In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia.

Jaundice

Bilirubin is formed when hemoglobin (the part of red blood cells that carries oxygen) is broken down as part of the normal process of recycling old or damaged red blood cells. Bilirubin is carried in the bloodstream to the liver, where it binds with bile. Bilirubin is then moved through the bile ducts into the digestive tract, so that it can be eliminated from the body. Most bilirubin is eliminated in stool, but a small amount is eliminated in urine. If bilirubin cannot be moved through the liver and bile ducts quickly enough, it builds up in the blood and is deposited in the skin. The result is jaundice.

Many people with jaundice also have dark urine and light-colored stool. These changes occur when a blockage or other problem prevents bilirubin from being eliminated in stool, causing more bilirubin to be eliminated in urine.

High bilirubin levels may cause people to itch all over, but jaundice itself causes few other symptoms in adults. However in newborns, high bilirubin levels (see Problems in Newborns: Jaundice in the Newborn) can cause a form of brain damage called kernicterus. Also, many disorders that cause jaundice cause other symptoms or serious problems. These symptoms may include nausea, vomiting and abdominal pain, and small spiderlike blood vessels that are visible in the skin (spider angiomas). Men may have enlarged breasts, shrunken testes, and pubic hair that grows as it does in women.

Spider Angiomas

Serious problems can include

• Ascites: Accumulation of fluid within the abdomen
• Coagulopathy: A tendency to bleed or bruise
• Hepatic encephalopathy: Deterioration of brain function because the liver malfunctions, allowing toxic substances to build up in the blood, reach the brain, and cause changes in mental function (such as confusion and drowsiness)
• Portal hypertension: High blood pressure in the veins that bring blood to the liver, which can lead to bleeding in the esophagus and sometimes stomach

If people eat large amounts of food rich in beta-carotene (such as carrots, squash, and some melons), their skin may look slightly yellow, but their eyes do not turn yellow. This condition is not jaundice and is unrelated to liver disease.

Did You Know... Eating too many carrots can make the skin look yellow, but this effect is not jaundice.

Causes

Jaundice has many causes. Most causes involve disorders and drugs that

• Damage the liver
• Interfere with the flow of bile
• Trigger the destruction of red blood cells (hemolysis), thus producing more bilirubin than the liver can handle

The most common causes are

• Hepatitis
• Alcoholic liver disease
• A blockage of a bile duct by a gallstone (usually) or tumor
• A toxic reaction to a drug or medicinal herb

Hepatitis damages the liver, making it less able to move bilirubin into the bile ducts. Hepatitis may be acute (short-lived) or chronic (lasting at least 6 months). It is usually caused by a virus. Acute viral hepatitis is a common cause of jaundice, particularly jaundice that occurs in young and otherwise healthy people. Sometimes hepatitis is caused by an autoimmune disorder or use of certain drugs. When hepatitis is caused by an autoimmune disorder or a drug, it cannot be spread from person to person.

Drinking large amounts of alcohol over a long period of time damages the liver. The amount of alcohol and time required to cause damage varies, but typically, people must drink heavily for at least 8 to 10 years. Other drugs, toxins, and some herbal products can also damage the liver (see Manifestations of Liver Disease: Some Causes and Features of Jaundice).

If the bile ducts are blocked, bilirubin can build up in the blood. Most blockages are caused by a gallstone, but some are caused by cancer (such as cancer in the pancreas or bile ducts) or rare liver disorders (such as primary biliary cirrhosis or primary sclerosing cholangitis).

Less common causes of jaundice include hereditary disorders that interfere with how the body processes bilirubin. They include Gilbert syndrome and other, less common disorders such as Dubin-Johnson syndrome. InGilbert syndrome, bilirubin levels are slightly increased but usually not enough to cause jaundice. This disorder is most often detected during routine screening tests in young adults. It causes no other symptoms and no problems.

Evaluation

Jaundice is obvious, but identifying its cause requires a doctor's examination, blood tests, and sometimes other tests.

Warning signs: In people with jaundice, the following symptoms are cause for concern:

• Severe abdominal pain and tenderness
• Changes in mental function, such as drowsiness, agitation, or confusion
• Blood in stool or tarry black stool
• Blood in vomit
• Fever
• A tendency to bruise or to bleed easily, sometimes resulting in a reddish purple rash of tiny dots or larger splotches (which indicate bleeding in the skin)

When to see a doctor: If people have any warning signs, they should see a doctor as soon as possible. People with no warning signs should see a doctor within a few days.

What the doctor does: Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see Manifestations of Liver Disease: Some Causes and Features of Jaundice).

