Jaundice and Cholestasis: Causes, Symptoms, and Management

Jaundice: Bilirubin Pigment in the Bloodstream

Jaundice is the yellowing of the skin and the whites of the eyes (sclera) caused by abnormally high levels of bilirubin pigment in the bloodstream.

Jaundice Symptoms (Clinical Manifestations)

• Yellowish skin and eyes.
• Dark urine (due to excess bilirubin excreted by the kidneys).
• Acholia (pale or white stools).
• Itching (pruritus).

If jaundice is caused by acute inflammation of the liver (acute hepatitis), it may also cause loss of appetite, nausea, vomiting, and fever. Obstruction of bile flow may produce symptoms similar to those of cholestasis.

Diagnosis and Management of Jaundice

Diagnosis is based on the analysis of laboratory and imaging tests to determine the underlying cause of jaundice.

Treatment Approach

• If the cause is acute hepatitis, jaundice gradually disappears as the liver improves.
• If the cause is an occlusion of a bile duct, surgical or endoscopic intervention is typically performed as soon as possible.

Cholestasis: Reduced or Stopped Bile Flow

Cholestasis is defined as the reduced or completely stopped flow of bile from the liver to the duodenum.

Causes of Cholestasis

Cholestasis can be categorized into two main types:

Intrahepatic Causes (Originating within the Liver)

• Acute hepatitis.
• Liver disease caused by alcohol.
• Primary Biliary Cholangitis (PBC), formerly Primary Biliary Cirrhosis (scarring and inflammation of the bile ducts).
• Effects of certain drugs or medications.
• Hormonal changes produced during pregnancy (Intrahepatic Cholestasis of Pregnancy).

Extrahepatic Causes (Originating outside the Liver)

• Presence of gallstones in the bile ducts (choledocholithiasis).
• Narrowing (stenosis) of any bile duct.
• Bile duct cancer.
• Pancreatic inflammation (pancreatitis) or cancer.

Cholestasis Symptoms

Common symptoms include:

• Jaundice and dark urine.
• Acholia (pale stools, caused by the absence of bile pigment in the intestine).
• General pruritus (itching).
• Steatorrhea (fat in the stool due to the lack of bile needed for fat digestion).

Nutritional Deficiencies and Complications

The lack of bile in the gut leads to poor absorption of fat-soluble vitamins:

• Vitamin D and Calcium: Can lead to bone loss.
• Vitamin K: Essential for coagulation; deficiency can cause a tendency to bleed.

Prolonged jaundice or the underlying cause of cholestasis may also determine other symptoms, such as abdominal pain, loss of appetite, and vomiting.

Diagnosis of Cholestasis

Diagnosis relies on clinical presentation, laboratory tests, and imaging.

Clinical Indicators

• Intrahepatic Causes: Symptoms like loss of appetite, nausea, and vomiting (typical of hepatitis), excessive alcohol intake, or recent drug use often indicate an intrahepatic cause. Signs of chronic liver disease, such as spider angiomas, enlarged spleen, and ascites, may be present.
• Extrahepatic Causes: Findings that suggest extrahepatic disease include intermittent pain in the right upper abdomen or an inflamed gallbladder.

Laboratory and Imaging Tests

In cholestatic disease, the concentration of the enzyme alkaline phosphatase (ALP) in the blood is typically high. While the amount of bilirubin indicates the severity of cholestasis, it does not determine the cause.

If initial blood test results are normal or inconclusive, an ultrasound or CT scan is usually performed to visualize the bile ducts and liver structure.

Treatment and Management of Cholestasis

• Extrahepatic Obstruction: Obstruction of the bile ducts is typically treated with surgery or endoscopic procedures.
• Intrahepatic Obstruction: Treatment varies depending on the specific cause.
• If the condition is drug-induced, suspending the causative medication is necessary.
• When the obstruction is caused by acute hepatitis, jaundice and cholestasis usually disappear as the liver function improves.