Jaundice in adults

Jaundice causes your skin and sometimes the whites of your eyes to become yellow. Other jaundice symptoms include:

• Yellow bodily fluids
• Dark-coloured, strong-smelling urine
• Stools that are either darker or lighter than normal
• Very itchy skin (pruritus)

Jaundice can be caused by a benign (non-harmful) condition but it can also be a symptom of several serious conditions. You should therefore always see a doctor for a diagnosis and to investigate the underlying cause. The treatment and outcome of treatment will vary depending on the cause.

Jaundice occurs when your body has too much bilirubin, a yellow waste product expelled by your liver. 

How is bilirubin made? 

Bilirubin is made from the breakdown of red blood cells. Your red blood cells last for about 120 days before they are broken down into various waste chemicals. The part of your red blood cells which carries iron is called haemoglobin; haemoglobin is broken down into heme and bilirubin. This type of bilirubin (unconjugated bilirubin) can’t dissolve in water and is carried to your liver. 

Your liver changes unconjugated bilirubin into conjugated bilirubin, which can dissolve in water. Conjugated bilirubin passes from your liver into your gallbladder via small tubes called bile ducts, where it becomes a part of your bile. 

Your gallbladder stores bile and drips it into your small intestine to help digest fat in the food you have eaten. The bilirubin in bile is what causes your stools to be brown in colour.

When levels of conjugated or unconjugated bilirubin in your blood become too high, you develop jaundice. Bilirubin can then leak into your tissues, causing yellow skin and eyes (hyperbilirubinemia). If bilirubin levels become very high, instead of yellowing, your skin and eyes may start to appear brownish. Jaundice can be caused by a problem at any stage of bilirubin production. 

Types of jaundice

There are three main types of jaundice: 

• Haemolytic jaundice — this is caused by haemolysis ie accelerated breakdown of your red blood cells
• Hepatocellular jaundice — this is caused by liver disease or injury
• Obstructive jaundice — this is caused by a blocked bile duct that stops bile from leaving your liver

There are a variety of health conditions that can cause jaundice, including: 

Conditions that affect your red blood cells

If your red blood cells are broken down at a faster rate than normal, the bilirubin levels in your blood will rise, causing jaundice. Conditions that increase the rate of red blood cell breakdown include: 

• Certain genetic diseases — this includes: 
• Glucose 6-phosphate dehydrogenase deficiency
• Sickle cell anaemia
• Spherocytosis 
• Thalassaemia
• Haemolytic uraemic syndrome
• Malaria

Conditions that affect your liver

Conditions that damage your liver can increase your bilirubin levels. In some cases, high bilirubin levels can then scar your liver (liver cirrhosis). 

Liver conditions that can increase your bilirubin levels include: 

• Cholestasis — a reduced flow of bile from your liver
• Cirrhosis — healthy liver tissue is gradually replaced by scar tissue in a process called fibrosis; there are no symptoms in the early stages but as the liver becomes more seriously damaged, jaundice can develop
• Hepatitis — inflammation of the liver, which can be caused by: 
• An autoimmune reaction where your immune system mistakenly attacks your liver (autoimmune hepatitis)
• Bacterial infection 
• Certain medications
• Excessive alcohol (alcoholic hepatitis)
• Poison
• Viral infection (viral hepatitis)
• Inherited conditions that affect enzymes that process bilirubin — this includes: 
• Crigler-Najjar syndrome 
• Dubin-Johnson syndrome
• Gilbert's syndrome
• Rotor's syndrome
• Non-alcoholic fatty liver disease — if you are overweight, you are at a greater risk of developing this condition
• Primary biliary cirrhosis — an autoimmune disorder that tends to affect women from middle age

Alcoholic liver disease can also cause jaundice.

Conditions that affect your bile ducts

The liver contains many small bile ducts which carry bile out of the liver via a larger bile duct called the common bile duct. If the small ducts are damaged or narrow, bile flow is reduced. This causes a backlog of bile which leaks into your bloodstream. As bile contains bilirubin, this causes jaundice. 

Certain medications can damage or narrow your small bile ducts, as can the following conditions: 

• Biliary atresia — this occurs in infants and affects bile ducts both in and outside the liver; the bile ducts narrow and become blocked due to scar tissue that forms as a result of inflammation
• Primary biliary cirrhosis 
• Primary sclerosing cholangitis

If your common bile duct is damaged or narrowed, you can also develop jaundice. 

