Jaundice
Jaundice is a condition wherein your skin turns yellow as a result of the accumulation and
deposition of bilirubin, a yellow pigment that will stain the skin, mucosa and sclera. The sclera is
the white part of our eyes; it will be identified earlier compared to the skin when jaundice
occurs.
Bilirubin comes from the breakdown product of our red blood cells. It is commonly bound to albumin and transported to the liver. Conjugation of bilirubin occurs in the liver to turn it into a water-soluble form and for elimination.
Doctors usually classify jaundice into three types, namely: pre-hepatic jaundice, hepatic
jaundice and post-hepatic jaundice. For laymen, the terms can be broadly classified into
medical jaundice and obstructive jaundice.
Examples of medical jaundice include:
- Haemolytic anaemia: The common types of hemolytic anaemia include sickle cell anaemia, Thalassaemia, spherocytosis and G6PD deficiency. Due to the excessive breakdown of red blood cells, there will be accumulation of bilirubin. Usually, the patients with haemolytic anaemia are known and are informed of having the conditions when they are at a younger age. This group of patients would have already been seen by a physician or haematologist when it was diagnosed.
- Acquired causes of anaemia: Examples of acquired causes of anaemia are transfusion-related anaemia, trauma, autoimmune haemolysis, infection and marathon runners.
- Congenital hepatic jaundice: It occurs when the liver fails to produce enzymes for conjugation of bilirubin, e.g. Wilson's Disease, Haemochromatosis, Gilbert's Syndrome
and Dubin-Johnson's syndrome. This type of jaundice will be treated by a physician or a hepatologist. - Acquired hepatic jaundice occurs when there is liver inflammation or when the liver fails to function,e.g. Hepatitis A, Hepatitis B, Hepatitis C, alcoholic hepatitis, sepsis, malnutrition and paracetamol overdose. This condition will commonly be managed by a physician or a hepatologist.
Obstructive jaundice occurs when there is a physical or mechanical cause of obstruction to the
bile flow. The obstruction can be due to benign or malignant conditions.
The example of benign causes are:
- Bile duct obstruction due to bile duct stone and cholangitis.
- Mirizzi syndrome, external compression of the bile duct due to compression of stone from the gallbladder.
- Bile duct cyst or choledochal cyst.
- Pancreatitis causes biliary stricture.
- Parasitic infection
- Recurrent pyogenic cholangitis (RPC), stones formation in the intrahepatic bile duct.
The examples of malignant causes of obstructive jaundice are:
- Klatskin tumour: bile duct cancer located at the bifurcation of the bile duct.
- Gallbladder cancer.
- Bile duct cancer.
- Head of pancreas cancer.
- Liver cancer, primary and secondary.
- Periampullary cancer.
- Duodenal cancer.
Symptoms:
Jaundice is often characterised by yellowing of the skin, along with various other symptoms
such as:
- Fever
- Chills
- Abdominal pain
- Flu-like symptoms
- Dark-coloured urine
- Clay-coloured stools
Treatment:
Treatment of this condition commonly requires a multidisciplinary approach, involving a surgeon, a gastroenterologist, an infectious disease physician, a medical oncologist and a radiation oncologist.
Prior to treatment doctors need to identify the type of jaundice to enable the correct
treatment. Common investigation tools used for correct diagnoses include blood investigations
and scans (including ultrasounds, CT scans, MRI scans and PET scans); sometimes, tissue
diagnosis with biopsy via endoscopy is needed.
Obstructive jaundice occurs when the normal bile flow is blocked; besides the yellowing of the
skin, the high level of bilirubin accumulation can lead to other complications such as skin
itching, abnormal blood clotting, confusion and drowsiness (hepatic encephalopathy).
When the bile is not flowing, an infection can occur in the obstructed system. This condition is called cholangitis. It requires early medical treatment with antibiotics and draining of the obstruction. Because the bile duct and the liver are rich in blood supply, a delay in treating cholangitis can lead to the dissemination of infection, known as sepsis. Draining of the obstruction can be performed via endoscopy retrograde cholangiopancreatography (ERCP) with stenting or percutaneous transhepatic biliary drainage (PTC or PTBD). Sometimes tissue
diagnoses can be obtained during an ERCP or PTBD.
Benign conditions related to gallstones can be treated with laparoscopic cholecystectomy with or without common bile duct exploration. Benign stricture will require a biliary bypass.
Conditions related to cancer require careful assessment to look for metastasis. If there is metastasis, the patient will require palliative treatment; for locally advanced cancer,
neoadjuvant chemotherapy will be offered before definitive surgical treatment. For cancer-causing obstructive jaundice, the principle of surgery is to obtain a clear margin and to clear the
regional lymph nodes during the surgery. After the surgical resection, the bile duct will be reconstructed with a bowel segment to allow biliary flow. The surgery includes liver resection
with bile duct resection, bile duct resection alone, or Whipple's procedure, depending on the location of the cancer. Open or minimally invasive surgery can be discussed carefully,
depending on the extent of the tumour.