Doctors ask when the jaundice started and how long it has been present. They also ask when urine started to look dark (which usually occurs before jaundice develops). People are asked about other symptoms, such as itching, fatigue, changes in stool, and abdominal pain. Doctors are particularly interested in symptoms that suggest a serious cause. For example, sudden loss of appetite, nausea, vomiting, pain in the abdomen, and fever suggest hepatitis, particularly in young people and people with risk factors for hepatitis. Fever and severe, constant pain in the upper right part of the abdomen suggest acute cholangitis (infection of the bile ducts), usually in people with a blockage in a bile duct. Acute cholangitis is considered a medical emergency.

Doctors ask people whether they have had liver disorders, whether they have had surgery that involved the bile ducts, and whether they take any drugs that can cause jaundice (including alcohol, over-the-counter drugs, medicinal herbs, and other herbal products such as teas). Knowing whether family members have also had jaundice or other liver disorders can help doctors identify hereditary liver disorders.

Because hepatitis is a common cause, doctors ask particularly about conditions that increase the risk of hepatitis, such as

• Working at a day care center
• Living in or working at an institution with long-term residents, such as a mental health care facility, prison, or long-term care facility
• Living in or traveling to an area where hepatitis is widespread
• Participating in anal sex
• Eating raw shellfish
• Injecting illegal or recreational drugs
• Having hemodialysis
• Sharing razor blades or toothbrushes
• Getting a tattoo or body piercing
• Working in a health care facility without being vaccinated against hepatitis
• Having had a blood transfusion before 1992
• Having sex with someone who has hepatitis

During the physical examination, doctors look for signs of serious disorders (such as fever, very low blood pressure, and a rapid heart rate) and for signs that liver function is greatly impaired (such as easy bruising, a rash of tiny dots or splotches, or changes in mental function). They gently press on the abdomen to check for lumps, tenderness, swelling, and other abnormalities, such as an enlarged liver or spleen.

