What are the management options for jaundice?

Management of Jaundice

The management of jaundice requires a systematic approach based on determining the underlying cause, with treatment strategies differing significantly between neonatal and adult presentations. 1, 2

Diagnostic Approach

Initial Assessment

• Determine if jaundice is due to:
  • Prehepatic causes (hemolysis, hematoma resorption)
  • Intrahepatic disorders (hepatocellular dysfunction)
  • Posthepatic causes (biliary obstruction) 3

Laboratory Evaluation

• First-line tests:
  • Urine bilirubin (indicates conjugated hyperbilirubinemia)
  • Total and fractionated bilirubin levels
  • Complete blood count
  • Liver function tests (AST, ALT, GGT, alkaline phosphatase)
  • Albumin, prothrombin time, INR 2

Imaging

• Abdominal ultrasonography (first-line for suspected biliary obstruction)
• CT with intravenous contrast (for suspected malignancy)
• MR cholangiography (for detailed biliary tract visualization)
• Consider endoscopic retrograde cholangiography for therapeutic intervention in biliary obstruction 1, 2

Management of Neonatal Jaundice

Phototherapy

• Initiate phototherapy based on AAP nomogram thresholds considering:

  • Age of infant in hours
  • Gestational age
  • Presence of risk factors (positive Coombs test, G6PD deficiency) 1

• For intensive phototherapy:

  • Use special blue fluorescent tubes or LED light (425-475 nm wavelength)
  • Target irradiance level >30 mW/cm² per nm
  • Maximize exposed surface area (lights above and fiber-optic pad below)
  • Line bassinet sides with aluminum foil to increase exposure 1

Monitoring During Treatment

• Measure TSB every 8-12 hours until levels clearly decline
• Continue phototherapy until bilirubin falls below treatment threshold
• Check TSB 8-12 hours after discontinuing phototherapy
• Consider additional measurement the following day to ensure continued decline 1

Advanced Interventions

• Consider IVIG (0.5-1 g/kg over 2 hours) if:

  • TSB rising despite intensive phototherapy
  • TSB within 2-3 mg/dL of exchange transfusion threshold 1

• Prepare for exchange transfusion if:

  • TSB ≥25 mg/dL (428 μmol/L)
  • TSB reaches exchange level per AAP guidelines 1

Management of Adult Jaundice

Treatment Based on Etiology

1. Prehepatic causes (unconjugated hyperbilirubinemia):

   • Address underlying hemolytic disorders
   • Discontinue offending medications 4, 5

2. Intrahepatic causes:

   • Alcoholic liver disease: alcohol cessation, nutritional support
   • Viral hepatitis: antiviral therapy when indicated
   • Drug-induced liver injury: discontinue offending agent
   • Autoimmune hepatitis: immunosuppressive therapy 4, 2

3. Posthepatic causes (conjugated hyperbilirubinemia):

   • Choledocholithiasis: endoscopic stone removal
   • Biliary strictures: endoscopic or surgical intervention
   • Malignancies: surgical resection, chemotherapy, radiation, or palliative biliary drainage 1, 3

Special Considerations

Risk Factors Requiring Closer Monitoring

• G6PD deficiency (can cause sudden bilirubin increases)
• Gestational age 37-38 weeks
• Hemolytic conditions
• Congenital porphyria (contraindication to phototherapy)
• Concomitant use of photosensitizing drugs 1

Follow-up Care

• For neonates:

  • Schedule follow-up within 24-48 hours after discharge based on risk assessment
  • Check hemoglobin levels at 2-4 weeks, especially with rare antibodies 1

• For adults:

  • Regular monitoring of liver function until resolution
  • Frequency depends on severity and underlying cause 5, 2

Common Pitfalls to Avoid

• Failing to distinguish between physiologic and pathologic jaundice
• Inadequate monitoring of bilirubin levels in high-risk cases
• Overlooking rebound hyperbilirubinemia after discontinuing phototherapy
• Delaying intervention for biliary obstruction, which can lead to cholangitis
• Not recognizing critical illness requiring immediate intervention 1, 6