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| {{CMG}}
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| {{DiseaseDisorder infobox | | | {{DiseaseDisorder infobox | |
| Name = Jaundice, NOS | | | Name = Jaundice, NOS | |
| Image = PHIL 2860 lores.jpg| | | Image = PHIL 2860 lores.jpg| |
| Caption = Yellowing of the [[skin]] and [[sclera]] caused by [[Hepatitis|Hepatitis A]].| | | Caption = Yellowing of the [[skin]] and [[sclera]], via Wikimedia Commons<ref>By Photo Credit: Content Providers(s): CDC/Dr. Thomas F. Sellers/Emory University [Public domain], <"https://commons.wikimedia.org/wiki/File%3AJaundice_eye.jpg"></ref>| |
| ICD10 = {{ICD10|R|17||r|10}} |
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| ICD9 = {{ICD9|782.4}} |
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| OMIM = |
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| MedlinePlus = 003243 |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| DiseasesDB = 7038 |
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| MeshID = D007565 |
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| }} | | }} |
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| {{SI}}
| | '''For patient information, click [[Jaundice (patient information)|here]].''' |
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| ==Overview==
| | '''For the approach to a patient with jaundice, click [[Approach to a patient with jaundice|here]].''' |
| '''Jaundice''', also known as '''icterus''' (attributive adjective: "icteric"), is yellowish discoloration of the [[skin]], [[conjunctiva]] (a clear covering over the [[sclera]], or whites of the eyes) and [[mucous membrane]]s caused by hyperbilirubinemia (increased levels of [[bilirubin]] in red blooded animals). Usually the concentration of bilirubin in the [[blood]] must exceed 2–3 [[milligram|mg]]/[[decilitre|dL]] for the coloration to be easily visible. ''Jaundice'' comes from the French word ''jaune'', meaning yellow. Jaundice typically appears in a 'top to bottom' progression (starting with the face, progressing toward the feet), and resolves in a 'bottom to top' manner. | |
| ==Pathophysiology==
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| * Bilirubin is the major breakdown product of hemoglobin that is released from dying or damaged erythrocytes
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| * The normal bilirubin range is 0.3-1.0 mg/dL
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| * Jaundice is visible in conjunctiva, skin and mucosa when the serum bilirubin level rises above 2 mg/dL
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| ==Causes==
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| When [[red blood cell]]s die, the [[heme]] in their [[haemoglobin]] is converted to [[bilirubin]] in the [[spleen]] and in the hepatocytes in the liver. The [[bilirubin]] is processed by the [[liver]], enters [[bile]] and is eventually excreted through [[feces]].
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| Consequently, there are three different classes of causes for jaundice. ''Pre-hepatic'' or ''hemolytic'' causes, where too many red blood cells are broken down, ''hepatic'' causes where the processing of [[bilirubin]] in the liver does not function correctly, and ''post-hepatic'' or ''extrahepatic'' causes, where the removal of bile is disturbed.
| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{FKH}}, {{FA}}, {{EG}}, {{MJ}} |
| == Differential Diagnosis<ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:98</ref><ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:51-54</ref> ==
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| * Abdominal mass
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| * Acute [[alcoholic hepatitis]]
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| * [[Alcoholic Hepatitis]]
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| * [[Alpha-1 Antitrypsin Deficiency ]]
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| * [[Amyloidosis]]
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| * Annular pancreas
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| * Autoimmune [[hepatitis]]
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| * Autoimmunohemolysis
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| * Benign recurring cholestasis
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| * [[Bile duct tumor]]
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| * [[Biliary atresia]]
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| * Biliary tract obstruction
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| * [[Cholangitis]]
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| * [[Cholecystitis]]
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| * [[Choledocholithiasis]]
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| * [[Choledochal cyst]]
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| * Conditions following [[hemorrhage]]
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| * [[Congestive Heart Failure]]
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| * [[Crigler-Najjar Syndrome]]
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| * [[Cystic Fibrosis]]
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| * [[Cytomegalovirus]] (CMV)
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| * Decompensated [[cirrhosis]]
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| * [[Dubin-Johnson Syndrome]]
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| * [[Drugs]] and toxins
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| * [[Eclampsia]]
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| * [[Epstein-Barr Virus]] (EBV)
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| * Fetal [[erythroblastosis]]
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| * Following [[hemolytic disease of the newborn]] syndrome
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| * [[Galactosemia]]
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| * [[Gallbladder tumor]]
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| * [[Gilbert's Syndrome]]
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| * [[Glucose-6-phosphate dehydrogenase deficiency]]
