Jaundice in Adults: What Yellow Eyes Are Telling You
Yellowing of the eyes and skin is one of the few signs a person can spot in a mirror. It is also one of the most useful, because it narrows the possibilities quickly once you understand the mechanism.
Why it happens
Old red blood cells are broken down and their haemoglobin becomes bilirubin. Bilirubin travels to the liver, is processed into a water-soluble form, and is excreted into bile, then into the intestine, and finally out in stool, which is what gives stool its colour.
Jaundice appears when bilirubin builds up in the blood. It becomes visible in the whites of the eyes first, and typically at roughly double the upper limit of normal.
The build-up can happen at three points, and distinguishing which one is the whole diagnostic task.
The three mechanisms
Pre-hepatic: too much bilirubin is being produced.
Usually from accelerated breakdown of red cells. Haemolytic anaemia, sickle cell disease, thalassaemia, malaria, some drug reactions, and after a large internal bleed.
Here the bilirubin is unconjugated, the liver enzymes are normal, urine stays normal in colour, and stools stay normal.
Hepatic: the liver itself is not processing bilirubin.
Viral hepatitis A, B, C or E; alcohol-related liver disease; drug-induced liver injury, with paracetamol overdose the classic and anti-tuberculosis drugs, some antibiotics, antifungals, anti-epileptics and many herbal and traditional preparations also relevant; autoimmune hepatitis; cirrhosis of any cause; Wilson disease; and Gilbert syndrome, which is a harmless inherited variant.
Here liver enzymes ALT and AST rise, often markedly.
Post-hepatic: the bile cannot get out.
An obstruction below the liver. Gallstones in the common bile duct, cancer of the head of the pancreas, bile duct cancer, strictures, and pancreatitis causing compression.
Here the pattern is distinctive and recognisable without any test: dark urine, pale clay-coloured stools, and itching. Bilirubin that cannot reach the intestine spills into urine instead, and stools lose their colour.
Gilbert syndrome, because it causes unnecessary alarm
Gilbert syndrome affects a notable percentage of the population. A mild enzyme deficiency means bilirubin rises slightly during fasting, illness, dehydration, stress or lack of sleep, producing mild intermittent jaundice.
Everything else is normal: liver enzymes, blood count, scans. It causes no liver damage, needs no treatment, and does not shorten life. It is worth knowing you have it, because it otherwise triggers repeated investigation every time someone notices yellow eyes.
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The pattern on blood tests
A liver panel usually separates the mechanisms quickly.
- Unconjugated bilirubin raised, everything else normal: haemolysis or Gilbert syndrome
- ALT and AST markedly raised, bilirubin raised: liver cell injury, so hepatitis, drugs, alcohol or toxins
- Alkaline phosphatase and GGT markedly raised, bilirubin raised: obstruction or cholestasis
- Albumin low and INR prolonged: the liver’s synthetic function is impaired, which indicates more serious or chronic disease
Ultrasound is the usual first imaging step, looking for dilated bile ducts, which point to obstruction, gallstones, liver texture and masses. MRCP, CT or endoscopic ultrasound follow depending on findings.
When jaundice is an emergency
Seek urgent medical care for jaundice with any of:
- Fever and chills, suggesting cholangitis
- Confusion, drowsiness or personality change, suggesting hepatic encephalopathy
- Vomiting blood, or black tarry stools
- Severe abdominal pain
- Abdominal swelling with rapid onset
- Easy bruising or bleeding
- Known paracetamol overdose, even if you feel well, because the serious damage appears after a delay
- Jaundice in pregnancy
- Rapidly deepening jaundice
Painless jaundice with weight loss in an older adult is a specific pattern that warrants prompt investigation, because it can indicate pancreatic or biliary cancer.
Hepatitis, briefly
A and E are transmitted through contaminated food and water. Usually self-limiting, though hepatitis E is dangerous in pregnancy. Hepatitis A is vaccine-preventable.
B is transmitted through blood, sexual contact and from mother to child. Vaccine-preventable, can become chronic, and chronic infection raises liver cancer risk. Treatable.
C is transmitted mainly through blood. Frequently silent for years. Now curable in the large majority with direct-acting antivirals over a few months, which is one of the genuine triumphs of recent medicine. Anyone with risk factors should be tested, since treatment is far easier than the disease.
D occurs only alongside hepatitis B.
What not to do
- Do not self-medicate with herbal “liver tonics”. Several traditional and herbal preparations are themselves causes of drug-induced liver injury, and taking them during jaundice can worsen it
- Do not drink alcohol at all while jaundiced or while liver enzymes are abnormal
- Review every medicine and supplement with a doctor; some need stopping or dose adjustment when the liver is impaired
- Do not assume it is “just acidity” if urine is dark and stools pale; that combination means obstruction until proven otherwise
The short version
Jaundice is a sign with three possible mechanisms, and the simplest clue is colour: dark urine with pale stools points to obstruction, normal urine and stools point to red cell breakdown, and everything else points at the liver itself. Fever, confusion or severe pain with jaundice means hospital the same day.