Jaundice
Jaundice is not a disease but a sign: the skin and the whites of the eyes turn yellow when bilirubin builds up in the blood.
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Jaundice is not a disease but a sign: the skin and the whites of the eyes turn yellow when bilirubin builds up in the blood. Everyone makes that pigment, every day, as red blood cells are renewed. A person turns yellow when the route bilirubin takes out of the body is blocked somewhere along the way. Finding where the fault lies matters far more than getting rid of the colour: identical-looking jaundice can come from a harmless inherited quirk or from a situation measured in hours.
Where the yellow comes from
Red blood cells that have served their time are dismantled, and what is left of the haemoglobin is bilirubin — a yellow pigment that does not dissolve in water. The blood carries it to the liver, where a soluble tag is attached; from there it passes with bile into the bowel and leaves in the stools, colouring them on the way out. A small share is reabsorbed and passed by the kidneys, giving urine its usual straw colour.
While there is little bilirubin in the blood it stays invisible. Once the level is several times higher than normal, the pigment soaks into tissues rich in elastic fibres: first the whites of the eyes, then the skin of the face, then the rest of the body. That is why yellow sclerae are noticed before yellow skin, and why they are best looked at in daylight — warm indoor bulbs mislead.
Three places where the route breaks down
Doctors work through jaundice along this chain, and where the break lies decides both the tests and the urgency.
- Before the liver. Red cells are destroyed faster than the liver can process the pigment: autoimmune haemolysis, inherited red cell disorders, malaria, a large bruise being reabsorbed. Urine and stools keep their usual colour, but pallor, tiredness and breathlessness on exertion appear — the picture of anaemia.
- In the liver itself. Liver cells are damaged and cannot keep up: viral hepatitis, alcohol-related liver disease, fatty liver and cirrhosis, drug and toxic injury, autoimmune hepatitis. Weakness, nausea and a heavy feeling under the right ribs usually come with the yellow.
- After the liver. Bile is made but cannot get out: a stone in the bile duct, inflammation or scarring that narrows it, a tumour of the head of the pancreas or of the duct itself, pressure from outside. This is the most recognisable picture — urine the colour of strong tea, stools drained of colour to pale grey, and often an exhausting itch.
What it most often turns out to be
In adults, bile duct stones and liver disease share first place. A stone that leaves the gallbladder and lodges in the duct causes jaundice with pain in the right upper abdomen that spreads to the back and under the shoulder blade. Alcohol-related and fatty liver disease creep up over years and turn a person yellow only once the liver is badly damaged. Viral hepatitis A, B, C and E differ in how they are caught and how they end, but they start alike: a few days of feeling wrung out, aching and queasy, after which the urine darkens and the yellow appears.
One separate and very common finding is Gilbert's syndrome. It is an inherited quirk in which the liver enzyme works more slowly than usual. Bilirubin rises slightly with fasting, an infection, a poor night's sleep or hard exercise, the eyes tinge faintly yellow and then clear on their own. The liver is healthy, no treatment is needed, and the point is to confirm the diagnosis rather than to blame every later episode of jaundice on it.
Medicines and supplements cause jaundice noticeably more often than people expect. The liver suffers from paracetamol overdose, from certain antibiotics and antifungals, from anti-tuberculosis drugs, from anabolic steroids, and from herbal products sold for weight loss or for "cleansing the liver". List for the doctor everything taken over the past few months, including anything bought over the counter or from a health shop.
What is not jaundice
An orange tint to the palms, the soles and the skin around the nose, with the whites of the eyes perfectly clear, is usually carotenaemia: too much carotene after a spell of heavy carrot, pumpkin, sweet potato or juice consumption. It is harmless and fades within a few weeks once the diet changes. The distinguishing rule is simple — in jaundice the whites of the eyes are always yellow, in carotenaemia never.
Nor should dark urine on its own be taken for jaundice. It darkens with dehydration, with beetroot, with some medicines and vitamins. What is worrying is the combination: urine going dark while the stools go pale at the same time.
