Jaundice: Causes and When to Worry

What jaundice means

Old red blood cells are broken down into bilirubin. The liver takes it up, attaches it to sugar molecules (conjugation) so it dissolves in water, and sends it into bile. Bile drains through the bile ducts into the bowel and gives stool its brown color. Jaundice becomes visible when bilirubin rises above about 2 to 3 mg/dL (35 to 50 µmol/L). It usually shows first in the whites of the eyes (scleral icterus), then in the skin.

Doctors sort the causes by where the problem lies:

Causes of jaundice in adults

Liver causes

• Hepatitis: viral hepatitis A, B, C and E, autoimmune hepatitis, and alcohol-related hepatitis. Often with tiredness, nausea, loss of appetite and aching under the right ribs.
• Alcohol-related liver disease and cirrhosis: scarred liver, often with a swollen belly, easy bruising and spider veins.
• Medicines and supplements: acetaminophen overdose, some antibiotics (amoxicillin-clavulanate), antiseizure drugs, anabolic steroids, and herbal and weight-loss supplements.
• Fatty liver disease: usually causes jaundice only when advanced.
• Gilbert syndrome: a common, harmless inherited condition affecting about 3 to 7% of people. Mild yellow eyes appear during fasting, illness, stress or exercise. Liver tests are otherwise normal.
• Rarer causes: primary biliary cholangitis, primary sclerosing cholangitis, hemochromatosis, Wilson disease.

Blocked bile ducts

• Gallstones in the bile duct (choledocholithiasis): jaundice with upper right belly pain. Add fever and it may be cholangitis.
• Pancreatic cancer: classically painless jaundice with itching, dark urine, pale stools and weight loss.
• Bile duct cancer (cholangiocarcinoma) and liver cancer.
• Strictures after surgery or from inflammation.

Blood causes

• Hemolytic anemia: inherited (sickle cell, spherocytosis, G6PD deficiency) or acquired (autoimmune, drug-induced).
• Infections: malaria in travelers.

Jaundice in newborns

Mild jaundice is common in the first week of life, because a newborn's liver is immature. It usually peaks at 3 to 5 days and fades within 2 weeks. Jaundice in the first 24 hours, very high levels, or jaundice lasting beyond 2 weeks (3 weeks in premature babies) needs checking, as do pale stools in a jaundiced baby, which can signal biliary atresia. See neonatal jaundice.

Symptoms that come with jaundice

Not jaundice

Yellow-orange skin with white eyes can come from eating large amounts of carrots, sweet potato or squash (carotenemia). It is harmless. Some medicines also tint the skin.

How doctors find the cause

1. History: alcohol, medicines and supplements, travel, sexual history, injecting drug use, blood transfusions, family history, pain, fever and weight loss.
2. Examination: of the eyes, skin, abdomen, liver size and signs of chronic liver disease.
3. Blood tests: total and direct (conjugated) bilirubin, ALT and AST, alkaline phosphatase and GGT, albumin, INR (clotting), blood count, hemolysis tests, and hepatitis virus serology.
4. Abdominal ultrasound: shows dilated bile ducts, gallstones, liver texture and masses.
5. Further imaging: CT, MRCP or endoscopic ultrasound to find blockages and tumors.
6. ERCP: to remove stones or place a stent.
7. Liver biopsy occasionally.

Treatment

Jaundice itself is not treated. The cause is:

• stopping alcohol or a harmful medicine
• antiviral treatment for hepatitis B or C
• ERCP and gallbladder removal for gallstones
• surgery, stenting, chemotherapy or palliative care for cancers
• treatment of the cause of hemolysis
• no treatment for Gilbert syndrome
• liver transplant for some people with liver failure

Itching from blocked bile can be eased by relieving the blockage, and with medicines such as cholestyramine. Phototherapy is used for newborn jaundice.

Frequently asked questions

What is the most common cause of jaundice in adults?

Common causes include viral and alcohol-related hepatitis, gallstones blocking the bile duct, medicine-related liver injury and Gilbert syndrome. In older adults, cancers of the pancreas and bile ducts become more important causes, especially when jaundice is painless.

Is jaundice in adults serious?

It can be. Jaundice is always a sign of an underlying problem, which may be harmless, such as Gilbert syndrome, or serious, such as hepatitis, a blocked bile duct or cancer. Any new jaundice in an adult should be checked by a doctor within a day or two, sooner with fever or confusion.

What does painless jaundice mean?

Painless jaundice, especially with dark urine, pale stools, itching and weight loss, can be a sign of cancer of the pancreas or bile duct pressing on the bile duct. It needs urgent assessment with blood tests and imaging, although other causes are also possible.

How long does jaundice last?

It depends on the cause. Jaundice from hepatitis A or a medicine reaction often fades over weeks once the cause stops. Jaundice from a blocked bile duct improves within days to weeks after the blockage is cleared. Newborn jaundice usually fades within 2 weeks.

Can stress cause jaundice?

Stress does not cause liver disease, but in people with Gilbert syndrome, stress, fasting, illness or hard exercise can make the eyes turn slightly yellow for a few days. This is harmless. Jaundice in anyone without known Gilbert syndrome should be checked.