Last Updated on May 8, 2025
Jaundice is a clinical condition marked by a yellow discoloration of the skin, eyes, and mucous membranes due to elevated levels of bilirubin in the blood.
While it is often associated with liver problems, jaundice can arise from various causes affecting different stages of bilirubin metabolism, from red blood cell breakdown to liver processing and bile drainage.
It can appear in newborns, children, or adults, and its presence may indicate anything from a benign condition to a serious underlying disease.
Recognizing jaundice early and understanding its causes, types, and treatment options is essential for timely medical evaluation and appropriate care. [1]
What is Jaundice?
Jaundice is a condition in which the skin, sclera (whites of the eyes), and other tissues turn yellow due to an excessive buildup of a substance called bilirubin in the blood.
Bilirubin is a yellow-orange pigment produced when red blood cells break down naturally in the body. Under normal circumstances, the liver processes bilirubin, which is then excreted through bile into the digestive tract and eliminated from the body. [1]
When this process is disrupted—whether due to excessive red cell breakdown, liver dysfunction, or bile flow obstruction—bilirubin accumulates in the bloodstream and deposits in tissues, leading to the characteristic yellow discoloration.
This visible change is often the first sign of an underlying disorder and should prompt further medical evaluation.
Jaundice itself is not a disease but a clinical sign of a wide range of potential conditions, like physiological jaundice in newborns to serious liver conditions or bile duct obstructions in adults. The severity and implications of jaundice depend largely on the underlying cause.
Liver and Bilirubin Metabolism
Hemoglobin, released by the breakdown of aged cells, is broken down into globin and heme. The heme is further broken into iron and bilirubin. Bilirubin attaches to serum albumin and is transported to the liver, where it is taken up.
In the liver, bilirubin is separated from albumin and conjugated to glucuronide by the enzyme glucuronyl transferase. The conjugated bilirubin is water-soluble and can be excreted by the kidneys.
The conjugated bilirubin through the bile canaliculi reaches the intestines, and is converted to stercobilinogen and urobilinogen by the intestinal bacteria.
About 70% of this is absorbed in the colon and brought back to the liver and re-excreted (enterohepatic circulation) and is excreted via the kidneys.
Unabsorbed stercobilinogen gives a brown color to the faces and is excreted along.
If, for some reason, the bilirubin is not excreted, its levels in blood rise, a state called hyperbilirubinemia. After a certain threshold, this increased level of bilirubin in the blood starts depositing in the skin and other organs.
This leads to a yellowish tinge to the skin and mucous membranes. This yellowish tinge is called jaundice or icterus.
Causes and Types of Jaundice
Jaundice occurs when there is an imbalance in the production, processing, or elimination of bilirubin. Understanding the underlying cause is essential because it determines the appropriate treatment and urgency of care.
Based on where the disruption occurs in the bilirubin pathway, jaundice is classified into three main clinical types:
Pre-Hepatic (Hemolytic) Jaundice
This type occurs when too many red blood cells are destroyed, overwhelming the liver’s ability to remove bilirubin. The bilirubin that accumulates is unconjugated (indirect), meaning it hasn’t yet been metabolized by the liver.
Common causes include:
- Hemolytic anemia
- Malaria
- Sickle cell disease
- Hereditary spherocytosis
- G6PD deficiency
Clues to diagnosis:
- No itching
- Normal-colored stool and urine
- Elevated indirect bilirubin
Hepatic (Hepatocellular) Jaundice
This form arises from damage to liver cells, which impairs the liver’s ability to take up, conjugate, or excrete bilirubin. Both conjugated and unconjugated bilirubin levels may be elevated.
Common causes include:
- Viral hepatitis (A, B, C, etc.)
- Alcoholic hepatitis [3]
- Drug-induced liver injury (e.g., paracetamol overdose)
- Cirrhosis
- Genetic disorders like Crigler-Najjar and Gilbert syndrome
- Wilson Disease [4]
Post-Hepatic (Obstructive) Jaundice
This type occurs when bilirubin has been processed by the liver (i.e., conjugated bilirubin), but cannot drain properly due to a blockage in the bile ducts. The bile—and the bilirubin it carries—leaks back into the bloodstream.
