Jaundice [Icterus]

A yellow discoloration of the skin, mucous membranes, or sclera of the eyes, jaundice indicates excessive levels of conjugated or unconjugated bilirubin in the blood. In fair-skinned patients, it’s 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. In fact, it may be undetectable in artificial or poor light. It’s commonly accompanied by pruritus (because bile pigment damages sensory nerves), dark urine, and clay-colored stools.

Jaundice may result from any of three pathophysiologic processes. (See Jaundice: Impaired bilirubin metabolism, page 460.) It may be the only warning sign of certain disorders such as pancreatic cancer.

History and physical examination

Documenting a history of the patient’s jaundice is critical in determining its cause. Begin by asking the patient when he first noticed the jaundice. Does he also have pruritus, clay-colored stools, or dark urine? Ask about past episodes or a family history of jaundice. Does he have nonspecific signs or symptoms, such as fatigue, fever, or chills; GI signs or symptoms, such as anorexia, abdominal pain, nausea, weight loss, or vomiting; or cardiopulmonary symptoms, such as shortness of breath or palpitations? Ask about alcohol use and a history of cancer or liver or gallbladder disease. Has the patient lost weight recently? Also, obtain a drug history. Ask about a history of hepatitis, gallstones, or liver or pancreatic disease.

Perform the physical examination in a room with natural light. Make sure that the orange-yellow hue is jaundice and not due to hypercarotenemia, which is more prominent on the palms and soles and doesn’t affect the sclera. Inspect the patient’s skin for texture and dryness and for hyperpigmentation and xanthomas. Look for spider angiomas or petechiae, clubbed fingers, and gynecomastia. If the patient has heart failure, auscultate for arrhythmias, murmurs, and gallops. For all patients, auscultate for crackles and abnormal bowel sounds. Palpate the lymph nodes for swelling and the abdomen for tenderness, pain, and swelling. Palpate and percuss the liver and spleen for enlargement, and test for ascites with the shifting dullness and fluid wave techniques. Obtain baseline data on the patient’s mental status: Slight changes in sensorium may be an early sign of deteriorating hepatic function. (See Differential diagnosis: Jaundice, pages 462 and 463.)

Medical causes

Agnogenic myeloid metaplasia

This myeloproliferative disorder of the bone marrow may cause jaundice. Its typical effects, however, are associated with anemia, including fatigue, weakness, anorexia, massive splenomegaly, hepatomegaly, purpura, and bleeding tendencies.

Carcinoma

Cancer of the ampulla of Vater initially produces fluctuating jaundice, mild abdominal pain, recurrent fever, and chills. Occult bleeding may be its first sign. Other findings include weight loss, pruritus, and back pain.

Hepatic cancer (primary liver cancer or another cancer that has metastasized to the liver) may cause jaundice by causing obstruction of the bile duct. Even advanced cancer causes nonspecific signs and symptoms, such as right-upper-quadrant discomfort and tenderness, nausea, weight loss, and slight fever. Examination may reveal irregular, nodular, firm hepatomegaly, ascites, peripheral edema, a bruit heard over the liver, and a right-upper-quadrant mass.

With pancreatic cancer, progressive jaundice—possibly with pruritus—may be the only sign. Related early findings are nonspecific, such as weight loss and back or abdominal pain. Other signs and symptoms include anorexia, nausea and vomiting, fever, steatorrhea, fatigue, weakness, diarrhea, pruritus, and skin lesions (usually on the legs).

Cholangitis

Obstruction and infection in the common bile duct cause Charcot’s triad: jaundice, right-upper-quadrant pain, and high fever with chills.

Cholecystitis

This disorder produces nonobstructive jaundice in about 25% of patients. Biliary colic typically peaks abruptly, persisting for 2 to 4 hours. The pain then localizes to the right upper quadrant and becomes constant. Local inflammation or passage of stones to the common bile duct causes jaundice. Other findings include nausea, vomiting (usually indicating the presence of a stone), fever, profuse diaphoresis, chills, tenderness on palpation, a positive Murphy’s sign, and, possibly, abdominal distention and rigidity.

