JAUNDICE: CAUSES AND REMEDIES
DR. S.M. ALAM
Feb 7 - 13, 2011
Jaundice is a disease, which occurs when the blood contains an excess of the pigment called bilirubin. The bilirubin is a natural product arising from the normal breakdown of red blood cells in the body and is excreted in the bile, through the actions of the liver.
Bilirubin comes from red blood cells. When red blood cells get old, they are destroyed. Hemoglobin, the iron-containing chemical in red blood cells that carries oxygen, is released from the destroyed red blood cells after the iron it contains is removed. The chemical that remains in the blood after the iron is removed becomes bilirubin.
The liver has many functions. One of the liver's functions is to produce and secrete bile into the intestines to help digest dietary fat. Another is to remove toxic chemicals or waste products from the blood, and bilirubin is a waste product. The liver removes bilirubin from the blood. After the bilirubin has entered the liver cells, the cells conjugate (attaching other chemicals, primarily glucuronic acid) to the bilirubin, and then secrete the bilirubin/glucuronic acid complex into bile. The complex that is secreted in bile is called conjugated bilirubin. The conjugated bilirubin is eliminated in the feces. (Bilirubin is what gives feces its brown color.) .
Jaundice occurs when there is 1) too much bilirubin being produced for the liver to remove from the blood. For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that release large amounts of bilirubin into the blood, 2) a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile, or 3) blockage of the bile ducts that decrease the flow of bile and bilirubin from the liver into the intestines. For example, the bile ducts can be blocked by cancers, gallstones, or inflammation of the bile ducts. The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice. The commonest cause is a viral infection of the liver cells (hepatitis). Many different types of infection including glandular fever (mononucleosis) can also be responsible for this. Alcohol abuse and subsequent scarring of the liver (cirrhosis) can cause significant cell damage leading to jaundice. Other less common conditions causing liver cell damage include haemochromatosis, alpha-1 antitrypsin deficiency and primary biliary cirrhosis. Tumours of the liver - either primary liver cancers (arising from the liver tissue itself) or more commonly, the secondary spread of a tumour from elsewhere in the body into the liver ñ can lead to cell failure and jaundice. The symptoms, other than that of the jaundice itself, will relate to the underlying cause. For example, someone with haemolysis might also be anemic and tired. If a gallstone were responsible, there would probably have been a preceding history of pain in the abdomen. A cancer might be accompanied by weight loss and so on.
Although jaundice is most often the result of a disorder affecting the liver, it can be caused by a variety of other conditions affecting, for example, the blood or spleen. It should be thoroughly investigated, so that the underlying cause can be identified and treated. The red blood cells in our circulation carry oxygen to all parts of the body and have a life span of about 120 days. At the end of their life, they are broken down and removed from the circulation by special cells called phagocytes, which are found within the bone marrow, spleen, and liver. New red blood cells are of course continually manufactured, and this also takes place within the bone marrow. Following breakdown of the red blood cells, some of their component parts - such as amino acids and iron ñ can be re-used by the body. Other components such as bilirubin need to be removed. Most waste products of the body are excreted in the urine via the kidneys, but the liver and bile system is the other main physical route out of the body for these substances. By waste products, we mean the many compounds that arise in the course of the body's metabolism. But, almost all forms of drugs must also be eliminated either via the urine or bile routes.
In the case of bilirubin released from old red blood cells, it passes through the bloodstream to the liver, where the liver cells process it. These cells carry out many complex chemical functions and also produce the liquid bile that is the 'vehicle' by which the cells discharge their output to the bile duct system. This is a branching network of tiny tubes throughout the liver that merge in the same way as the branches of a tree. Ultimately, a single main bile duct comes out of the liver and joins the first part of the small intestine (duodenum). Bile (and therefore bilirubin) then passes out through the small and large intestines and is excreted in the stool (faeces).
Bile is green in colour. But, bacteria in the large bowel act to change the bilirubin to substances that are brown, which give stool its characteristic colour. Some of the bilirubin is reabsorbed back into the body through the bowel wall - eventually appearing in the urine as a substance called urobilinogen (although the typical yellow or orange colour of urine is in fact due a different pigment called urochrome). Therefore, any failure of the bilirubin removal pathway will lead to a build-up of bilirubin in the blood. When this happens, the individual's skin turns yellow ñ causing jaundice.
The balance between manufacture and breakdown of red blood cells is normally precisely balanced and equal. But, there are several conditions in which the rate of breakdown increases. If the amount of bilirubin released exceeds the liver's capacity to remove it ñ jaundice will develop. The medical term for excessive red cell breakdown is 'haemolysis', and within the developed world, it's a fairly rare condition.
Jaundice can turn the skin and sclerae yellow. In addition, stool can become light in color, even clay-colored because of the absence of bilirubin that normally gives stool its brown color. The urine may turn dark or brownish in color. This occurs when the bilirubin that is building up in the blood begins to be excreted from the body in the urine. Just as in feces, the bilirubin turns the urine brown.