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| * [[Graft-versus-host disease]]
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| * [[HELLP Syndrome]] ('''H'''emolysis, '''E'''levated '''L'''iver enzymes, '''L'''ow '''P'''latelet count)
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| * Hepatic trauma
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| * [[Hepatitis]]
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| * Hepatotoxic liver damage
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| * Hyperbilirubinemia after heart surgery
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| * Hyperbilirubinemia after portocaval shunt insertion
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| * [[Hyperemesis gravidarum]]
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| * Hypermethioninemia
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| * [[Hypopituitarism]]
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| * [[Hypothyroidism]]
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| * Intrauterine viral infections
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| * Intrahepatic cholestasis of [[pregnancy]]
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| * Intrahepatic and extrahepatic [[biliary atresia]]
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| * Intravascular [[hemolysis]]
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| * Jaundice of newborn
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| * [[Liver abscess]]
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| * Liver allograft rejection
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| * [[Liver cell carcinoma]]
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| * [[Lucey-Driscoll Syndrome]]
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| * [[Lymphoma]]
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| * [[Malignancy]]
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| * Neonatal [[hepatitis]]
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| * Nonalcoholic steatohepatitis or [[non-alcoholic fatty liver disease]]
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| * [[Pancreatic cancer]]
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| * [[Pancreatitis]]
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| * [[Parasite]]s
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| * [[Pernicious anemia]]
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| * [[Polycythemia vera]]
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| * Postoperative jaundice
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| * [[Primary biliary cirrhosis]]
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| * [[Hyperbilirubinemia|Primary hyperbilirubinemia]]
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| * [[Primary sclerosing cholangitis]]
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| * [[Rotor's Syndrome]]
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| * [[Sarcoidosis]]
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| * [[Sepsis]]
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| * [[Shock]]
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| * [[Sickle Cell Anemia]]
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| * [[Spherocytosis]]
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| * Storage diseases
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| * Strictures
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| * [[Thalassemia]]
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| * Total parenteral nutrition
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| * [[Transfusion]] reaction
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| * [[Trisomy 18]]
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| * [[Tuberculosis]]
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| * [[Tyrosinemia]]
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| * [[Viral hepatitis]] ([[Hepatitis A|A]], [[Hepatitis B|B]], [[Hepatitis C|C]], [[Hepatitis D|D]], [[Hepatitis E|E]])
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| == Diagnosis ==
| | {{Jaundice}} |
| === History ===
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| The caregiver should ask questions regarding
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| * Alcohol/hepatotoxic medication use
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| === Various Symptoms ===
| | '''''Synonyms and keywords:''''' Icterus; hyperbilirubinemia, yellow discolouration. |
| * '''Alcohol Hepatitis'''
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| *:* Aspartate aminotransferase:alanine aminotransferase ratio > 2 (AST:ALT)
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| *:* [[Ddx:Fever|Fever]]
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| *:* [[Leukocytosis]]
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| * '''Viral Hepatitis'''
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| *:* [[Anorexia]]
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| *:* Dark urine
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| *:* [[Ddx:Fatigue|Fatigue]]
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| *:* [[Hepatomegaly]]
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| *:* Light-colored (acholic) loss stools
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| *:* [[Ddx:Nausea and Vomiting|Nausea]]
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| *:* [[Ddx:Pruritis|Pruritis]]
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| *:* [[Abdominal pain|Right upper quadrant (RUQ) pain]]
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| *:* [[Nausea and Vomiting]]
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| == Physical Examination == | | ==[[Jaundice overview|Overview]]== |
| * Complete physical exam including evidence of:
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| *:* [[Ddx:Hepatomegaly|Hepatomegaly]]
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| *:* [[Ddx:Splenomegaly|Splenomegaly]]
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| *:* Palpable gallbladder