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Some Causes and Features of Jaundice Cause Common Features* Tests† Liver and gallbladder disorders Alcoholic liver disease Jaundice that develops slowly A history of heavy alcohol consumption In men, development of feminine characteristics, including loss of muscle tissue, smooth skin, enlarged breasts, shrunken testes, and growth of pubic hair in a female pattern Sometimes swelling of the abdomen due to accumulation of fluid (ascites) A doctor's examination Blood tests Sometimes liver biopsy Blockage of a bile duct by a gallstone or, less commonly, by a tumor of the pancreas or bile ducts Dark urine and light-colored, soft, bulky, oily-looking, and unusually foul-smelling stool Usually pain in the upper right part or middle of the abdomen If the cause is a tumor, weight loss and sometimes chronic abdominal pain Imaging such as Ultrasonography (done by putting the ultrasound probe on the abdomen) Endoscopic ultrasonography (done with a probe inserted via a flexible viewing tube into the small intestine) CT cholangiography (CT of the bile ducts done after a radiopaque dye is injected into a vein) MRCP (MRI of the bile and pancreatic ducts using specialized techniques) ERCP (x-rays of the bile and pancreatic ducts taken after a radiopaque dye is injected into these ducts through a flexible viewing tube inserted through the mouth and into the small intestine) Biopsy if imaging results suggest cancer Cholestasis of pregnancy Severe itching Later, jaundice and dark urine Usually develops during late pregnancy Blood tests Usually ultrasonography Hepatitis (viral) Symptoms that occur before jaundice develops: Nausea or vomiting Loss of appetite Fatigue Constant pain in the upper right part of the abdomen Fever Sometimes joint pain Often in people with risk factors, such as recreational use of injected drugs or participation in anal sex Blood tests for hepatitis viruses Usually liver biopsy if hepatitis is chronic Primary biliary cirrhosis (an autoimmune disorder causing destruction of the small bile ducts in the liver) Symptoms that often occur before jaundice develops: Fatigue Itching Dry mouth and eyes Sometimes discomfort in the upper right part of the abdomen, darkening of the skin, and small yellow deposits of fat in the skin (xanthomas) or eyelids (xanthelasmas) Blood tests to check for the antibodies that occur in most people with this disorder Ultrasonography and often MRI of the abdomen Liver biopsy Primary sclerosing cholangitis (scarring and destruction of small and large bile ducts) Symptoms that occur before jaundice develops: Worsening fatigue Itching Pain in the upper right part of the abdomen Sometimes light-colored, soft, bulky, oily-looking, and unusually foul-smelling stool Often in people with inflammatory bowel disease MRI of the abdomen ERCP Other disorders Breakdown of red blood cells (hemolysis), which may be caused by Drugs Toxins (including some snake venoms) Hereditary red blood cell disorders Enzyme deficiencies (such as G6PD deficiency) Infections (such as malaria) Symptoms of anemia (paleness, weakness, and fatigue) Sometimes use of a drug that causes hemolysis or presence of a red blood cell disorder in a family member Blood tests Wilson disease (which causes copper to accumulate in the liver) Tremors, difficulty speaking and swallowing, involuntary movements, loss of coordination, and personality changes Gold or greenish gold rings in the cornea of the eyes (Kayser-Fleischer rings) Slit-lamp examination of the eyes to check for Kayser-Fleischer rings Blood tests to measure levels of copper and copper proteins Urine tests to measure the level of copper eliminated in the urine If the diagnosis is still unclear, liver biopsy Surgical complications such as Scarring of the bile ducts due to surgery on or near these ducts Reduced blood flow to the liver due to blood loss or other complications of major surgery Develops soon after surgery, particularly major surgery A doctor's examination Sometimes other tests, depending on the likely causes Drugs and toxins Acetaminophen (in high doses or as an overdose) Certain medicinal herbs such as germander, kava, or pyrrolizidine Isoniazid Iron when taken in large amounts Amanita phalloides mushroom toxin Use of a substance that can cause jaundice A doctor's examination *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. †Doctors typically measure bilirubin levels in the blood and do blood tests to determine how well the liver is functioning and whether it is damaged (liver function tests) and to assess the blood's ability to clot. CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; G6PD = glucose-6-phosphate dehydrogenase; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging. Some Causes and Features of Jaundice Cause Common Features* Tests† Liver and gallbladder disorders Alcoholic liver disease Jaundice that develops slowly A history of heavy alcohol consumption In men, development of feminine characteristics, including loss of muscle tissue, smooth skin, enlarged breasts, shrunken testes, and growth of pubic hair in a female pattern Sometimes swelling of the abdomen due to accumulation of fluid (ascites) A doctor's examination Blood tests Sometimes liver biopsy Blockage of a bile duct by a gallstone or, less commonly, by a tumor of the pancreas or bile ducts Dark urine and light-colored, soft, bulky, oily-looking, and unusually foul-smelling stool Usually pain in the upper right part or middle of the abdomen If the cause is a tumor, weight loss and sometimes chronic abdominal pain Imaging such as Ultrasonography (done by putting the ultrasound probe on the abdomen) Endoscopic ultrasonography (done with a probe inserted via a flexible viewing tube into the small intestine) CT cholangiography (CT of the bile ducts done after a radiopaque dye is injected into a vein) MRCP (MRI of the bile and pancreatic ducts using specialized techniques) ERCP (x-rays of the bile and pancreatic ducts taken after a radiopaque dye is injected into these ducts through a flexible viewing tube inserted through the mouth and into the small intestine) Biopsy if imaging results suggest cancer Cholestasis of pregnancy Severe itching Later, jaundice and dark urine Usually develops during late pregnancy Blood tests Usually ultrasonography Hepatitis (viral) Symptoms that occur before jaundice develops: Nausea or vomiting Loss of appetite Fatigue Constant pain in the upper right part of the abdomen Fever Sometimes joint pain Often in people with risk factors, such as recreational use of injected drugs or participation in anal sex Blood tests for hepatitis viruses Usually liver biopsy if hepatitis is chronic Primary biliary cirrhosis (an autoimmune disorder causing destruction of the small bile ducts in the liver) Symptoms that often occur before jaundice develops: Fatigue Itching Dry mouth and eyes Sometimes discomfort in the upper right part of the abdomen, darkening of the skin, and small yellow deposits of fat in the skin (xanthomas) or eyelids (xanthelasmas) Blood tests to check for the antibodies that occur in most people with this disorder Ultrasonography and often MRI of the abdomen Liver biopsy Primary sclerosing cholangitis (scarring and destruction of small and large bile ducts) Symptoms that occur before jaundice develops: Worsening fatigue Itching Pain in the upper right part of the abdomen Sometimes light-colored, soft, bulky, oily-looking, and unusually foul-smelling stool Often in people with inflammatory bowel disease MRI of the abdomen ERCP Other disorders Breakdown of red blood cells (hemolysis), which may be caused by Drugs Toxins (including some snake venoms) Hereditary red blood cell disorders Enzyme deficiencies (such as G6PD deficiency) Infections (such as malaria) Symptoms of anemia (paleness, weakness, and fatigue) Sometimes use of a drug that causes hemolysis or presence of a red blood cell disorder in a family member Blood tests Wilson disease (which causes copper to accumulate in the liver) Tremors, difficulty speaking and swallowing, involuntary movements, loss of coordination, and personality changes Gold or greenish gold rings in the cornea of the eyes (Kayser-Fleischer rings) Slit-lamp examination of the eyes to check for Kayser-Fleischer rings Blood tests to measure levels of copper and copper proteins Urine tests to measure the level of copper eliminated in the urine If the diagnosis is still unclear, liver biopsy Surgical complications such as Scarring of the bile ducts due to surgery on or near these ducts Reduced blood flow to the liver due to blood loss or other complications of major surgery Develops soon after surgery, particularly major surgery A doctor's examination Sometimes other tests, depending on the likely causes Drugs and toxins Acetaminophen (in high doses or as an overdose) Certain medicinal herbs such as germander, kava, or pyrrolizidine Isoniazid Iron when taken in large amounts Amanita phalloides mushroom toxin Use of a substance that can cause jaundice A doctor's examination *Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. †Doctors typically measure bilirubin levels in the blood and do blood tests to determine how well the liver is functioning and whether it is damaged (liver function tests) and to assess the blood's ability to clot. CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; G6PD = glucose-6-phosphate dehydrogenase; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging.