Specifically, if the jaundice is due to liver disease, the patient may have symptoms or signs of liver disease or cirrhosis. (Cirrhosis represents advanced liver disease). The symptoms and signs of liver disease and cirrhosis include fatigue, swelling of the ankles, muscle wasting, ascites (fluid accumulation in the abdominal cavity), mental confusion, or coma, and bleeding into the intestines.
Many tests are available for determining the cause of jaundice, but the history and physical examination are important as well. The history can suggest possible reasons for the jaundice. For example, heavy use of alcohol suggests alcoholic liver disease, whereas use of illegal, injectable drugs suggests viral hepatitis. Recent initiation of a new drug suggests drug-induced jaundice. Episodes of abdominal pain associated with jaundice suggests blockage of the bile ducts usually by gallstones.
The most important part of the physical examination in a patient who is jaundiced is examination of the abdomen. Masses (tumors) in the abdomen suggest cancer infiltrating the liver (metastatic cancer) as the cause of the jaundice. An enlarged firm liver suggests cirrhosis. A rock-hard, nodular liver suggests cancer within the liver.
Measurement of bilirubin can be helpful in determining the causes of jaundice. Markedly greater elevations of unconjugated bilirubin relative to elevations of conjugated bilirubin in the blood suggest hemolysis (destruction of red blood cells). Marked elevations of liver tests (aspartate amino transferase or AST and alanine amino transferase or ALT) suggest inflammation of the liver (such as viral hepatitis).
Elevations of other liver tests, e.g., alkaline phosphatase, suggest diseases or obstruction of the bile ducts.
A blood test will confirm the raised bilirubin level and other tests, such as those for hepatitis and haemolysis are also done on the blood. Other tests are as:
Ultrasonography is a simple, safe, and readily-available test that uses sound waves to examine the organs within the abdomen. Ultrasound examination of the abdomen may disclose gallstones, tumors in the liver or the pancreas, and dilated bile ducts due to obstruction (by gallstones or tumor).
Computerized tomography or CT scans are scans that use x-rays to examine the soft tissues of the abdomen. They are particularly good for identifying tumors in the liver and the pancreas and dilated bile ducts, though they are not as good as ultrasonography for identifying gallstones.
Magnetic Resonance Imaging scans are scans that utilize magnetization of the body to examine the soft tissues of the abdomen. Like CT scans, they are good for identifying tumors and studying bile ducts. MRI scans can be modified to visualize the bile ducts better than CT scans (a procedure referred to as MR cholangiography), and, therefore, are better than CT for identifying the cause and location of bile duct obstruction.
Endoscopic retrograde cholangiopancreatography (ERCP) provides the best means for examining the bile duct. For ERCP, an endoscope is swallowed by the patient after he or she has been sedated. The endoscope is a flexible, fiberoptic tube approximately four feet in length with a light and camera on its tip. The tip of the endoscope is passed down the esophagus, through the stomach, and into the duodenum where the main bile duct enters the intestine. A thin tube then is passed through the endoscope and into the bile duct, and the duct is filled with x-ray contrast solution. An x-ray is taken that clearly demonstrates the contrast-filled bile ducts. ERCP is particularly good at demonstrating the cause and location of obstruction within the bile ducts. A major advantage of ERCP is that diagnostic and therapeutic procedures can be done at the same time as the x-rays. For example, if gallstones are found in the bile ducts, they can be removed. Stents can be placed in the bile ducts to relieve the obstruction caused by scarring or tumors. Biopsies of tumors can be obtained.
Ultrasonography can be combined with ERCP by using a specialized endoscope capable of doing ultrasound scanning. Endoscopic ultrasound is excellent for diagnosing small gallstones in the gallbladder and bile ducts that can be missed by other diagnostic methods such as ultrasound, CT, and MRI. It also is the best means of examining the pancreas for tumors and can facilitate biopsy through the endoscope of tumors within the pancreas.
Biopsy of the liver provides a small piece of tissue from the liver for examination under the microscope. The biopsy most commonly is done with a long needle after local injection of the skin of the abdomen overlying the liver with anesthetic. The needle passes through the skin and into the liver, cutting off a small piece of liver tissue. When the needle is withdrawn, the piece of liver comes with it. Liver biopsy is particularly good for diagnosing inflammation of the liver and bile ducts, cirrhosis, cancer, and fatty liver.
With the exception of the treatments for specific causes of jaundice mentioned previously, the treatment of jaundice usually requires a diagnosis of the specific cause of the jaundice and treatment directed at the specific cause, e.g., removal of a gallstone blocking the bile duct.
The Muslim scholars have suggested for jaundice, the recitations of Surah-98 Al-Bayyinah and Surah-106 Quraish and also Darud Ibrahami (three times) and giving water for drinking to the patients f daily.
May Al-Allah always save us from many kinds of diseases and distresses Aamin.