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| *:* Signs of chronic liver disease
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| === Appearance of the Patient ===
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| ====Skin====
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| * Jaundice is visible in conjunctiva, skin and mucosa when the serum bilirubin level rises above 2 mg/dL
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| ==== Eyes ====
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| * Jaundice is usually best seen in the periphery of the ocular conjunctivae
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| ==== Abdomen ====
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| * Hepatomegaly may be present
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| ==== Neurologic ====
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| * A flap may be present
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| == Laboratory Findings ==
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| * Total and unconjugated bilirubin
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| * Aspartate aminotransferase
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| * Alanine aminotransferase
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| * Albumin
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| * Alkaline phosphatase
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| * HIV serologies
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| * Hepatitis serologies
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| * Antinuclear antibody (ANA)
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| * Antimitochondrial antibodies
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| * Haptoglobin
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| * Reticulocyte count
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| * Lactic dehydrogenase (LDH)
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| === MRI and CT ===
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| * Abdominal CT scan may be helpful
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| === Echocardiography or Ultrasound ===
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| * Abdominal ultrasound
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| === Other Diagnostic Studies ===
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| * Endoscopic retrograde cholangio-pancreatography (ERCP)
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| == Treatment ==
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| * Discontinue (and avoid) use of hepatotoxic medications
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| * Rehydrate
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| * Treat underlying etiologies
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| === Acute Pharmacotherapies ===
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| * Steroids
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| == Surgery and Device Based Therapy ==
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| * Cholecystectomy or ERCP
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| ===Pre-hepatic===
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| ''''''Pre-hepatic'''''' -(or hemolytic) jaundice is caused by anything which causes an increased rate of [[hemolysis]] (breakdown of [[red blood cell]]s). In tropical countries, [[malaria]] can cause jaundice in this manner. Certain [[Genetic disorder|genetic diseases]], such as [[sickle cell anemia]] and [[glucose 6-phosphate dehydrogenase deficiency]] can lead to increased red cell lysis and therefore hemolytic jaundice. Commonly, diseases of the kidney, such as [[hemolytic uremic syndrome]], can also lead to coloration. Defects in [[bilirubin metabolism]] also present as jaundice. Jaundice usually comes with high fevers.
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| The laboratory findings include
| | ==[[Jaundice historical perspective|Historical Perspective]]== |
| * Urine: no bilirubin present, urobilirubin > 2 units (except in infants where [[gut flora]] has not developed).
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| * Serum: increased unconjugated bilirubin.
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| ===Hepatic=== | | ==[[Jaundice classification scheme|Classification]]== |
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| Hepatic causes include acute [[hepatitis]], [[hepatotoxicity]] and [[alcoholic liver disease]], whereby cell necrosis reduces the liver's ability to metabolise and excrete [[bilirubin]] leading to a buildup in the blood. Less common causes include [[primary biliary cirrhosis]], [[Gilbert's syndrome]] (a genetic disorder of bilirubin metabolism which can result in mild jaundice, which is found in about 5% of the population) and [[metastasis|metastatic]] [[carcinoma]]. Jaundice seen in the newborn, known as neonatal jaundice, is common, occurring in almost every newborn as [[hepatic]] machinery for the conjugation and excretion of bilirubin does not fully mature until approximately two weeks of age..
| | ==[[Jaundice pathophysiology|Pathophysiology]]== |
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| Laboratory Findings: Urine: bilirubin present, Urobilirubin > 2 units but variable (Except in children)
| | ==[[Jaundice causes|Causes]]== |
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| ===Post-hepatic=== | | ==[[Jaundice differential diagnosis|Differentiating Jaundice from other Conditions]]== |
| Post-hepatic (or obstructive) jaundice, also called [[cholestasis]], is caused by an interruption to the drainage of [[bile]] in the biliary system. The most common causes are [[gallstone]]s in the [[common bile duct]], and [[pancreatic cancer]] in the head of the [[pancreas]]. Also, a group of parasites known as "[[liver fluke]]s" live in the common bile duct, causing obstructive jaundice. Other causes include strictures of the common bile duct, [[biliary atresia]], [[ductal carcinoma]], [[pancreatitis]] and [[pancreatic pseudocyst]]s. A rare cause of obstructive jaundice is [[Mirizzi's syndrome]].
