Jaundice is a common problem. There are many misconceptions regarding jaundice in the public. The moment you tell the patient that he is having jaundice he would immediately run to an Ayurvedic practitioner thinking that there is no treatment of jaundice in allopathic medicine. Today, in this talk I would be discussing the various aspects of jaundice so that next time when you have jaundice you understand what is to be done.
Jaundice is a yellow discolouration of eyes and skin. Majority of the time the urine becomes yellow but not always. There are some cases in which although the eyes are yellow but urine has a normal colour. I will explain it later.
Now, why do the eyes become yellow? This is because there is an increased amount of bilirubin in the blood. Normally it is less than 1 mg per deciliter but when it is > 2 then we start noticing that the eyes are yellow.
The red blood cells which are present in our blood have a lifespan of about 120 days. When these RBC become old, they are destroyed in the spleen. Haemoglobin in the blood is split which produces a protein known as heme. This heme is broken down into bilirubin. Normally the liver will take up this bilirubin and modify it in such a way that it can be passed out in the bile. This bile then enters the intestine where the majority of the bilirubin is converted into stercobilin which is then passed out in the stool. If there is any disruption in this normal pathway of bilirubin, one can get jaundice. So you realize that jaundice is not a disease but a symptom that can occur due to a variety of diseases.
There are basically three types of jaundice. Whenever a patient with jaundice comes to us, we quickly determine which type of jaundice this patient is having, then we direct our focus to that particular type of jaundice.
The first type of jaundice is called prehepatic meaning thereby before the bilirubin enters the liver. This type of jaundice can occur only in 2 circumstances. Either, there is an increased production of bilirubin in the spleen. This may occur if your RBC are not normal and they are destroyed very fast. You may have heard the disease called thalassaemia. Because of some defect in haemoglobin, the RBC is destroyed very fast. This, in turn, leads to increased production of bilirubin. These patients will also have anaemia because of the destruction of RBC. This jaundice is called haemolytic jaundice. Another condition in which you can get prehepatic jaundice is where there is some defect because of which either the bilirubin cannot enter the liver or after entering the liver it cannot be converted into the form in which it can be passed out in bile. A very common condition is Gilbert’s disease whereby birth there is a defect because of which the liver cannot take up the bilirubin. In both these conditions which I just described the liver is absolutely normal. Because this bilirubin which is circulating in the blood is insoluble in water, it cannot be passed out by the kidneys. Therefore, the urine colour is normal. In all prehepatic jaundice, there is no treatment required for the liver.
The second type of jaundice occurs because of the problem in the liver. This is called a hepatic type of jaundice. This may be of short duration or acute or it can be a long-standing problem or chronic. The most common reason for acute liver disease is hepatitis caused by viruses. This is called viral hepatitis. There are 5 different viruses called hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus and hepatitis E virus. There are some other viruses also which can affect the liver but we will not discuss them. Out of these 5 viruses two are spread by water and food contamination. These are hepatitis A and E. Sometimes we can get large epidemics of hepatitis. In our country, these epidemics of jaundice are caused by hepatitis E. The good thing about hepatitis A and E are that they are self-limiting, which means even if you do not treat them, these patients would become alright in three to four weeks. The other three types of viruses hepatitis B, C and D are spread by contaminated blood. So they can be spread by blood transfusion, contaminated needle and sexual intercourse and from a mother to the child during childbirth.
28th July is World Hepatitis Day. This is the birthday of Dr Blumberg who was an American scientist and he discovered the hepatitis B virus. The Discovery of this virus led to the development of the hepatitis B vaccine because of which hepatitis B is totally preventable. This vaccine is responsible for preventing a large number of cases of cirrhosis and liver cancer.
All three of the viruses which are spread by contaminated blood can lead to long term damage of the liver and lead to cirrhosis and even liver cancer. By doing proper blood tests we can find out whether a patient is having hepatitis due to a virus and which type of virus it is.
Chronic damage to the liver can lead to cirrhosis where there is significant destruction of the liver cells. This leads to the loss of function of the liver. The liver is essential for life. If liver function is bad, a person cannot survive. These patients with cirrhosis will not only have jaundice but can develop a collection of water in their abdomen and legs. They can have vomiting of blood and they can have a loss of consciousness. Hepatitis virus is a major cause of cirrhosis. Today we have good medications for hepatitis B and C. If the liver disease is not too advanced then the majority of patients will respond to these drugs. However, sometimes, liver disease is very advanced and medicines will not work. In these situations, patients will require liver transplantation, where half of the liver from a donor is put inside the patient. The success rate of liver transplantation is good but it is expensive and costs approximately 20 lakhs for the procedure.
Apart from viruses, the other important cause of liver disease is alcohol. Excess alcohol intake can lead to hepatitis as well as cirrhosis. In this part of the country alcohol is the leading cause of cirrhosis. Unfortunately, we do not have good medicines to treat alcoholic liver disease. Stopping alcohol intake is mandatory.
This was about jaundice due to liver disease. There is a third type of jaundice called obstructive jaundice, where the jaundice is caused by the blockage of the bile duct which leads to obstruction of bile flow. The two main reasons for this obstruction are gall stones that have slipped out of the gallbladder and block the bile duct or else there is a tumour that is compressing the bile duct. This tumour could be arising from the gallbladder, the bile duct and the pancreas. These are examples of obstructive jaundice because there is an obstruction to the flow of bile.
These patients have jaundice which is often accompanied by severe itching all over the body. When we do an ultrasound of the abdomen we can demonstrate that the bile ducts are dilated or enlarged because of the obstruction. We may do a CT scan or MRI to find out the cause of obstruction, whether it is a stone or a tumour. In the case of a tumour, sophisticated investigations like CT scan and MRI also tell us whether or not these patients are operable. The block in the bile duct can often be relieved by an ERCP which is an endoscopic procedure wherein a flexible tube is passed into the duodenum and with the help of a balloon or a basket, the stone can be taken out. In case of a tumour, plastic or a metal tube is placed inside the bile duct across the obstruction so that the bile flow is started. This, in turn, will reduce jaundice. However, if the cancer is in early stage surgery should be performed.
Thus we see that jaundice is not one disease. There are different types of jaundice. When you have jaundice you need to go to a doctor usually a gastroenterologist who would do the necessary testing to determine whether you have prehepatic jaundice or jaundice due to liver disease or is it because of an obstruction in the bile duct. He may perform blood tests, ultrasound of the abdomen and if necessary a CT scan or MRI. The treatment would depend upon the condition which is causing jaundice.
HOD – Gastroenterology Dept
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