What is jaundice or Hepatitis?

• What is jaundice or Hepatitis?
• Babies with Jaundice 
• What causes jaundice? 
• Treatments

Jaundice means the yellow appearance of the skin and whites of the eyes that occurs when the blood contains an excess of the pigment called bilirubin.
Bilirubin is a natural product arising from the normal breakdown of red blood cells in the body and is excreted in the bile, through the actions of the liver.
Although jaundice is most often the result of a disorder affecting the liver, it can be caused by a variety of other conditions affecting, for example, the blood or spleen. It should be thoroughly investigated, so that the underlying cause can be identified and treated.

How does a person get jaundice?

The red blood cells in our circulation carry oxygen to all parts of the body and have a life span of about 120 days. At the end of their life, they are broken down and removed from the circulation by special cells called phagocytes, which are found within the bone marrow, spleen and liver.

New red blood cells are of course continually manufactured, and this also takes place within the bone marrow.

Following breakdown of the red blood cells some of their component parts – such as amino acids and iron – can be re-used by the body. Other components such as bilirubin need to be removed.

Knowing how this removal pathway works is the key to understanding how jaundice occurs.

Most waste products of the body are excreted in the urine via the kidneys, but the liver and bile system is the other main physical route out of the body for these substances.

By 'waste products', we mean the many compounds that arise in the course of the body's metabolism. But almost all forms of drugs must also be eliminated either via the urine or bile routes.

In the case of bilirubin released from old red blood cells, it passes through the bloodstream to the liver, where the liver cells process it.

These cells carry out many complex chemical functions and also produce the liquid bile that is the 'vehicle' by which the cells discharge their output to the bile duct system. This is a branching network of tiny tubes throughout the liver that merge in the same way as the branches of a tree.

Ultimately, a single main bile duct comes out of the liver and joins the first part of the small intestine (duodenum). Bile (and therefore bilirubin) then passes out through the small and large intestines and is excreted in the stool (faeces).

Bile is green in colour. But bacteria in the large bowel act to change the bilirubin to substances that are brown, which gives stool its characteristic colour.

Some of the bilirubin is reabsorbed back into the body through the bowel wall – eventually appearing in the urine as a substance called urobilinogen (although the typical yellow or orange colour of urine is in fact due a different pigment called urochrome).

Therefore, any failure of the bilirubin removal pathway will lead to a build-up of bilirubin in the blood. When this happens the individual's skin turns yellow – causing jaundice.

What conditions can be associated with jaundice?

An excessive breakdown of red blood cells

The balance between manufacture and breakdown of red blood cells is normally precisely balanced and equal. But there are several conditions in which the rate of breakdown increases. If the amount of bilirubin released exceeds the liver's capacity to remove it – jaundice will develop.

The medical term for excessive red cell breakdown is 'haemolysis', and within the developed world it's a fairly rare condition. Malaria is however a major cause in tropical climates because the malaria parasites live within the red blood cells and shorten their life.

Similarly, the condition in which a foetus develops haemolysis, due to incompatibility of its Rhesus blood group with that of its mother, is now rarely seen in the UK – where we routinely check for 'Rhesus antibodies' in the mother's blood. In parts of the world where antenatal care isn't as good, haemolytic disease of the newborn is more common.

A temporary jaundice of newborn babies is however quite common, due to the relative immaturity of the baby's liver cells and the higher than normal rate of cell breakdown that occurs in the first few weeks of life.

It improves rapidly without treatment, although when too high it can be speeded up by exposing the baby to ultraviolet light. Jaundice of the newborn is commoner in premature babies because their liver is even more immature than a baby born at term.

Autoimmune haemolytic anaemia is a rare disease in which the body's immune system seems to attack the red cells. It usually affects adults.

Haemolysis can also be a side-effect of some drugs,

What causes jaundice?

Babies with Jaundice 

Treatments

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What causes jaundice?