What to note besides the colour
The signs around jaundice tell both you and the doctor far more than its exact shade. Make a note of:
- the colour of urine and stools, and whether both changed together;
- pain: whether there is any, where, whether it spreads to the back, whether meals set it off;
- fever and shivering;
- itching, especially at night, and scratch marks;
- weight: how much has gone and over what period;
- bruises from minor knocks, bleeding gums, blood in the stools;
- swollen legs and a swelling abdomen;
- drowsiness, muddled thinking, any out-of-character behaviour.
One combination is worth committing to memory. Painless jaundice with weight loss and a persistent itch in someone over fifty calls for prompt investigation even when the person still feels reasonably well. That is often how a tumour of the head of the pancreas or of the bile duct begins: it blocks the flow of bile before it causes pain, and the early stage is the only one at which curative treatment is possible.
When it cannot wait
Call an ambulance or go to the emergency department at once if the jaundice comes with:
- a high temperature with shivering and pain in the right upper abdomen, which can mean infection of the bile ducts and can deteriorate fast;
- confusion, drowsiness, slurred speech, trembling hands or unusual aggression — signs of severe liver failure;
- vomiting blood, or black tarry stools;
- severe abdominal pain that will not settle;
- jaundice after a paracetamol overdose or mushroom poisoning.
The single European emergency number is 112. In all other cases jaundice in an adult is a reason to be seen by a doctor the same day or the next, not to watch and wait for a week.
How the cause is worked out
Blood tests come first. Not just total bilirubin but its fractions: a predominance of the unconjugated form points to red cells breaking down or to Gilbert's syndrome, a predominance of the conjugated form to liver disease or to an obstruction to bile flow. Liver enzymes, clotting and blood proteins, a full blood count and hepatitis serology are added to that.
The first scan is almost always an ultrasound: it shows stones, dilated ducts and changes in the tissue of the liver and pancreas. If that is not enough, an MRI scan of the bile ducts or a CT scan follows, and once an obstruction is confirmed, an endoscopic procedure during which the stone is removed or a stent is placed in the duct. Where the picture stays unclear, a liver biopsy is taken.
How it is treated
What gets treated is the cause, not the yellow colour, so there is no single remedy. A stone is removed, a narrowed duct is widened and drained, a tumour raises the question of surgery and of relieving the blockage. Hepatitis B and C are now treated with antiviral drugs, and in hepatitis C cure has become the usual outcome. In alcohol-related liver damage the first and central condition remains stopping drinking altogether; in haemolysis the illness destroying the red cells is treated. Itching caused by pooled bile responds to drugs that bind bile acids — there is no reason to put up with it.
One thing worth knowing yourself: with a damaged liver, every medicine is discussed first. Pain relief in that situation rests on paracetamol at an agreed dose, while anti-inflammatory drugs such as ibuprofen are best avoided, since in liver disease they raise the risk of bleeding and put a load on the kidneys. So-called liver protectors and herbal mixtures are themselves a recognised cause of liver injury, so they are not something to start on your own.
Jaundice in newborn babies works differently: it comes from an immature liver, affects most babies and usually settles by itself — it has its own separate article.
Online consultation
An online appointment is most useful at the first step, when the question is how urgent this is and how not to waste time going the wrong way. The doctor will ask about what actually decides the case: when the yellow appeared, what colour the urine and stools are, whether there is pain, itching or fever, how much weight has gone, what medicines and supplements you take, how much you drink and for how long, whether you have had bile duct surgery, transfusions or travel to the tropics.
You will come away with a list of tests and scans to arrange, an explanation of any results you already have, and a clear line between what needs doing today and what can safely wait. Examining the abdomen and feeling the liver cannot be done over video, and if there are signs of a bile duct infection or of altered consciousness the consultation comes down to one short instruction: get to hospital now.
This material is for information only and does not replace medical advice.
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