What are the treatment approaches for jaundice?

Treatment Approaches for Jaundice

The treatment of jaundice requires first determining its underlying cause through appropriate diagnostic imaging and laboratory testing, followed by targeted interventions based on whether it is obstructive or non-obstructive in nature. 1, 2

Diagnostic Approach

Initial Laboratory Evaluation

• Obtain complete laboratory profile including total and fractionated bilirubin, complete blood count, liver enzymes (AST, ALT), alkaline phosphatase, gamma-glutamyltransferase, albumin, prothrombin time, and international normalized ratio 2
• Differentiate between conjugated (obstructive) and unconjugated (non-obstructive) hyperbilirubinemia to guide further management 1, 3
• For jaundice in the first 24 hours of life in neonates, measure total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) 1

Imaging Studies

• Abdominal ultrasound is the first-line imaging study for evaluating jaundice, with high sensitivity for detecting biliary obstruction (32-100%) and specificity (71-97%) 1
• CT abdomen with IV contrast or MRI abdomen with MRCP are equivalent alternatives for initial imaging of jaundice with no known predisposing conditions 1
• For suspected non-obstructive jaundice (medical, metabolic, or functional etiologies), options include CT abdomen with IV contrast, MRI abdomen with or without contrast with MRCP, or abdominal ultrasound 1

Treatment Based on Etiology

Obstructive Jaundice Treatment

• For choledocholithiasis (bile duct stones):

  • Endoscopic internal biliary catheter with removable plastic stent is the preferred initial therapeutic approach 1
  • ERCP with sphincterotomy and stone extraction is the standard treatment 1

• For malignant biliary obstruction:

  • Endoscopic biliary drainage is preferred in patients with coagulopathy due to lower bleeding risk (1-2%) 1
  • Percutaneous transhepatic biliary drainage (PTBD) is generally second-line when ERCP fails or is not possible 1
  • Decompression of obstructive biliary system improves overall quality of life compared to medical management alone 1

Non-Obstructive Jaundice Treatment

• For alcoholic hepatitis:

  • Abstinence from alcohol is the cornerstone of treatment 1
  • Patients with severe alcoholic hepatitis (Maddrey discriminant function >32 or MELD score >20) may be treated with methylprednisolone 32 mg daily if no contraindications exist 1
  • Patients with contraindications to glucocorticoids may receive pentoxifylline 400 mg three times daily 1
  • Ensure adequate nutrition with 1-1.5g protein and 30-40 kcal/kg body weight; consider feeding tube if patient cannot eat 1

• For neonatal jaundice:

  • Phototherapy is the primary treatment for hyperbilirubinemia in neonates 1, 4, 5
  • Blue-green spectrum light is most effective for phototherapy 1
  • Higher irradiance levels (>30 mW/cm² per nm) are required for intensive phototherapy 1
  • For breastfed infants, avoid routine supplementation with water or dextrose water as it does not prevent hyperbilirubinemia 1

Special Considerations

Infection Management

• Patients with jaundice, particularly those with alcoholic hepatitis, should have cultures of blood, urine, and ascites (if present) to rule out bacterial infections 1
• Infection often precedes development of acute kidney injury and multi-organ failure, which carries high mortality 1

Avoiding Complications

• Use caution when administering iodinated contrast in jaundiced patients due to increased risk of acute kidney injury 1
• Avoid nephrotoxic drugs including diuretics in patients with alcoholic hepatitis 1
• When imaging does not identify a cause for jaundice, liver biopsy may be necessary for definitive diagnosis 1, 2

Monitoring Response

• For patients receiving phototherapy, monitor bilirubin levels to assess treatment efficacy 1
• For patients with alcoholic hepatitis, monitor for development of systemic inflammatory response syndrome (SIRS), which increases risk of multi-organ failure 1