Bilirubin comes from red blood cells. When red blood cells get old, they are destroyed. Hemoglobin, the iron-containing chemical in red blood cells that carries oxygen, is released from the destroyed red blood cells after the iron it contains is removed. The chemical that remains in the blood after the iron is removed becomes bilirubin.


The liver has many functions. One of the liver's functions is to produce and secrete bile into the intestines to help digest dietary fat. Another is to remove toxic chemicals or waste products from the blood, and bilirubin is a waste product. The liver removes bilirubin from the blood. After the bilirubin has entered the liver cells, the cells conjugate (attaching other chemicals, primarily glucuronic acid) to the bilirubin, and then secrete the bilirubin/glucuronic acid complex into bile. The complex that is secreted in bile is called conjugated bilirubin. The conjugated bilirubin is eliminated in the feces. (Bilirubin is what gives feces its brown color.) Conjugated bilirubin is distinguished from the bilirubin that is released from the red blood cells and not yet removed from the blood which is termed unconjugated bilirubin.


Jaundice occurs when there is 1) too much bilirubin being produced for the liver to remove from the blood. (For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood), 2) a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile, or 3) blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. (For example, the bile ducts can be blocked by cancers, gallstones, or inflammation of the bile ducts). The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

What diseases cause jaundice? 


Increased production of bilirubin 


There are several uncommon conditions that give rise to over-production of bilirubin. The bilirubin in the blood in these conditions usually is only mildly elevated, and the resultant jaundice usually is mild and difficult to detect. These conditions include: 1) rapid destruction of red blood cells (referred to as hemolysis), 2) a defect in the formation of red blood cells that leads to the over-production of hemoglobin in the bone marrow (called ineffective erythropoiesis), or 3) absorption of large amounts of hemoglobin when there has been much bleeding into tissues (e.g., from hematomas, collections of blood in the tissues).

Acute inflammation of the liver 


Any condition in which the liver becomes inflamed can reduce the ability of the liver to conjugate (attach glucuronic acid to) and secrete bilirubin. Common examples include acute viral hepatitis, alcoholic hepatitis, and Tylenol-induced liver toxicity.



Chronic liver diseases 


Chronic inflammation of the liver can lead to scarring and cirrhosis, and can ultimately result in jaundice. Common examples include chronic hepatitis B and C, alcoholic liver disease with cirrhosis, and autoimmune 





Infiltrative diseases of the liver 


Infiltrative diseases of the liver refer to diseases in which the liver is filled with cells or substances that don't belong there. The most common example would be metastatic cancer to the liver, usually from cancers within the abdomen. Uncommon causes include a few diseases in which substances accumulate within the liver cells, for example, iron (hemochromatosis), alpha-one antitrypsin (alpha-one antitrypsin deficiency), and copper (Wilson's disease).






Inflammation of the bile ducts 


Diseases causing inflammation of the bile ducts, for example, primary biliary cirrhosis or sclerosing cholangitis and some drugs, can stop the flow of bile and elimination of bilirubin and lead to jaundice.





Blockage of the bile ducts 


The most common causes of blockage of the bile ducts are gallstones and pancreatic cancer. Less common causes include cancers of the liver and bile ducts.

Drugs 


Many drugs can cause jaundice and/or cholestasis. Some drugs can cause liver inflammation (hepatitis) similar to viral hepatitis. Other drugs can cause inflammation of the bile ducts, resulting in cholestasis and/or jaundice. Drugs also may interfere directly with the chemical processes within the cells of the liver and bile ducts that are responsible for the formation and secretion of bile to the intestine. As a result, the constituents of bile, including bilirubin, are retained in the body. The best example of a drug that causes this latter type of cholestasis and jaundice is estrogen. The primary treatment for jaundice caused by drugs is discontinuation of the drug. Almost always the bilirubin levels will return to normal within a few weeks, though in a few cases it may take several months

Genetic disorders 

There are several rare genetic disorders present from birth that give rise to jaundice. Crigler-Najjar syndrome is caused by a defect in the conjugation of bilirubin in the liver due to a reduction or absence of the enzyme responsible for conjugating the glucuronic acid to bilirubin. Dubin-Johnson and Rotor's syndromes are caused by abnormal secretion of bilirubin into bile. 