Common causes include:
- Gallstones blocking the bile duct
- Tumors (pancreatic carcinoma, cholangiocarcinoma)
- Biliary strictures or cysts
- Congenital biliary atresia in infants
Clues to diagnosis:
- Pale, clay-colored stool
- Dark urine
- Significant itching
- Enlarged gallbladder or liver on imaging
Special Categories
Neonatal Jaundice
Occurs in newborns, often within the first week of life. It is mostly physiological, due to immature liver function, but can also be pathological due to hemolysis, infections, or metabolic disorders.
Physiological jaundice is normal in many newborns and resolves spontaneously. Pathological jaundice appears too early, rises too high, or lasts too long and may need treatment.
Mixed-Type Jaundice
Some patients—especially those with chronic liver disease—may show features of both hepatocellular and obstructive jaundice.
Symptoms of Jaundice
The primary symptom of jaundice is the yellow discoloration of the skin, sclera (whites of the eyes), and mucous membranes. However, this discoloration is often a signal of underlying liver, biliary, or hematological conditions. Other associated symptoms vary depending on the cause and severity of jaundice:
Common Symptoms
- Yellowing of skin and eyes – most noticeable in natural light, begins in the face and progresses downward.
- Dark-colored urine – due to excess bilirubin excreted by the kidneys.
- Pale or clay-colored stools – often seen when bile flow is obstructed and stools lack coloration due to the absence of pigment
- Fatigue and malaise
- Loss of appetite and weight loss – common in chronic diseases.
- Itching (pruritus) – particularly in cholestatic jaundice due to bile salt accumulation.
- Abdominal pain – more likely in obstructive or infectious causes.
- Nausea or vomiting can accompany hepatic inflammation or biliary obstruction.
- Fever and chills – typically associated with infectious causes like hepatitis or cholangitis.
Red Flags Requiring Urgent Evaluation
- Altered mental status (hepatic encephalopathy)
- Bleeding or bruising (coagulopathy)
- Sudden onset of jaundice in infants or newborns
- Associated with severe abdominal pain and fever
Diagnosis of Jaundice
Accurate diagnosis of jaundice involves a stepwise approach beginning with clinical assessment and followed by targeted investigations. The goal is to identify the underlying cause—whether pre-hepatic, hepatic, or post-hepatic—and guide appropriate management.
Clinical Presentation
A thorough history often provides the first clue to the underlying cause. Key points to be looked at are
- Onset and progression of yellowing
- Associated symptoms (e.g., fever, pain, pruritus, fatigue)
- Drug or alcohol use
- Recent travel or high-risk exposures (for hepatitis)
- Family history of liver disease or hemolytic disorders
Physical findings may include-
- Jaundice (visible in sclera, skin)
- Hepatomegaly or splenomegaly
- Ascites – Ascites is abnormal fluid buildup in the abdomen
- Edema- Swelling caused by fluid retention, commonly in the legs and feet
- Spider angiomas- Small, spider-like blood vessels visible under the skin
- Palmar erythema- Redness of the palms
- Murphy’s sign – Pain during deep breath when pressing on the right upper abdomen — suggests gallbladder inflammation
Laboratory Investigations
Routine blood tests are essential for determining the pattern and severity of jaundice.
Liver Function Tests (LFTs):
- Total bilirubin: Elevated in all types of jaundice
- Direct (conjugated) bilirubin: High in obstructive or hepatocellular jaundice
- Indirect (unconjugated) bilirubin: Predominant in hemolytic jaundice
- Liver Enzymes: Elevated levels of
- ALT (alanine aminotransferase) and AST (aspartate aminotransferase — enzymes released from damaged liver cells
- Alkaline phosphatase (ALP)- Elevated in cholestasis or biliary obstruction
- Gamma-glutamyl transferase (GGT)- Often elevated in biliary disease or alcohol use
Complete Blood Count (CBC)
- Anemia or hemolysis in pre-hepatic causes
- Leukocytosis in infection
Read – What is Complete Blood Count
Coagulation Profile:
- PT/INR abnormalities may indicate liver synthetic dysfunction in making clotting proteins.
Serology and Viral Markers:
- Hepatitis A, B, C, and E
- Autoimmune markers (ANA, ASMA)
- Wilson’s disease tests (serum ceruloplasmin, copper levels) [4]
Imaging Studies
Used to detect anatomical or obstructive causes.
