Jaundice, or icterus, is a yellowish discoloration of tissue resulting from the deposition of bilirubin. Bilirubin pigment has high affinity for elastic tissue and hence jaundice is particularly noticeable in tissue rich in elastin content.
Tissue deposition of bilirubin occurs only in the presence of serum hyperbilirubinemia and is a sign of either liver disease or, less often, a hemolytic disorder.
The degree of serum bilirubin elevation can be estimated by physical examination. Slight increases in serum bilirubin are best detected by examining the sclerae which have a particular affinity for bilirubin due to their high elastin content.
Normal serum bilirubin concentration ranges from 0.2-0.8 mg/dL, about 80 % of which is unconjugated. The presence of scleral icterus indicates a serum bilirubin of at least 3.0 mg/dL.
The ability to detect scleral icterus is made more difficult if the examining room has fluorescent lighting. If the examiner suspects scleral icterus, a second place to examine is underneath the tongue. As serum bilirubin levels rise, the skin will eventually become yellow in light-skinned patients and even green if the process is longstanding; the green
color is produced by oxidation of bilirubin to biliverdin.
Another sensitive indicator of increased serum bilirubin is darkening of the urine, which is due to the renal excretion of conjugated bilirubin. Bilirubinuria indicates an elevation of the direct serum bilirubin fraction and therefore the presence of liver disease.
Increased serum bilirubin levels occur when an imbalance exists between bilirubin production and clearance.
Types of Jaundice
Haemolytic Jaundice Results from increased destruction of red blood cells or their precursor in the marrow, causing increased bilirubin production.
Hepatocellular Jaundice Results from an inability of the liver to transport bilirubin into the bile, occurring as a result of parenchymal liver diseases. Hepatocellular diseases that can cause jaundice include viral hepatitis, drug or environmental toxicity, alcohol, and end-stage cirrhosis from any cause.
Cholistatic Jaundice When the pattern of the liver tests suggests a cholestatic disorder, the next step is to determine whether it is intra- or extrahepatic cholestasis. In the USG the absence of biliary dilatation suggests intrahepatic cholestasis, while the presence of biliary dilatation indicates extrahepatic cholestasis. Intrahepatic causes include primary
biliary cirrhosis, alcohol, drugs, viral hepatitis, autoimmune hepatitis, pregnancy etc.
Extrahepatic can be caused by choledocholithiasis , pancreatic, gallbladder, ampullary, and cholangiocarcinoma, cystic fibrosis and parasitic infection.
Cholestasis of pregnancy caused probably due to an inherited susceptibility of the patients liver cells to oestrogen. Pruritus is the dominant symptom and jaundice occurs in about half of the patients.
Itching almost always starts in the third trimester and remits within about 2 weeks of delivery, condition tends to recur in subsequent pregnancies.
Jaundice of newborn children must not be confounded with the slight yellowish discolouration of the skin, which, in most children, is seen a few days after birth and is nothing but a change of colour of the haematin, which, in consequence of the great hypreaemia of the skin after birth, becomes deposited in the skin. In such cases the yellow colour of the white of eye is absent.
A complete medical history is perhaps the single most important part of the evaluation of the patient with unexplained jaundice. Important considerations include the use of or exposure to any chemical or medication, either physician-prescribed or over-the-counter, such as herbal and vitamin preparations and other drugs such as anabolic steroids.
The patient should be carefully questioned about possible parenteral exposures, including transfusions, intravenous and intranasal drug use, tattoos, and sexual activity.
Other important questions include recent travel history, exposure to people with jaundice, exposure to possibly contaminated foods, occupational exposure to hepatotoxins, alcohol consumption, the duration of jaundice, and the presence of any accompanying symptoms such as arthralgias, myalgias, rash, anorexia, weight loss, abdominal pain, fever, pruritis, and changes in the urine and stool. While none of these latter symptoms are specific for any one condition, they can suggest a particular diagnosis.
Physical Examination The general assessment should include assessment of the patient's nutritional status. Temporal and proximal muscle wasting suggests longstanding diseases such as pancreatic cancer or cirrhosis. Stigmata of chronic liver disease, including spider nevi, palmar erythema, gynecomastia, caput medusae, Dupuytren's contractures, parotid gland enlargement, and testicular atrophy are commonly seen in advanced alcoholic (Laennec's) cirrhosis and occasionally in other types of cirrhosis.
An enlarged left supraclavicular node (Virchow's node) or periumbilical nodule (Sister
Mary Joseph's nodule) suggest an abdominal malignancy. Jugular venous distention, a sign of right-sided heart failure, suggests hepatic congestion. Right pleural effusion, in the absence of clinically apparent ascites, may be seen in advanced cirrhosis.
The abdominal examination should focus on the size and consistency of the liver, whether the spleen is palpable and hence enlarged, and whether there is ascites present. Patients with cirrhosis may have an enlarged left lobe of the liver which is felt below the xiphoid and an enlarged spleen.