The only common genetic disorder that may cause jaundice is Gilbert's syndrome which affects approximately 7% of the population. Gilbert's syndrome is caused by a mild reduction in the activity of the enzyme responsible for conjugating the glucuronic acid to bilirubin. The increase in bilirubin in the blood usually is mild and infrequently reaches levels that cause jaundice. Gilbert's syndrome is a benign condition that does not cause health problems.






Developmental abnormalities of bile ducts 


There are rare instances in which the bile ducts do not develop normally and the flow of bile is interrupted. Jaundice frequently occurs. These diseases usually are present from birth though some of them may first be recognized in childhood or even adulthood. Cysts of the bile duct (choledochal cysts) are an example of such a developmental abnormality. Another example is Caroli's diseas

Jaundice of pregnancy 


Most of the diseases discussed previously can affect women during pregnancy, but there are some additional causes of jaundice that are unique to pregnancy




Cholestasis of pregnancy. 


Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis is often accompanied by itching but infrequently causes jaundice. The itching can be severe, but there is treatment (ursodeoxycholic acid or ursodiol). Pregnant women with cholestasis usually do well although they may be at greater risk for developing gallstones. More importantly, there appears to be an increased risk to the fetus for developmental abnormalities. Cholestasis of pregnancy is more common in certain groups, particularly in Scandinavia and Chile, and tends to occur with each additional pregnancy. There also is an association between cholestasis of pregnancy and cholestasis caused by oral estrogens, and it has been hypothesized that it is the increased estrogens during pregnancy that are responsible for the cholestasis of pregnancy






Pre-eclampsia. Pre-eclampsia,


 previously called toxemia of pregnancy, is a disease that occurs during the second half of pregnancy and involves several systems within the body, including the liver. It may result in high blood pressure, fluid retention, and damage to the kidneys as well as anemia and reduced numbers of platelets due to destruction of red blood cells and platelets. It often causes problems for the fetus. Although the bilirubin level in the blood is elevated in pre-eclampsia, it usually is mildly elevated, and jaundice is uncommon. Treatment of pre-eclampsia usually involves delivery of the fetus as soon as possible if the fetus is mature.

Acute fatty liver of pregnancy.

 Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy of unclear cause that often is associated with pre-eclampsia. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but not always present in AFLP. Treatment usually involves delivery of the fetus as soon as possible.

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Babies with Jaundice

Jaundice tends to be more common in breastfed babies and to last a bit longer. In most cases, it's harmless, but jaundice phobia on the part of parents and healthcare providers often creates obstacles to successful breastfeeding. Here's some background on jaundice and ways to minimize interference with breastfeeding.

WHAT IS NEWBORN JAUNDICE?


Jaundice (also known as hyperbilirubinemia) is the cause of the yellow tinge that colors the skin and eyeballs of newborn infants, especially in the first week or two. Jaundice happens because babies are born with more red blood cells than they need. When the liver breaks down these excess cells it produces a yellow pigment called bilirubin. Because the newborn's immature liver can't dispose of bilirubin quickly, the excess yellow pigment is deposited in the eyeballs and skin of the newborn.


This kind of a jaundice is called physiologic jaundice, because it is part of a normal body process. Once the newborn's bilirubin-disposal system matures and the excess red blood cells diminish, the jaundice subsides – usually within a week or two – and causes baby no harm. Jaundice is more common in premature infants, who are less able to cope with excess bilirubin.