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| The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause as normal feces get their color from [[bile pigment]]s.
| | ==[[Jaundice epidemiology and demographics|Epidemiology and Demographics]]== |
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| Patients also can present with elevated serum cholesterol.
| | ==[[Jaundice risk factors|Risk Factors]]== |
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| Patients often complain of severe itching or "pruritus".
| | ==[[Jaundice screening|Screening]]== |
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| ==[[Neonatal jaundice]]== | | ==[[Jaundice natural history|Natural History, Complications and Prognosis]]== |
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| | ==Diagnosis== |
| {{main|Neonatal jaundice}}
| | [[Jaundice history & symptoms|History and Symptoms]] | [[Jaundice physical examination|Physical Examination]] | [[Jaundice lab tests|Laboratory Findings]] | [[Jaundice chest x ray|Chest X Ray]] | [[Jaundice CT|CT]] | [[Jaundice MRI|MRI]] | [[Jaundice echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Jaundice other imaging findings|Other Imaging Findings]] | [[Jaundice other diagnostic studies|Other Diagnostic Studies]] |
| '''Neonatal jaundice''' is usually harmless: this condition is often seen in [[infants]] around the second day after birth, lasting until day 8 in normal births, or to around day 14 in [[premature birth]]s. Serum [[bilirubin]] normally drops to a low level without any intervention required: the jaundice is presumably a consequence of metabolic and physiological adjustments after birth. In extreme cases, a brain-damaging condition known as [[kernicterus]] can occur; there are concerns that this condition has been rising in recent years due to inadequate detection and treatment of neonatal hyperbilirubinemia. Neonatal jaundice is a risk factor for hearing loss.<ref>{{cite web |url=http://aapnews.aappublications.org/cgi/content/full/18/5/231 |title=Increased vigilance needed to prevent kernicterus in newborns -- O�Keefe 18 (5): 231 -- AAP News |accessdate=2007-06-27 |format= |work=}}</ref>
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| ==Jaundiced eye== | | == Treatment == |
| It was once believed persons suffering from the medical condition jaundice saw everything as yellow. By extension, the jaundiced eye came to mean a prejudiced view, usually rather negative or critical. [[Alexander Pope]], in 'An Essay on Criticism' (1711), wrote: "All seems infected that the infected spy, As all looks yellow to the jaundiced eye." <ref name=eye>From "The Dictionary of Cliches" by James Rogers (Ballantine Books, New York, 1985).</ref>
| | [[Jaundice medical therapy|Medical Therapy]] | [[Jaundice surgery|Surgery]] | [[Jaundice primary prevention|Primary Prevention]] | [[Jaundice secondary prevention|Secondary Prevention]] | [[Jaundice cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Jaundice future or investigational therapies|Future or Investigational Therapies]] |
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| ==External links== | | ==Case Studies== |
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| [http://www.childliverdisease.org/education/yellowalert - Children's Liver Disease Foundation: information on jaundice in infants] | | [[Jaundice case study one|Case #1]] |
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| ==See also== | | ==Related Chapters== |
| *[[Cholestasis]] | | *[[Cholestasis]] |
| | | *[[Bilirubin]] |
| ==External Links==
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| * [http://www.bidmc.org/YourHealth/ConditionsAZ.aspx?ChunkID=11737 Beth Israel Deaconess Medical Center: Jaundice] | |
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| ==References== | | ==References== |
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| {{Reflist}}
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| {{SIB}}
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| {{Symptoms and signs}}
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| [[ar:يرقان]]
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| [[bs:Žutica]]
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| [[ca:Icterícia]]
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| [[cs:Žloutenka]]
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| [[da:Gulsot]]
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| [[de:Ikterus]]
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| [[es:Ictericia]]
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| [[eo:Iktero]]
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| [[fr:Ictère]]
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| [[it:Ittero]]
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| [[he:צהבת]]
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| [[la:Icterus]]
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| [[lt:Gelta]]
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| [[ml:മഞ്ഞപ്പിത്തം]]
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| [[ms:Demam kuning jaundis]]
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| [[nl:Geelzucht]]
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| [[ja:黄疸]]
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| [[no:Gulsott]]
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| [[nn:Gulsot]]
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| [[pl:Żółtaczka (medycyna)]]
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| [[pt:Icterícia]]
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| [[sk:Žltačka]]
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| [[sl:Zlatenica]]
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| [[fi:Keltaisuus]]
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| [[sv:Gulsot]]
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| [[te:పచ్చకామెర్లు]]
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| [[tr:Sarılık]]
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| [[zh:黄疸]]
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| [[Category:Disease]] | | [[Category:Disease]] |
| [[Category:Digestive system]]
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| [[Category:Gastroenterology]] | | [[Category:Gastroenterology]] |
| [[Category:Hepatology]] | | [[Category:Hepatology]] |