A grossly enlarged nodular liver or an obvious abdominal mass suggests malignancy. An enlarged tender liver could be viral or alcoholic hepatitis or, less often, an acutely congested liver secondary to right-sided heart failure. Severe right upper quadrant tenderness with respiratory arrest on inspiration (Murphy's sign) suggests cholecystitis or, occasionally, ascending cholangitis. Ascites in the presence of jaundice suggests either cirrhosis or malignancy with peritoneal spread.
Here are few clinical clues according to symptom for assessing disease and patient condition.
1. Jaundice occurring suddenly in apparent health , and painlessly, is usually of emotional origin and transitory.
2. When it depends on disease or injury of brain, acute atrophy of liver, snake poisoning, or infectious fever, it is always associated with mental disturbances.
3. If it be attended with fever and well marked, it is secondary to inflammation of biliary passages, pneumonia, toxemia, or infective inflammation of the portal vein.
4. If it occurs suddenly and is preceded by paroxysmal pain and vomiting, it is caused nine times out of ten by biliary calculi.
5. Impassable obstruction of the common bile duct is shown by great intensity of jaundice, clay colored stools, and in recent cases by distention of the gall bladder.
6. Jaundice caused by sudden obstruction of the biliary passages is always associated with paroxysmal pain and nausea. In the rare cases of sudden obstruction by cancerous, hydatid and aneurismal tumors, there is almost always a history of impaired health, enlargement and deformity of the liver, ascitis etc. In theses cases USG is must and may pin point the disease.
7. Sudden return of normal colouration of stool confirms the diagnosis of obstruction.
8. Occlusion of the cystic duct may be attended with as much pain, nausea and distension of gall bladder as occlusion of the common duct, but there is no jaundice. In occlusion of the hepatic duct, the same symptoms are present, including jaundice and excluding distension of gall bladder.
9. A history of repeated attacks points to the probability of gall stone.
10. Slight but persistent jaundice may be due to incomplete occlusion of the common bile duct, or the complete occlusion of branch of the hepatic ducts.
11. If ascitis be associated with it, the disease is either cirrhosis or cancer of the liver; if the liver be abnormally small, the disease is cirrhosis; if it be large, the disease is either hypertrophic cirrhosis or cancer.
12. Absence of jaundice does not imply absence of hepatic disease; since the liver may be destroyed by disease or extirpated by operation without jaundice ensuing.
A detailed history of patient should be taken including previous illness, mental disposition and general symptoms. Below are some clinical rubrics from Synthesis Repertory 9.1. These are mostly general rubric but must not be utilized as eliminating rubrics. These can be used as additional confirmation of remedy. Besides these rubrics any particular and general rubrics may be considered.
[color=#0000FF]1- EYE - DISCOLORATION - yellow
2 -MOUTH - DISCOLORATION - Tongue - white
3 -MOUTH - TASTE - bitter
4 -MOUTH - TASTE - sour
5 -EXTERNAL THROAT - SWELLING - Cervical Glands
6 -STOMACH - APPETITE - wanting
7 -STOMACH - VOMITING - heat - during
8-ABDOMEN - ATROPHY - Liver
9 -ABDOMEN - ENLARGED - Liver
10-ABDOMEN - ENLARGED - Spleen
11-ABDOMEN - INFLAMMATION - Liver
12-ABDOMEN - PAIN - Liver
13-ABDOMEN - PAIN - Liver - sore
14 -RECTUM - CONSTIPATION
15 -RECTUM - DIARRHEA
16-STOOL - CLAY COLORED
17-STOOL - GRAY
18 -STOOL - LIGHT COLORED
19 -STOOL - WHITE
20 -URINE - BILE, containing
21-URINE - SCANTY
22 -SLEEP - SLEEPINESS - heat - during
23 -FEVER - CHILL; with
24 -SKIN - DISCOLORATION - yellow
25 -SKIN - ITCHING
26 -SKIN - ITCHING - jaundice; during
27 -SKIN - NETWORK of blood vessels
28 -GENERALS - SWELLING - Glands; of Therapeutics Of Jaundice
Acon Great unquenchable thirst, pain changing about from stomach to liver, during pregnancy; in newborn children; after fright.
Arsenic In different liver affections, in consequence of intermittent fevers; heat, restlessness, anxiety, irritable mood alternating with low spiritedness.
Berberis Spells of icterus. Very valuable for hepatic diseases; with indigestion, eructations, salivation, heartburn, vomiting of food after eating. Soreness in the region of the liver. Bilious colic, colic from gall-stones, with jaundice.
Bryonia there are sharp, stitching pains in the liver, worse from motion, relieved by lying on the right side; jaundice from duodenal catarrh or when caused by anger indicates it.
Card.Mar.In complication with gall stone. Swelling of gall bladder with tenderness; stools hard, difficult, knotty, alternates with bright yellow diarrhoea.Jaundice with intolerable itching, when lying down at night.