In some situations, such as an incompatibility of blood types between mother and baby, jaundice may be the result of problems that go beyond the normal breakdown of excess red blood cells. In rare instances, the bilirubin levels can rise high enough to damage baby's brain. For this reason, if the healthcare provider suspects that something more than normal physiologic jaundice is the cause of baby's yellow color, bilirubin levels will be monitored more closely, using blood samples. If the bilirubin level gets too high, your doctor may try to lower the bilirubin level using phototherapy, special lights which dissolve the extra bilirubin in the skin, allowing it to be excreted in the urine.

WHY IS JAUNDICE A PROBLEM FOR BREASTFEEDING BABIES?


Bilirubin levels average 2-3 milligrams higher in breastfed infants than in formula-fed infants (14.8 milligrams versus 12.4 milligrams). The difference is thought to be due to an as-yet unidentified factor in breastmilk that promotes increased intestinal absorption of bilirubin, so that it goes back into the bloodstream rather than moving on to the liver. Higher rates of jaundice in breastfed infants may also be related to lower milk intakes in the first days after birth, because of infrequent or inefficient feeding. It is normal for jaundice to last a bit longer in breastfeeding infants, sometimes until the third week after birth.


While most newborn jaundice is harmless, common medical remedies for jaundice can interfere with getting breastfeeding off to a good start. Therefore, healthcare providers and parents should be cautious about treating a condition in which the cure can create more problems than the disease. Watch out for what we call the "yellow flags" that signal an overreaction to jaundice in the breastfeeding baby.

• In most cases, it is not necessary to treat jaundice when bilirubin levels are less than 20 milligrams.
• Most jaundiced infants do not need supplements of water, sugar water or formula.
• Avoiding breastfeeding for a day or two is not usually necessary to bring down bilirubin levels.
• Shake off any suggestion that something about your milk is bad for your baby. As long as your baby is otherwise healthy, jaundice is short-lived and harmless. If your baby's jaundice is related to other health problems, your milk is very valuable for him and you should continue to breastfeed.

WHAT TO DO ABOUT JAUNDICE?

• Lowering baby's bilirubin levels also helps to lower the worry level of both parents and healthcare providers. The things you do to get breastfeeding off to a good start will also help you avoid problems with jaundice.

• Early, frequent, unrestricted breastfeeding helps to eliminate bilirubin from baby's body. Bilirubin exits the body in the infant's stools, and because breastmilk has a laxative effect, frequent breastfeeders tend to have lots of soiled diapers and thus, lower bilirubin levels.
• Be sure that your baby is latched on well and is sucking efficiently. See "Latch-on basics" and "Signs of efficient latch" for tips on getting baby to nurse well.
• Jaundice sometimes makes babies sleepy, so they nurse less enthusiastically. You may have to take the lead and wake your baby during the day to encourage her to nurse. See "Waking the sleepy baby" for suggestions.
• If phototherapy treatment is necessary because of a high bilirubin level, talk to your healthcare provider about alternatives to placing baby in the hospital nursery under phototherapy lights. For most babies a photo-optic bilirubin-blanket (phototherapy lights that wrap around the baby) works well. You can hold and breastfeed your baby at home while the lights dissolve the bilirubin.
• Giving breastfed babies bottles of sugar water in hopes of reducing bilirubin levels has been shown to be ineffective. It may even aggravate the jaundice, because babies whose tummies are full of glucose solutions may nurse less often, reducing their milk intake and the opportunities for bilirubin to be excreted in stools.
• If your doctor advises giving formula supplements to provide more fluids and calories and decrease the intestinal absorption of bilirubin, work with a lactation consultant to give supplements via a supplementary nursing system, syringe, or finger-feeding methods. See "Alternatives to bottles". This will avoid problems with nipple confusion.
• Don't worry, make milk. If your baby is jaundiced, be sure you understand what type of jaundice your baby has. If it's normal physiologic jaundice, you have absolutely nothing to worry about. If it's jaundice due to a medical cause, such as a blood group incompatibility, be sure you understand that this is easily treated and should not interfere with your breastfeeding. Worry may cause you to make less milk and doubt your ability to nourish your baby at the breast. This gets in the way of breastfeeding success.

