdose. The combination of jaundice, fever, and right upper quadrant pain is known as Charcot’s triad and is treated as a medical emergency.

How jaundice is investigated

A GP can usually arrange same-day tests, including liver function tests that split bilirubin into its direct and indirect components alongside ALP, ALT, AST and albumin, a full blood count to screen for haemolysis, an INR blood test to check the liver’s clotting function, hepatitis blood tests, and an ultrasound scan of the abdomen to look for duct dilation, gallstones, and changes in liver texture. Referral on a two-week wait pathway is used when painless jaundice occurs alongside weight loss, to rule out cancer, while referral to gastroenterology or hepatology is used for suspected hepatitis, and ERCP is used when a duct stone is suspected.

How jaundice is treated

Treatment for jaundice depends entirely on its underlying cause. Gallstones are treated with endoscopic removal and often removal of the gallbladder (cholecystectomy). Hepatitis B and C are treated with antiviral therapy, while alcohol-related liver disease is treated with abstinence from alcohol and specialist support. Autoimmune causes are treated with steroids or other immune-suppressing medicines, and cancer-related jaundice is managed through an oncology pathway. There is no effective self-treatment for jaundice, and herbal “liver detox” products are not effective and may cause harm.

Jaundice in newborn babies

Jaundice is common in newborn babies because their livers are still immature, and it follows a different assessment pathway involving midwife or paediatric monitoring, since severe untreated newborn jaundice carries a risk of a condition called kernicterus. This guide focuses on jaundice in adults, and children who develop jaundice need a paediatric assessment rather than following the advice above.

Yellow eyes are never normal in an adult, so a same-day GP appointment is the minimum step you should take, and the combination of pain, fever, and yellowing of the skin or eyes means you should go to A&E.

Common questions about jaundice

What causes yellow skin and eyes?

Yellow skin and eyes are caused by high bilirubin in the blood, which can build up from increased red cell breakdown (haemolysis), a liver that cannot process bilirubin properly (as in hepatitis, cirrhosis, or fatty liver), or a blocked bile duct from gallstones or a tumour that stops bilirubin reaching the stool. A GP arranges blood tests and scans to work out which type is causing your jaundice.

Is jaundice always serious?

Jaundice always needs medical assessment, even though some causes are mild, such as the benign genetic condition Gilbert's syndrome, while others are urgent, such as a blocked bile duct with infection or acute liver failure. You should never assume jaundice is harmless without a medical evaluation.

What is obstructive jaundice?

Obstructive jaundice happens when the bile duct is blocked and bilirubin backs up into the blood, causing dark urine, pale stools, itchy skin, and often pain if a gallstone is responsible. It needs an ultrasound scan and sometimes a procedure called ERCP to remove the stone, and painless, progressively worsening jaundice needs urgent referral to rule out pancreatic or biliary cancer.

Can alcohol cause jaundice?

Yes, alcohol can cause jaundice through alcoholic hepatitis or cirrhosis, and this needs you to stop drinking alcohol immediately and seek urgent medical care. Fatty liver disease with inflammation can also cause jaundice once the disease is advanced.

What tests are done for jaundice?

Jaundice is investigated with liver blood tests measuring ALT, AST, ALP and bilirubin, a full blood count, hepatitis B and C blood tests, and an ultrasound scan of the abdomen to look at the bile ducts and gallbladder. Further scans such as CT, MRI or ERCP may follow depending on the findings, and coagulation tests assess how well the liver is functioning.

Does jaundice cause itching?

Yes, jaundice can cause itching because bile salts build up in the skin, and this itching is often worse at night in obstructive jaundice. Treating the underlying cause usually relieves the itch, and a medicine called cholestyramine can sometimes help with symptom relief in the meantime.

Sources

• NHS — Jaundice
• NICE — Jaundice in adults