Cham After chagrin, imprudent diet; in newborn children.
Chelidonium The jaundiced skin, and especially the constant pain under inferior angle of right scapula, are certain indications. In affections of the liver, where there is a great deal of pain and soreness in the region of that organ; jaundice; yellow tongue, taking the imprint of the teeth; bitter taste and craving for sour things. Fatty liver; painful enlargement of liver; gall stones; bilious condition in general.
China Gastro-duodenal catarrh, ending in jaundice, particularly after great loss of animal fluids or after heavy illness. Old liver subjects with jaundice. After meals there is a sensation of weight or of a lump behind the middle of the sternum.
Flatulent distension of the belly may be extremes as tight as a drum, and this is accompanied by sour eructations and loud belchings which afford no relief. Nor does the passage of flatus give any relief. Flatulence also accompanies liver and gall-bladder complaints. Jaundice is common. Gall stone colic. Yellow coating of tongue.
Digitalis Excessive jaundice, with slow weak heart and ashy-white stools. Jaundice, with slow pulse, with uneasiness in the liver, pale stool. Jaundice from cardiac troubles, with white, ashy stools; liver enlarged, sore and bruised; bitter taste; tongue clean or whitish yellow; slow pulse; drowsiness; high-colored urine, jaundice due to functional imperfections of the
Hydrastis Gastroduodinal catarrh; sense of sinking and prostration at epigastrium. The skin is jaundiced; the stool is light, even white, showing the absence of bile, and there is distress in the region of the liver. Colic, gallstone.
Kali Carb Swelling of the liver; stitch pain in the right side of the chest through to shoulder; pressive, sprained pain in the liver; can lie only on the right side.
Lach There is lowered coagulability with liability to sub-cutaneous haemorrhages : great destruction of red blood corpuscles which may give rise to haemotogenous jaundice. Enlarged liver of drunkards, going on to a low grade of symptoms with inflammation and abscess of liver, jaundice, tenderness to pressure all the time ( Lyco. only after meal), intolerance of clothing; constant urging in anus, but no stool follows or extremely offensive stools.
Leptandra Great prostration, stupor, heat and dryness of skin,coldness of the extremities, dark, foetid, tarry, or watery stools mixed with bloody mucus, and a jaundiced skin. Full aching pain in the region of gall bladder.
Lyco The remedy is often indicated when the liver is affected with local tenderness in the right hypochondrium and, possibly, evident jaundice. Also when there are recurrent bilious attacks or actual bile duct spasm.Hepatitis, especially of children (? with pneumonia). Jaundice with flatulence.
Mag Mur Liver : enlarged; congested and face and eyes yellow, jaundice, stool gray, feet and legs swell, urine scanty and high color, constipation; worse lying on right side; or, sour vomiting, breath offensive, face yellow, constipation; or, abdomen bloated, tongue large and coated yellow Merc Jaundice of newborn children. Flabby tongue with imprint of teeth. Soreness in the region of liver; gall stone.
Myrica These are the distinctive features : Aching pain in liver, fulness, drowsiness, despondency, dull, heavy headache, agg. in morning, dirty, dingy, yellowish white of eyes, lids abnormally red, weakness, ash-coloured stools, slow pulse, pains under scapulae (agg. left), dirty yellow tongue, muscular soreness, aching in limbs, jaundice of all degrees. It is in cases attended with jaundice that Myrica has had the greatest success, cases of black jaundice having been cured with it, and it meets the itching of jaundice as well.
Nux Vom -Jaundice from anger (Cham.), high living. There may even be definite enlargement of the liver with a constant feeling of distension in the upper abdomen; and actual attacks of jaundice and even the development of gallstones, with acute hepatic colic.
Phos Diffuse hepatitis.Hyperaemia and enlargement of liver.Liver hard, large, with subsequent atrophy.Hepatitis when suppuration ensues, hectic fever, night sweats, marked soreness over liver (Hepar, Hipp. Lach., Crot. h., Sil.).Jaundice.
Pale stools. Abdomen tympanitic.Hepatic congestion, quantities of bright or dark blood discharged with stool.Craves cold food and drink: ice cream: wine."Bad effects from excessive use of salt”. AA characteristic symptom : as soon as water becomes warm in stomach it is vomited.
Podo In complication with gall stone. Pain extends from region of stomach towards the region of gall bladder. Soreness about the liver. Torpidity of the liver; portal engorgement with a tendency to haemorrhoids, hypogastric pain, fullness of superficial veins, jaundice.
Sulph This is one of the most commonly indicated drugs in jaundice of children - acute catarrhal jaundice - particularly with the marked intolerance that SULPHUR has to milk in its acute conditions, intense skin irritation, feeling of burning heat on the surface very often with attacks of colic, frequently with attacks of diarrhoea. In psoric persons with or withot hardness and swelling of liver.
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