Chapter 58

### Introduction

The disease is produced by black bile when it flows into the liver. The symptoms are these: ‘an acute pain in the liver, also below the breast, a feeling of suffocation is strong during these days and becomes less strong later’. The liver is tender to palpation and the complexion of the patient is somewhat livid. These are symptoms that occur in the beginning but as the disease progresses, the fever diminishes in strength and the patient feels sated after ingesting a little amount of food. He must drink melikration [a mixture of water and honey].

Hippocrates on hepatitis

Jaundice is a yellow discolouration of the skin and mucosal surfaces caused by the accumulation of excessive bilirubin.1 It is a cardinal symptom of hepatobiliary disease and haemolysis. Important common causes include gallstones, hepatitis A, hepatitis B, hepatitis C, drugs, alcohol and Gilbert syndrome. The commonest clinical encounter with jaundice, especially physiological jaundice, is in the newborn. As for all patients, the history and examination are paramount, but investigations are essential to clinch the diagnosis of jaundice.

The three major categories of jaundice are (see FIG. 58.1):

###### FIGURE 58.1

The jaundice pathway

• obstructive:

• extrahepatic

• intrahepatic

• hepatocellular

• haemolytic

Key facts and checkpoints

• Jaundice is defined as a serum bilirubin level exceeding 19 μmol/L.2

• Clinical jaundice manifests only when the bilirubin level exceeds 50 μmol/L.1

• However, jaundice is difficult to detect visually below 85 μmol/L if lighting is poor.

• It can be distinguished from yellow skin due to hypercarotenaemia (due to dietary excess of carrots, pumpkin, mangoes or pawpaw) and hypothyroidism by involving the sclera.

• The most common causes of jaundice recorded in a general practice population are (in order) viral hepatitis, gallstones, pancreatic cancer, cirrhosis, pancreatitis and drugs.3

• Always take a full travel, drug and hepatitis contact history in any patient presenting with jaundice.

• Acute hepatitis is usually self-limiting in patients with hepatitis A and in adults with hepatitis B but progresses to chronic infections with hepatitis C and children with hepatitis B.4

• A fatty liver (steatosis) can occur not only with alcohol excess but also with obesity, diabetes and starvation. There is usually no liver damage and thus no jaundice.

Table 58.1

Abbreviations used in this chapter

### A diagnostic approach

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