Ultrasonography (Abdominal):
- First-line imaging
- Detects gallstones, biliary dilation, and liver texture
CT Scan or MRI:
- Detailed evaluation of masses, tumors, and strictures
- Can show complex biliary anatomy
MRCP (Magnetic Resonance Cholangiopancreatography):
It is the use of MRI for non-invasive assessment of the biliary tree
ERCP (Endoscopic Retrograde Cholangiopancreatography)
- Both diagnostic and therapeutic in obstructive jaundice [5]
- Allows stenting or stone removal
Liver Biopsy
Indicated when other investigations are inconclusive. Helps diagnose conditions like:
- Autoimmune hepatitis
- Drug-induced liver injury
- Chronic hepatitis
- Fibrosis or cirrhosis
Management of Jaundice
Pre-hepatic Jaundice (Hemolytic Causes)
The aim is to reduce hemolysis and manage complications such as anemia.
Management may include:
- Treating underlying conditions like malaria, thalassemia, or autoimmune hemolysis
- Corticosteroids or immunosuppressants in autoimmune hemolytic anemia
- Blood transfusions if anemia is severe
- Folic acid supplementation to support red cell production
Hepatic Jaundice (Liver Parenchymal Diseases)
Treatment targets liver inflammation or hepatocellular injury.
- Alcoholic liver disease: Complete alcohol cessation, nutritional support, corticosteroids in severe cases [3]
- Drug-induced liver injury: Immediate discontinuation of the offending agent
- Autoimmune hepatitis: Immunosuppressive therapy (e.g., steroids, azathioprine)
- Wilson’s disease: Chelating agents like penicillamine or zinc therapy [4]
Post-hepatic (Obstructive) Jaundice
Relief of biliary obstruction is the key therapeutic goal.
Interventions may include:
Gallstones: Endoscopic removal via ERCP or surgical cholecystectomy
- Tumors (e.g., pancreatic or cholangiocarcinoma): Surgical resection, stenting, or palliative care depending on stage
- Strictures or bile duct injury: Biliary stenting or surgical reconstruction
- Biliary atresia in infants: Kasai portoenterostomy or liver transplantation
Supportive Care Across All Types
Supportive measures for all hepatic causes include:
- Adequate hydration and nutrition
- Monitoring for complications like encephalopathy or coagulopathy
- Avoidance of hepatotoxic drugs
- Pruritus relief: Cholestyramine, antihistamines
- Nutritional support, especially fat-soluble vitamins (A, D, E, K) in cholestasis
- Monitoring liver function serially
- Management of complications like ascites, varices, or encephalopathy in chronic liver disease
Conclusion
Jaundice is a visible clinical sign that can be linked to a broad spectrum of underlying disorders, ranging from mild, self-limiting conditions to life-threatening hepatic or biliary diseases.
Understanding the classification, common causes, symptoms, and diagnostic workup is critical for timely management.
While treatment always depends on the root cause, early recognition and appropriate intervention significantly improve patient outcomes.
In clinical settings, a structured approach to jaundice ensures both accurate diagnosis and effective care across all age groups.
References
- Winger J, Michelfelder A. Diagnostic approach to the patient with jaundice. Prim Care. 2011 Sep;38(3):469-82; viii. doi: 10.1016/j.pop.2011.05.004. PMID: 21872092. [Pubmed]
- Sharma A, Nagalli S. Chronic Liver Disease. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554597/
- Liu SY, Tsai IT, Hsu YC. Alcohol-Related Liver Disease: Basic Mechanisms and Clinical Perspectives. Int J Mol Sci. 2021 May 13;22(10):5170. [Pubmed]
- Członkowska A, Litwin T, Dusek P, Ferenci P, Lutsenko S, Medici V, Rybakowski JK, Weiss KH, Schilsky ML. Wilson disease. Nat Rev Dis Primers. 2018 Sep 6;4(1):21. doi: 10.1038/s41572-018-0018-3. PMID: 30190489; PMCID: PMC6416051.
- Søreide JA, Karlsen LN, Sandblom G, Enochsson L. Endoscopic retrograde cholangiopancreatography (ERCP): lessons learned from population-based national registries: a systematic review. Surg Endosc. 2019 Jun;33(6):1731-1748. doi: 10.1007/s00464-019-06734-w. Epub 2019 Mar 12. PMID: 30863927. [Pubmed]