Testing: Tests include the following:

• Blood tests to evaluate how well the liver is functioning and whether it is damaged (liver function tests)
• Usually imaging tests such as ultrasonography
• Sometimes biopsy or laparoscopy

Liver function tests help doctors determine whether the cause is liver malfunction or a blocked bile duct. If a bile duct is blocked, imaging tests, such as ultrasonography, are usually required.

Other blood tests are done based on the disorder doctors suspect and the results of the examination and the initial tests. They may include

• Tests to assess the blood's ability to clot (prothrombin time and partial thromboplastin time)
• Tests to check for hepatitis viruses or abnormal antibodies (due to autoimmune disorders)
• A complete blood count
• Blood cultures to check for infection of the bloodstream
• Examination of a blood sample under a microscope to check for excessive destruction of red blood cells

If imaging is needed, ultrasonography of the abdomen is often done first. It can usually detect blockages in the bile ducts. Alternatively, computed tomography (CT) or magnetic resonance imaging (MRI) may be done.

If ultrasonography shows a blockage in a bile duct, other tests may be needed to determine the cause. Typically, magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP) is used (see Diagnosis of Liver, Gallbladder, and Biliary Disorders: Understanding Endoscopic Retrograde Cholangiopancreatography). MRCP is MRI of the bile and pancreatic ducts, done with specialized techniques that make the fluid in the ducts appear bright and the surrounding tissues appear dark. Thus, MRCP provides better images of the ducts than conventional MRI. For ERCP, a flexible viewing tube (endoscope) is inserted through the mouth and into the small intestine, and a radiopaque dye is injected through the tube into the bile and pancreatic ducts. Then x-rays are taken. When available, MRCP is usually preferred because it is just as accurate and is safer. But ERCP may be used because it enables doctors to take a biopsy sample, remove a gallstone, or do other procedures.

Occasionally, liver biopsy is needed. It may be done when certain causes (such as viral hepatitis, use of a drug, or exposure to a toxin) are suspected or when the diagnosis is unclear after doctors have the results of other tests.

Laparoscopy may be done when other tests have not identified why bile flow is blocked. For this procedure, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to examine the liver and gallbladder directly. Rarely, a larger incision is needed (a procedure called laparotomy).

Treatment

The underlying disorder and any problems it causes are treated as needed. If jaundice is due to acute viral hepatitis, it may disappear gradually, without treatment, as the condition of the liver improves. However, hepatitis may become chronic, even if the jaundice disappears. Jaundice itself requires no treatment in adults (unlike in newborns—see Problems in Newborns: Jaundice in the Newborn).

Usually, itching gradually disappears as the liver's condition improves. If itching is bothersome, taking cholestyramine by mouth may help. However, cholestyramine is ineffective when a bile duct is completely blocked.

If the cause is a blocked bile duct, a procedure may be done to open the bile duct. This procedure can usually be done during ERCP, using instruments threaded through the endoscope (see Diagnosis of Digestive Disorders: Endoscopy).

Essentials for Older People

In older people, the disorder causing jaundice may not cause the same symptoms as it typically does in younger people, or the symptoms may be milder or harder to recognize. For example, if older people have acute viral hepatitis, they often have much less abdominal pain than younger people. When older people become confused, doctors may mistakenly diagnose dementia and not realize that the cause is hepatic encephalopathy. That is, doctors may not realize that brain function is deteriorating because the liver is unable to remove toxic substances from the blood (as it usually does), and thus, the toxic substances can reach the brain.

In older people, jaundice usually results from a blockage in the bile ducts, and the blockage is more likely to be cancer. Doctors suspect that the blockage is cancer when older people have lost weight, have only mild itching, have no abdominal pain, and have a lump in the abdomen.

Key Points

• If damage to the liver is severe, jaundice may be accompanied by serious problems, such as deterioration of brain function and a tendency to bleed or bruise.
• Acute viral hepatitis is a common cause of jaundice, particularly in young and otherwise healthy people.
• People should see a doctor promptly if they have jaundice so that the doctor can check for serious causes.
• Cholestyramine may help relieve itching.

Last full review/revision August 2012 by Steven K. Herrine, MD