Jaundice

Aka: Jaundice, Yellow Skin, Dermal Icterus, Yellow Complexion

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II. Definition

  1. "Yellow Skin" related to Hyperbilirubinemia

III. Pathophysiology

  1. See Hyperbilirubinemia

IV. Causes

  1. See Hyperbilirubinemia
  2. See Conjugated Hyperbilirubinemia
  3. See Unconjugated Hyperbilirubinemia
  4. Intrahepatic causes (55% of cases)
    1. Viral Hepatitis (especially Hepatitis C)
    2. Alcoholic Liver Disease
    3. Hepatotoxin
  5. Extrahepatic causes (45% of cases)
    1. Gallstone Disorders (e.g. Acute Cholecystitis, Choledocholithiasis)
    2. Hemolysis
    3. Cancer
  6. Pseudojaundice (skin pigmentation that mimics Jaundice)
    1. See Differential Diagnosis below

V. Symptoms

  1. Pruritus
    1. See Cholestasis associated Pruritus
  2. Yellow Skin
  3. Abdominal Pain
  4. Weight loss

VI. Signs: Jaundice

  1. See Jaundice in Newborns
  2. Jaundice sites of predilection
    1. Face
    2. Trunk
    3. Tongue frenulum (early finding)
    4. Sclera (see Scleral Icterus)
  3. Factors that accentuate Jaundice
    1. Tanned skin
  4. Factors that may hide Jaundice
    1. Artificial light

VII. Signs: General

  1. Abdominal exam
    1. Hepatomegaly
    2. Splenomegaly
    3. Ascites
  2. Signs of Chronic Liver Disease
    1. Ecchymosis
    2. Spider Angiomas
    3. Gynecomastia
    4. Palmar erythema
    5. Testicular atrophy
  3. Hepatic Encephalopathy signs
    1. Asterixis (flapping Tremor)
    2. Mental status changes
  4. Findings suggestive of Obstructive Jaundice
    1. Sinus Bradycardia
    2. Dark yellow or brown colored Urine
      1. Direct Hyperbilirubinemia (increased Urobilinogen)
      2. Shaking specimen results in yellow foam
    3. Acolic Stools
      1. Gray-white, malodorous stools

VIII. Labs: Initial

  1. Complete Blood Count
  2. Bilirubin: Diagnosis requires Bilirubin fractionation
    1. See Bilirubin
    2. Jaundice visible when Bilirubin >3-4 mg/dl
    3. See Indirect Bilirubin (Hemolytic Jaundice)
    4. See Direct Bilirubin (Obstructive Jaundice)
  3. Other Liver Function Tests
    1. Aspartate transaminase (AST)
    2. Alanine transaminase (ALT)
    3. Gamma-glutamyl transpeptidase (GGT)
    4. Alkaline Phosphatase
    5. Prothrombin Time or INR
    6. Serum Albumin
    7. Serum Protein
  4. Urinalysis
    1. Bilirubin in urine suggests Conjugated Bilirubin

IX. Differential Diagnosis: Causes of Yellow Skin

  1. See Hyperbilirubinemia
  2. Carotenemia
  3. Quinacrine
  4. Addison Disease
  5. Anorexia Nervosa
  6. Spray-on tanning substances
  7. Occupational exposure to Explosive manufacturing (Dinitrophenol, Tetryl)

X. Evaluation: Based on Bilirubin fractionation (as above)

  1. Unconjugated Hyperbilirubinemia
    1. See Indirect Bilirubin for causes
    2. Evaluate for Hemolysis
      1. Peripheral Smear
      2. Lactate Dehydrogenase
      3. Haptoglobin
      4. Direct Coombs Test
      5. Consider G6PD testing
  2. Conjugated Hyperbilirubinemia
    1. See Direct Bilirubin for causes
    2. Screen for Viral Hepatitis (Hepatitis A, Hepatitis B, and Hepatitis C)
    3. Evaluate for obstruction
      1. Consider abdominal right upper quadrant Ultrasound or Abdominal CT
      2. Consider Abdominal MRCP
    4. Consider Autoimmune Condition screening
      1. Antinuclear Antibody (ANA)
      2. Anti Liver-Kidney microsomal Antibody
      3. Anti-Smooth Muscle Antibody

XI. References

  1. Degowin (1987) Diagnostic Exam, Macmillan, p.480-1
  2. Feldman (1998) Sleisenger and Fordtran's, p. 220-231
  3. Fargo (2017) Am Fam Physician 95(3): 164-8 [PubMed]
  4. Pasha (1996) Med Clin North Am 80:995-1019 [PubMed]
  5. Roche (2003) Am Fam Physician 69:299-304 [PubMed]

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