PROLONGED JAUNDICE

In some breastfed babies, bilirubin levels may exceed 20 milligrams and jaundice may last well into the second week of life or longer. It was once thought that this was a distinct type of jaundice, called breast milk jaundice, that was found in a small group of mothers whose milk contained a substance believed to interfere with bilirubin absorption. Treatment for this type of jaundice involved taking baby off the breast for 24 to 48 hours. This brought bilirubin levels down, but sabotaged the course of breastfeeding.


More recent research suggests that high bilirubin levels and prolonged jaundice in otherwise healthy breastfed babies are just normal variants of ordinary physiologic newborn jaundice. There may well be a substance in the milk of most mothers that inhibits the absorption of bilirubin by the intestines, but whether a baby has a little jaundice or a lot is largely due to individual differences in both babies and mothers.


Nevertheless, some healthcare providers may suggest a period of temporary weaning (24 to 48 hours) to bring down bilirubin levels. Work with your doctor to determine if there are other alternatives, for example, phototherapy, that would allow breastfeeding to continue without restrictions. If you do decide to try formula for a day or two, be sure to pump your breasts every two to three hours so that you will continue to make milk and avoid a breast infection. Formula supplements can be given using alternatives to bottles, to avoid problems with nipple confusion when baby returns to the breast.

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jaundice or Hepatitis Treatment

What can your doctor do?

If you or one of your friends or relatives suspect that you may have jaundice, it's essential that you arrange to see your doctor in order that the underlying cause is identified and any possible treatment initiated as soon as possible.
Treatment will depend upon the diagnosis behind the symptom of jaundice. For example, if the problem is one of gallstones, removal of the gallbladder may be required.






Jaundice in newborns must be treated if it becomes severe as deposits can cause permanent brain damage. In all other cases, it is not the jaundice that needs to be treated but the underlying condition. When/if the condition resolves, then the jaundice will resolve as well. If an obstruction is present, surgery may be necessary.

Mild or moderate forms of jaundice will usually go away without specific treatment after five to seven days, as the baby's liver becomes more mature. In babies with higher levels of bilirubin, close monitoring — and possibly treatment — is needed.


Light therapy, also called phototherapy, is the usual treatment for jaundice. Phototherapy chemically breaks down the bilirubin in your baby's skin to non-toxic forms. During this treatment, your baby is placed under special white or blue light for one to two days. Their eyes will be covered to protect them from the bright lights.


If phototherapy isn't effective, and your baby's bilirubin levels continue to increase, a procedure known as an exchange transfusion may be necessary. During an exchange transfusion, the infant's blood is gradually removed and replaced with donor blood. This procedure removes bilirubin and lowers the bilirubin to safer, non-toxic levels.


What treatments are currently approved for HBV? 


 The good news is that there are sev-eral promising treatment options. Currently, there are seven FDA approved drugs in the U.S. to 

treat chronic HBV: 

•  Intron A (Interferon Alpha), 
• Pegasys (Pegylated Interferon),
•  Epivir HBV (Lamivudine), 
• Hepsera (Adefovir), 
• Baraclude (Entecavir), 
• Tyzeka (Telbivudine),
•  and Viread (Tenofovir).  

You and your doctor will need to discuss the treatment options before deciding which one is best for you.  
For many patients, these medications will decrease or stop hepatitis B virus reproduction. This results in 
patients feeling better within a month or two because liver damage from the virus iis slowed down, or even 
reversed in some cases. Although the FDA has approved these drugs for chronic hepatitis B, they do not 
provide a complete cure at this time. They do, however, significantly decrease the risk of progressive liver 
damage from the hepatitis B virus. To learn more about these approved drugs as well as the experimental 
drugs still being tested

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