Jaundice, and Signs of Liver Disease

Jaundice, also known as icterus, is the yellowish discoloration of the mucous membrane, sclera, and skin. It indicates a serum bilirubin of at least 3 mg/dL. Jaundice is a sign indicating the presence of underlying diseases involving abnormal bilirubin metabolism, liver dysfunction, or biliary tract obstruction.

The incidence of jaundice is approximately 40,000 per 100,000 individuals of intensive care unit patients. In 2015, in the United States, the prevalence of cirrhosis was approximately 270 per 100,000 individuals. Most cases of jaundice are caused by chronic liver diseases which are often undiagnosed. In the developed countries, most CLD are caused by chronic and heavy alcohol use, whereas in developing countries it is due to viral hepatitis. The 10-year mortality rate of liver cirrhosis is approximately 34% to 66%, and is largely dependent on the cause of cirrhosis.

Hepatocellular jaundice, particularly from viral hepatitis, commonly affects young persons. However, cholestatic jaundice, particularly from liver cancer, viral hepatitis, and liver cirrhosis, commonly affects older patients. Males are more commonly affected by hepatocellular jaundice and liver cancer, while females are more commonly affected by haemolytic jaundice.

Jaundice is classified into three categories, depending on the pathophysiological mechanism, and the causes vary from benign to potentially fatal.

The three categories are:

1. Pre-hepatic - The pathology occurs prior to the liver metabolism, due to either intrinsic causes to red blood cell rupture or extrinsic causes to red blood cell rupture most commonly caused by a pathological increased rate of red blood cell (erythrocyte) haemolysis.

   Common causes:

   • Severe malaria (in endemic countries)
   • Sickle cell anaemia
   • Thalassaemia
   • Glucose-6-phosphate dehydrogenase deficiency
   • Spherocytosis
   • Pyruvate kinase deficiency
   • Microangiopathic haemolytic anaemia
   • Haemolytic-uraemic syndrome
2. Hepatic/hepatocellular – This is caused by abnormal liver metabolism of bilirubin. The pathology is due to damage of parenchymal liver cells.

   Common causes:

   • Acute hepatitis eg hepatitis A, B, etc.
   • Chronic hepatitis
   • Liver cirrhosis
   • Hepatotoxicity
   • Drug-induced hepatitis
   • Alcoholic liver disease
   • Gilbert's syndrome (found in about 5% of the population, results in induced mild jaundice)
   • Crigler-Najjar syndrome, types I and II
   • Dubin-Johnson syndrome
   • Leptospirosis
   • Schistosomiasis
3. Post-hepatic/cholestatic - The pathology occurs after bilirubin conjugation in the liver, due to obstruction of the biliary tract and/or decreased bilirubin excretion. It causes obstructive jaundice.

   Common causes:

   • Choledocholithiasis (common bile duct stones)
   • Biliary atresia
   • Biliary tract strictures
   • Primary biliary cholangitis
   • Acute pancreatitis
   • Chronic pancreatitis
   • Pancreatic pseudocyst
   • Cholestasis of pregnancy
   • Mirizi’s syndrome
   • Liver flukes due to Opisthorchiidae and Fasciolidae

1. A yellowish discolouration of the sclera, mucous membrane, and skin, normally starting at the head and spreading down the body
2. Pale stools
3. Dark coloured urine
4. Itchiness
5. Other symptoms from obstructive jaundice are: fatigue, vomiting, fever, abdominal pain, weight loss, pale stools, dark coloured urine etc.

The liver has a multitude of complex and important functions such as:

1. Synthesizes proteins, including albumin, and clotting factors
2. Synthesizes, stores, and metabolizes fats, including fatty acids and cholesterol
3. Eliminates potentially harmful products such as bilirubin and ammonia
4. Metabolizes and stores carbohydrates, which serve as the source of glucose for tissues and organs such as red blood cells and the brain
5. Synthesizes and secretes bile that contains bile acids which facilitate the intestinal absorption of fats, and fat-soluble vitamins such as A, D, E, and K.
6. Detoxify drugs, alcohol, and environmental toxins

1. Acute hepatitis e.g., viruses, alcohol, toxin, drug-induced, herbs etc.
2. Chronic hepatitis
3. Fatty liver disease
4. Cirrhosis
5. Cancer
6. Hereditary disorders

1. Bleeding or easy bruising
2. Abdominal pain and swelling
3. Fatigue
4. Jaundice
5. Itchy skin
6. Dark urine color
7. Nausea
8. Vomiting
9. Pale stool colour
10. Bloody stool
11. Tarry stool
12. Swelling in the ankles and legs
13. Loss of appetite

1. Fluffy hair
2. Jaundice
3. Pallor
4. Parotid fullness
5. Loss of axillary hair
6. Gynaecomastia (in males)
7. Breast atrophy (in females)
8. Spider nevi
9. Caput medusae
10. Ascites
11. Female pattern hair distribution
12. Palmar erythema
13. Loss of thenar and hypothenar muscles
14. Finger clubbing
15. Leukonychia
16. Testicular atrophy
17. Pedal edema