Treatment of Jaundice
The treatment of jaundice must be directed at the underlying cause, with initial diagnostic evaluation including laboratory tests and imaging studies to differentiate between obstructive and non-obstructive etiologies. 1
Diagnostic Evaluation
Initial Laboratory Assessment
- Total and direct (conjugated) bilirubin
- Liver enzymes: AST, ALT, alkaline phosphatase, GGT
- Complete blood count
- Coagulation studies (PT/INR)
- Albumin and total protein
- Renal function tests
Initial Imaging
- Abdominal ultrasound is the first-line imaging modality to differentiate between obstructive and non-obstructive causes 2, 1
- Sensitivity of 65-95% for detecting cirrhosis and 32-100% for biliary obstruction 1
Treatment Algorithm Based on Etiology
1. Obstructive Jaundice
If biliary dilation is present on ultrasound:
- Next imaging step: MR cholangiopancreatography (MRCP) or CT with contrast 1
- Treatment options:
2. Non-Obstructive Jaundice
Viral Hepatitis
- Antiviral therapy for hepatitis B and C based on genotype and prior treatment history 1
- Supportive care for hepatitis A and E
Alcoholic Liver Disease
- Alcohol abstinence is the cornerstone of therapy 2, 1
- Nutritional support (35-40 kcal/kg/day and protein 1.2-1.5 g/kg/day) 1
- For severe alcoholic hepatitis (Maddrey DF ≥32): Consider corticosteroids 2, 1
Autoimmune Hepatitis
- Initial therapy with prednisolone (1 mg/kg/day) with or without azathioprine (1-2 mg/kg/day) 1
- Maintenance therapy with azathioprine after biochemical remission 1
Primary Biliary Cholangitis
- Ursodeoxycholic acid (UDCA) at 13-15 mg/kg/day 1, 3
- Dosing typically divided into 2-3 doses per day 3
Primary Sclerosing Cholangitis
- Management of complications and consideration of liver transplantation 1
Neonatal Jaundice
- Phototherapy for physiological jaundice 2, 4
- For jaundice in first 24 hours: Measure TcB and/or TSB 2
- For severe hyperbilirubinemia: Consider exchange transfusion 2
Supportive Care and Prevention of Complications
Nutritional Support
- Ensure adequate caloric and protein intake 1
- Supplement fat-soluble vitamins (A, D, E, K) in cholestatic liver disease 1
Management of Pruritus
- Cholestyramine, rifampicin, naltrexone, or sertraline for cholestatic pruritus 1
Coagulopathy Management
- Vitamin K supplementation for coagulopathy associated with jaundice 1
Prevention of Complications
- Screening for hepatocellular carcinoma in cirrhotic patients 1
- Vaccination against hepatitis A and B in susceptible patients 1
Liver Transplantation Considerations
Consider liver transplantation evaluation for:
- End-stage liver disease when medical therapies fail 1
- Acute liver failure without improvement within 7 days of optimal medical treatment 1
- Intractable pruritus refractory to medical therapy in PBC 1
- End-stage PSC 1
- Hepatocellular carcinoma within transplant criteria 1
Important Caveats and Pitfalls
- Jaundice appearing in the first 24 hours of life requires immediate evaluation 2
- Sick infants and those jaundiced beyond 3 weeks should have measurement of total and direct bilirubin to identify cholestasis 2
- Visual estimation of jaundice can lead to errors, particularly in darkly pigmented individuals 2
- Failure to recognize obstructive jaundice can lead to delayed treatment and poor outcomes 5, 6
- Jaundice is an alarm symptom that should always be treated urgently 7
- When imaging does not yield a cause for jaundice, liver biopsy may be necessary for diagnosis 2
The management of jaundice requires prompt recognition of the underlying cause and appropriate treatment to prevent complications and improve outcomes. The approach should be systematic, starting with differentiation between obstructive and non-obstructive causes, followed by targeted therapy for the specific etiology.