Cholelithiasis

This disorder commonly causes jaundice and biliary colic. It’s characterized by severe, steady pain in the right upper quadrant or epigastrium that radiates to the right scapula or shoulder and intensifies over several hours. Accompanying signs and symptoms include nausea and vomiting, tachycardia, and restlessness. Occlusion of the common bile duct causes fever, chills, jaundice, clay-colored stools, and abdominal tenderness. After consuming a fatty meal, the patient may experience vague epigastric fullness and dyspepsia.

Cholestasis

With benign, recurrent intrahepatic cholestasis, the patient experiences prolonged attacks of jaundice (sometimes spaced several years apart) accompanied by pruritus. Other signs and symptoms are similar to those of hepatitis—fatigue, nausea, weight loss, anorexia, pale stools, and right-upper-quadrant pain.

Cirrhosis

With Laënnec’s cirrhosis, mild to moderate jaundice with pruritus usually signals hepatocellular necrosis or progressive hepatic insufficiency. Common early findings include ascites, weakness, leg edema, nausea and vomiting, diarrhea or constipation, anorexia, weight loss, and right-upper-quadrant pain. Massive hematemesis and other bleeding tendencies may also occur. Other findings include an enlarged liver and parotid gland, clubbed fingers, Dupuytren’s contracture, mental changes, asterixis, fetor hepaticus, spider angiomas, and palmar erythema. Males may exhibit gynecomastia, scanty chest and axillary hair, and testicular atrophy; females may experience menstrual irregularities.

With primary biliary cirrhosis, fluctuating jaundice may appear years after the onset of other signs and symptoms, such as pruritus that worsens at bedtime (commonly the first sign), weakness, fatigue, weight loss, and vague abdominal pain. Itching may lead to skin excoriation. Associated findings include hyperpigmentation; indications of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and osteomalacia; hematemesis from esophageal varices; ascites; edema; xanthelasmas; xanthomas on the palms, soles, and elbows; and hepatomegaly.

Dubin-Johnson syndrome

With this rare, chronic inherited syndrome, fluctuating jaundice that increases with stress is the major sign, appearing as late as age 40. Related findings include slight hepatic enlargement and tenderness, upper abdominal pain, nausea, and vomiting.

Glucose-6-phosphate dehydrogenase deficiency

Acute intravascular hemolysis following ingestion of such drugs as quinine or aspirin causes jaundice, pallor, dyspnea, tachycardia, and malaise. Palpation may reveal splenomegaly and hepatomegaly.

Heart failure

Jaundice due to liver dysfunction occurs in patients with severe right-sided heart failure. Other effects include jugular vein distention, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, hepatomegaly, nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Oliguria, marked weakness, and anxiety may also occur. If left-sided heart failure develops first, other findings may include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, arrhythmias, and tachycardia.

Hemolytic anemia (acquired)

This disorder may produce prominent jaundice along with dyspnea, fatigue, pallor, tachycardia, and palpitations. Rapid hemolysis causes chills, fever, irritability, headache, and abdominal pain; severe hemolysis causes signs of shock.

Hepatic abscess

Multiple abscesses may cause jaundice, but the primary effects are persistent fever with chills and sweating. Other findings include steady, severe pain in the right upper quadrant or midepigastrium that may be referred to the shoulder; nausea and vomiting; anorexia; hepatomegaly; elevated right hemidiaphragm; and ascites.

Hepatitis

Dark urine and clay-colored stools usually develop before jaundice in the late stages of acute viral hepatitis. Early systemic signs and symptoms vary and include fatigue, nausea, vomiting, malaise, arthralgias, myalgias, headache, anorexia, photophobia, pharyngitis, cough, diarrhea or constipation, and a low-grade fever associated with liver and lymph node enlargement. During the icteric phase (which subsides within 2 to 3 weeks unless complications occur), systemic signs subside, but an enlarged, palpable liver may be present along with weight loss, anorexia, and right-upper-quadrant pain and tenderness.