Gallstones

Gallstones are small, fatty lumps that form in your bile. They don't usually cause problems but can sometimes block the common bile duct, causing jaundice. 

Certain types of cancer 

• Gallbladder cancer — this can narrow or block the common bile duct, blocking bile flow and causing jaundice
• Liver cancer 
• Pancreatic cancer that develops in the head of the pancreas — the head of the pancreas is near the common bile duct and cancer in this area can therefore narrow or block this duct, causing jaundice

Other jaundice causes

• Advanced chronic (long-term) pancreatitis — inflammation of the pancreas which causes swelling that can block bile flow
• Certain medications eg certain antibiotics and anti-epileptic drugs

Pseudojaundice

This is not caused by increased levels of bilirubin but by excess beta-carotene. It is not harmful and is usually caused by eating large amounts of foods high in beta-carotene eg carrots, melons and pumpkins.

One of the first symptoms of jaundice is often the whites of your eyes turning yellow. This can occur even if your bilirubin levels are only mildly raised and in this case, it may be the only area of your body that turns yellow. Higher bilirubin levels cause your skin to become yellow too. 

If your jaundice is caused by an infection and is therefore short-term, you may also have: 

• Dark-coloured, strong-smelling urine
• Fever and/or chills
• Flu-like symptoms
• Pain your abdomen
• Stools that are either darker or lighter than normal

If your jaundice is not caused by an infection, you may also have itchy skin (pruritus) and unintentional weight loss.

Other symptoms include fatigue and vomiting. If your jaundice is caused by cancer, the most common symptom is pain in your abdomen.

You are at greater risk of jaundice if you:

• Are middle-aged 
• Drink excessive alcohol 
• Have hepatitis 

Pruritus ie itchy skin caused by jaundice can be so severe that you may develop insomnia and/or scratch your skin until it is raw.

In most cases, jaundice complications are not due to jaundice per se but the underlying condition that is causing jaundice. For example, if your jaundice is caused by a blocked bile duct, you may develop uncontrolled bleeding due to a lack of vitamins needed for clotting.

If your skin or the whites of your eyes look yellow, contact your GP immediately. As there are many causes of jaundice, your GP will need to ask you a lot of questions to investigate the underlying cause. 

They will ask about any other jaundice symptoms, your general health and your medical history. They will also discuss your lifestyle, including any travel abroad, alcohol intake, diet and drug use.

They may perform a physical examination to check: 

• For any lumps or bumps that could be tumours 
• The firmness of your liver — a firm liver suggest liver cirrhosis or scarring; a rock-hard liver suggests cancer
• Your abdomen

Your GP will also test your urine to check bilirubin levels and may do blood tests. If necessary, your GP will refer you for further investigations, such as an ultrasound scan or MRI scan of your liver.

In some cases, they may refer you for a liver biopsy. This is where a sample of your liver tissue is collected by inserting a needle into your liver. This tissue is sent to a lab and examined under a microscope to check for cancer, cirrhosis, inflammation and fatty liver. 

Depending on your results, your GP may arrange for you to see a consultant. If the above tests are not conclusive, your doctor may recommend further tests. 

Jaundice in adults requires prompt diagnosis and treatment for the underlying cause.

Once the cause of your jaundice has been diagnosed, your GP or consultant will arrange treatment for your underlying condition. This may involve medical or surgical treatment and, if needed, you’ll be admitted to hospital.

Treatments include: 

• Antiviral or steroid medications if your jaundice is caused by hepatitis
• Changing medications if your jaundice is a side effect of a specific medication you’re taking
• Gallbladder removal if your jaundice is caused by gallstones
• Surgery to remove an obstruction if your jaundice is caused by a tumour or other obstruction blocking your bile duct
• Taking iron supplements or following an iron-rich diet if your jaundice is caused by anaemia.

Jaundice has many different causes, so there are few general prevention tips. However, you can reduce your overall risk by: 

• Avoiding infection with hepatitis
• Maintaining a healthy liver — this involves following a healthy, balanced diet, regularly exercising and not drinking excessive amounts of alcohol
• Maintaining a healthy weight
• Maintaining healthy cholesterol levels