Definition

Icterus, or jaundice, is a condition characterized by the yellowing of the skin, sclera (the white part of the eye), and mucous membranes. The term "icterus" is derived from the Greek word "icteros," while "jaundice" is derived from the French word "jaune," meaning yellow. This yellowish discoloration is caused by elevated bilirubin levels, a yellow-orange pigment, in the blood. Bilirubin is produced from the breakdown of red blood cells.

Jaundice commonly occurs in infants and is usually not severe, often resolving within a few weeks. During pregnancy, the mother's liver removes bilirubin from the baby. However, after birth, the baby's liver must remove bilirubin independently. If the baby's liver is not fully developed, it may struggle to eliminate bilirubin efficiently, leading to a yellowish appearance of the skin. Jaundice is a common condition in babies born before 37 weeks and in some babies who are transitioning to breastfeeding.

Causes

Jaundice can stem from various issues in the three phases of the bilirubin production process:

• Pre-bilirubin formation: Elevated levels of unconjugated bilirubin may occur before bilirubin formation. This can result from reabsorption from hematomas (collections of blood or partially clotted blood under the skin) or hemolytic anemia (a condition where red blood cells are prematurely destroyed and removed from the bloodstream).
• Bilirubin production: Jaundice may arise during bilirubin production due to factors such as viral infections (e.g., hepatitis A, chronic hepatitis B and C, Epstein-Barr virus), alcohol consumption, autoimmune disorders, rare genetic metabolic disorders, and certain medications like acetaminophen, penicillin, birth control pills, chlorpromazine, as well as estrogenic or anabolic steroids.
• Post-bilirubin production: Jaundice can be caused by blockages in the bile ducts occurring after bilirubin production. This obstruction may result from conditions such as gallstones, inflammation of the gallbladder, gallbladder cancer, and pancreatic tumors.

Read more: Gallstones (Cholelithiasis) - Definition, Causes, Symptoms, and Management

Risk factor

In children, the likelihood of jaundice is relatively low, but approximately 60% of infants will experience it to some degree. However, certain infants are more prone to severe jaundice with higher bilirubin levels than others.

Several risk factors for jaundice include:

• Premature birth: Babies born before 37 weeks or 8.5 months of pregnancy may experience jaundice due to underdeveloped livers, which may struggle to eliminate bilirubin effectively.
• Darker skin tones, particularly in infants born into East Asian or Mediterranean families, can make jaundice more challenging to detect visually.
• Feeding difficulties in infants which can contribute to dehydration and worsen jaundice.
• Family history of jaundice, indicating a potential genetic predisposition.
• Blood type: Women with blood type O with Rh negative may have a higher risk of jaundice in their infants.
• Middle-aged individuals are at higher risk of jaundice, particularly in cases of hepatitis and excessive alcohol consumption.

Symptoms

In some cases of jaundice, patients may exhibit no symptoms or discover them incidentally. The severity of symptoms depends on the underlying cause and the rate at which the condition progresses. Short-term jaundice, often caused by infection, can result in symptoms such as fever, chills, abdominal pain, flu-like symptoms, changes in skin color, and dark-colored urine or stool.

If jaundice is not infection-related, other symptoms, such as weight loss or itching (pruritus) may occur. For instance, jaundice caused by pancreatic cancer or bile duct obstruction commonly presents with abdominal pain. In liver disorders like chronic hepatitis or liver inflammation, symptoms may include pyoderma gangrenosum (a type of skin disorder), acute hepatitis A, B, or C, or polyarthralgia (joint inflammation).

In newborns, signs of jaundice include a yellowish tint to the skin, typically most noticeable on the baby's face and whites of the eyes when exposed to natural light. As bilirubin levels rise, the yellowish hue may extend to the baby's chest, abdomen, arms, and legs.

Detecting jaundice in babies with darker skin tones may be challenging, but it can still be identified by examining the whites of their eyes for a yellowish tint.

Diagnosis

The doctor will conduct a physical examination to assess whether you or your baby have jaundice. They will diagnose jaundice by examining symptoms of liver disorders such as skin discoloration, spider angiomas (abnormal collections of blood vessels on the skin surface), and palmar erythema (redness on the palms and fingertips). Additionally, the doctor will assess the size and firmness of your liver during the examination.

In newborns, the doctor will typically perform a bilirubin test between 3 to 5 days of age, a critical time frame for monitoring jaundice. This test involves placing a probe on the baby's head to assess bilirubin levels. If the results indicate elevated bilirubin levels, the doctor may recommend a blood test for confirmation. This blood sample is typically obtained from the baby's heel. Moreover, a urine test (urinalysis) showing positive bilirubin can suggest conjugated jaundice, which should be confirmed with a serum test. Serum testing, which may include a complete blood count and bilirubin level examination, provides further insight into the condition.

Furthermore, the doctor may opt to perform imaging tests such as ultrasound or CT scans and a liver biopsy (obtaining a sample of liver tissue) for additional confirmation and assessment of the underlying cause.

Management

In adults, jaundice typically does not require specific treatment as it tends to be less severe than infants. However, the underlying causes and complications of jaundice can be addressed. Treatment for jaundice in infants may not always be necessary, especially in cases of moderate severity, as it often resolves on its own as the baby's liver matures. This resolution process may take one to two weeks.

If a baby's bilirubin levels are high and continue to rise, the doctor may recommend phototherapy treatment. During phototherapy, specialized lights help the baby's liver process and remove bilirubin more effectively. This therapy usually lasts for one to two days. In cases where the baby's bilirubin levels are not excessively high, phototherapy can be administered at home. However, if phototherapy is ineffective, the doctor may suggest a blood transfusion, where a portion of the baby's blood is replaced with healthier donor blood.

Complications

Complications that may arise from jaundice include:

• Constipation
• Bloating
• Abdominal pain or discomfort
• Vomiting
• Diarrhea

Prevention

Jaundice can be caused by various factors, making it challenging to suggest specific prevention measures. However, here are some general recommendations:

• Avoiding hepatitis infection
• Consuming alcohol in moderation or abstaining from alcohol altogether.
• Maintaining a healthy body weight
• Managing cholesterol levels

For infants, jaundice is normal and cannot be prevented. However, you can reduce the risk of your baby developing more severe jaundice by breastfeeding more frequently.

Breastfeeding stimulates bowel movements, aiding in eliminating bilirubin from the baby's body. It's recommended to breastfeed your baby 8 to 12 times per day during the first week of life and ensure your baby receives 30 to 60 milliliters of breast milk every 2 to 3 hours during the first week after birth. Additionally, ensure your baby's health, including bilirubin levels, is monitored before leaving the hospital.

When to see a doctor?

It's crucial to contact your doctor if you have just received a diagnosis of a liver disorder or if your baby's health needs to be discussed shortly after leaving the hospital. For newborns, bilirubin levels typically peak between days 3 and 5, so prompt medical attention is necessary if your baby's jaundice worsens or persists for more than 2 weeks.

Severe symptoms of jaundice in babies include:

• Yellowish skin color changes
• Excessive sleepiness or difficulty waking up for feedings
• Fussiness or irritability
• Reluctance to breastfeed or difficulty feeding
• Inadequate urination or bowel movements

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