Leptospirosis

Severe leptospirosis (Weil’s disease) may cause jaundice. This disorder begins suddenly with a frontal headache, severe muscle aches in the thighs and lumbar area, cutaneous hyperesthesia, abdominal pain, nausea, conjunctival suffusion, and vomiting. Chills and a rapidly rising fever follow. Signs and symptoms of meningeal irritation include drowsiness, decreased mentation, stiff neck, and positive Kernig’s and Brudzinski’s signs. Right-upper-quadrant tenderness, hepatomegaly, and jaundice indicate hepatic involvement; proteinuria, pyuria, and hematuria indicate renal involvement. Epistaxis, hematemesis, melena, and hemoptysis may also occur.

Pancreatitis (acute)

Edema of the head of the pancreas and obstruction of the common bile duct can cause jaundice; however, this disorder’s primary symptom is usually severe epigastric pain that commonly radiates to the back. Lying with the knees flexed on the chest or sitting up and leaning forward brings relief. Early associated signs and symptoms include nausea, persistent vomiting, abdominal distention, and Turner’s or Cullen’s sign. Other findings include fever, tachycardia, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles.

Severe pancreatitis produces extreme restlessness; mottled skin; cold, diaphoretic extremities; paresthesia; and tetany—the last two being symptoms of hypocalcemia. Fulminant pancreatitis causes massive hemorrhage.

Sickle cell anemia

Hemolysis produces jaundice in patients with this disorder. Other findings include impaired growth and development, increased susceptibility to infection, life-threatening thrombotic complications and, commonly, leg ulcers, (painful) swollen joints, fever, and chills. Bone aches and chest pain may also occur. Severe hemolysis may cause hematuria and pallor, chronic fatigue, weakness, dyspnea (or dyspnea on exertion), and tachycardia. The patient may also have splenomegaly. During a sickle cell crisis, the patient may have severe bone, abdominal, thoracic, and muscular pain; low-grade fever; and increased weakness, jaundice, and dyspnea.

Zieve syndrome

Caused by alcohol abuse, this relatively rare disorder produces abdominal pain and a sudden onset of severe jaundice. However, spider angiomas, ascites, and other signs of advanced liver disease are absent.

Other causes

Drugs

Many drugs may cause hepatic injury and resultant jaundice. Examples include acetaminophen, I.V. tetracycline, isoniazid, hormonal contraceptives, sulfonamides, mercaptopurine, erythromycin estolate, niacin, troleandomycin, androgenic steroids, HMG-CoA reductase inhibitors, phenothiazines, ethanol, methyldopa, rifampin, and phenytoin.

Treatments

Upper abdominal surgery may cause postoperative jaundice, which occurs secondary to hepatocellular damage from the manipulation of organs, leading to edema and obstructed bile flow; from the administration of halothane; or from prolonged surgery resulting in shock, blood loss, or blood transfusion.

A surgical shunt used to reduce portal hypertension (such as a portacaval shunt) may also produce jaundice.

Special considerations

To help decrease pruritus, frequently bathe the patient, apply an antipruritic lotion, such as calamine, and administer diphenhydramine hydrochloride or hydroxyzine hydrochloride. Prepare the patient for diagnostic tests to evaluate biliary and hepatic function. Laboratory studies include urine and fecal urobilinogen, serum bilirubin, hepatic enzyme, and cholesterol levels; prothrombin time; and a complete blood count. Other tests include ultrasonography, cholangiography, liver biopsy, and exploratory laparotomy.

Pediatric pointers

Physiologic jaundice is common in neonates, developing 3 to 5 days after birth. In infants, obstructive jaundice usually results from congenital biliary atresia. A choledochal cyst—a congenital cystic dilation of the common bile duct—may also cause jaundice in children, particularly those of Japanese descent.

The list of other causes of jaundice is extensive and includes, but isn’t limited to, Crigler-Najjar syndrome, Gilbert’s disease, Rotor’s syndrome, thalassemia major, hereditary spherocytosis, erythroblastosis fetalis, Hodgkin’s disease, infectious mononucleosis, Wilson’s disease, amyloidosis, and Reye’s syndrome.

Geriatric pointers

In patients older than age 60, jaundice is usually caused by cholestasis resulting from extrahepatic obstruction.

Patient counseling

Encourage the patient with a hepatic disorder to decrease his protein intake sharply and increase his intake of carbohydrates. If he has obstructive jaundice, encourage a nutritious, balanced diet (avoiding high-fat foods) and frequent small meals.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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