What are the treatment options for jaundice?

Treatment Options for Jaundice

The treatment of jaundice must be tailored to the underlying cause, with initial imaging via ultrasound, CT, or MRI to differentiate between obstructive and non-obstructive etiologies. 1, 2

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Laboratory assessment:

   • Fractionated bilirubin (total, direct/conjugated, indirect/unconjugated)
   • Liver enzymes (ALT, AST, alkaline phosphatase, GGT)
   • Complete blood count
   • Coagulation studies (PT/INR)
   • Albumin and total protein 2

2. Initial imaging:

   • Ultrasound is the first-line imaging modality (sensitivity 65-95% for cirrhosis, 32-100% for biliary obstruction)
   • If biliary dilation is present, proceed to MRCP or CT with contrast 1, 2

Treatment Based on Etiology

1. Obstructive Jaundice

• Biliary obstruction due to stones:

  • Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction
  • Biliary stenting if complete extraction is not possible 1

• Malignant biliary obstruction:

  • Biliary drainage via endoscopic or percutaneous approaches
  • Stent placement (metal or plastic depending on prognosis)
  • Management of underlying cancer (surgery, chemotherapy, radiation) 1, 3

• Primary sclerosing cholangitis:

  • Management of complications
  • Consideration of liver transplantation for end-stage disease 2

2. Hepatocellular Jaundice

• Viral hepatitis:

  • Antiviral therapy for hepatitis C with direct-acting antivirals 2
  • Supportive care for hepatitis A and E
  • Antiviral therapy for hepatitis B in appropriate cases

• Alcoholic liver disease:

  • Alcohol abstinence
  • Nutritional support (35-40 kcal/kg/day, protein 1.2-1.5 g/kg/day)
  • Corticosteroids for severe alcoholic hepatitis (Maddrey discriminant function ≥32) 2

• Autoimmune hepatitis:

  • Prednisolone (starting at 1 mg/kg/day) with or without azathioprine (1-2 mg/kg/day)
  • Maintenance therapy with azathioprine after biochemical remission 2

• Primary biliary cholangitis:

  • Ursodeoxycholic acid (UDCA) at 13-15 mg/kg/day 2

• Drug-induced liver injury:

  • Discontinuation of the offending agent
  • Supportive care 4

3. Neonatal Jaundice

• Physiological jaundice:

  • Phototherapy for bilirubin levels exceeding treatment thresholds
  • Adequate hydration and feeding 1, 5

• Pathological jaundice:

  • Phototherapy
  • Exchange transfusion for severe cases
  • Treatment of underlying cause (e.g., hemolysis, infection) 1, 6

• Prolonged jaundice:

  • Measurement of conjugated bilirubin to rule out biliary atresia
  • Appropriate referral for surgical intervention if biliary atresia is confirmed 5

4. Wilson Disease

• Pharmacological therapy:

  • Penicillamine, trientine, or zinc for copper chelation
  • Lifelong therapy required 1

• Liver transplantation:

  • Reserved for severe or resistant cases
  • Corrects the underlying hepatic defect 1

Management of Complications

• Pruritus:

  • Cholestyramine, rifampicin, naltrexone, or sertraline for cholestatic pruritus 2

• Coagulopathy:

  • Vitamin K supplementation
  • Fresh frozen plasma for severe cases 2

• Nutritional deficiencies:

  • Supplementation of fat-soluble vitamins (A, D, E, K) 2

• Hepatic encephalopathy:

  • Lactulose
  • Rifaximin for recurrent episodes
  • Protein restriction in severe cases 2

Advanced Treatment Options

• Liver transplantation indications:

  • End-stage liver disease
  • Acute liver failure without improvement within 7 days
  • Intractable pruritus refractory to medical therapy
  • Hepatocellular carcinoma within transplant criteria 2

• Local ablative therapies for hepatocellular carcinoma:

  • Radiofrequency ablation
  • Stereotactic body radiotherapy for tumors ≤3 cm 1

Preventive Measures

• Hepatitis A and B vaccination for susceptible patients
• Regular screening for hepatocellular carcinoma in cirrhotic patients
• Regular colonoscopy for PSC patients with ulcerative colitis 2

Treatment Algorithm

1. Determine if jaundice is obstructive or non-obstructive through imaging
2. Identify specific etiology through laboratory tests and additional imaging
3. Implement targeted therapy based on underlying cause
4. Manage complications and provide supportive care
5. Consider advanced options (transplantation) for end-stage disease

Remember that early diagnosis and prompt treatment are crucial to prevent progression of liver disease and improve outcomes.