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With the first group, the prehepatic icterus, the cause lies before the liver. Here so many red blood cells are broken down that more bilirubin arises than the liver can process. The liver itself is healthy in this case, it just cannot keep up with the large amount. This increased blood breakdown is called haemolysis. Causes can be an autoimmune reaction, certain infections, congenital disorders of the red blood cells such as a sickle cell anaemia or rarely artificial heart valves that mechanically damage the blood cells. Typical here is often an accompanying anaemia with tiredness and paleness, while stool and urine usually stay normally coloured or the urine only darkens slightly. With a very strong haemolysis, the urine can become dark through released blood pigment, which is a serious condition and should be assessed quickly.
With the second group, the hepatic icterus, the problem lies in the liver itself. It can no longer properly take up and process the bilirubin, because the liver cells are damaged or inflamed. Common causes are an inflammation of the liver, that is a hepatitis, for example through viruses such as hepatitis A or B, a fatty liver, a liver cirrhosis after long-term alcohol consumption or other liver diseases, as well as damage through medications or toxins. A pronounced fatty liver can also lead over time to an inflammation and scarring and thus impair the liver function. Here, besides the jaundice, nausea, loss of appetite, tiredness and a feeling of pressure in the right upper abdomen often appear. The stool is usually normal or somewhat paler, the urine can darken. With a viral hepatitis, depending on the form, flu-like symptoms and aching limbs also occur before the yellowing becomes noticeable. Some forms of hepatitis are contagious, which is why the cause is important for protecting others.
With the third group, the posthepatic or cholestatic icterus, the flow of the bile is blocked. The liver has indeed made the bilirubin able to pass into the bile, but it can no longer flow into the gut and backs up into the blood. This is also called an obstructive icterus, because the path of the bile is mechanically blocked. The most common cause is gallstones that block the bile duct. More rarely a tumour, for example of the pancreas, or a narrowing of the bile duct presses on the flow. A painless icterus with pale stool and without colic in particular should be taken especially seriously, because a tumour can also be behind it. Typical here is the combination of dark, brown urine and pale, discoloured stool, often accompanied by itching and pain in the right upper abdomen. This combination is a clear warning sign, because a lasting bile congestion can damage the liver and become inflamed.
The overview below orders the three groups by the place of the disturbance and shows typical accompanying signs. It does not replace a diagnosis but helps to classify the symptoms and prepare the conversation at the practice.
| Place of the disturbance | Common causes | Typical accompanying signs |
|---|---|---|
| Before the liver (prehepatic) | Increased blood breakdown (haemolysis) | Paleness, tiredness, anaemia |
| In the liver (hepatic) | Hepatitis, fatty liver, liver cirrhosis, medications | Nausea, tiredness, pressure in the right upper abdomen |
| After the liver (posthepatic) | Gallstones, tumour, bile duct narrowing | Dark urine, pale stool, itching |
| Harmless variants | Gilbert's syndrome, a lot of beta-carotene | Mild yellowing, white of the eye often normal |
The accompanying symptoms often give the decisive clue to the cause. Therefore pay specific attention to the following signs and report them to the medical practice, because they help to assign the jaundice to the right group.
Act immediately
With jaundice together with high fever and chills, very strong abdominal pain, persistent vomiting, confusion, strong drowsiness or a rapidly increasing yellowing, immediately call the emergency number or go to an emergency department. These combinations can point to a life-threatening inflammation of the bile ducts or a liver failure and must not be waited out. When in doubt, it is always better to seek help once too often than once too rarely.
Not every yellowing is equally dangerous, but it should be assessed nonetheless, because from the outside you cannot reliably tell how serious the cause is. A harmless variant is Gilbert's syndrome, in which the uptake of bilirubin into the liver is slightly reduced. This affects about five percent of people and leads especially with fasting, stress or infections to a mild yellowing, usually in the white of the eye, without disease value. Many of those affected do not even know that they have this predisposition until it is noticed by chance in a blood test. Another harmless cause is a very high consumption of beta-carotene, for example from carrots. The skin then turns yellowish, especially on the palms and soles, but the white of the eye stays white, which is an important difference from real jaundice. Since these harmless forms cannot be reliably distinguished from serious ones, however, a new jaundice should first be assessed by a doctor. Only when serious causes are ruled out can a harmless variant be assumed as the explanation.
At the start there are a conversation and a physical examination. This also includes questions about previous illnesses, medications, alcohol and travel, because this can give important clues to the cause. Then a blood test follows that measures the bilirubin and the liver values such as ALT, AST and GGT. From the pattern of these values it can often already be read whether the cause lies more in the liver or in the bile flow. If above all the values ALT and AST are raised, this points to liver cell damage, if GGT and the alkaline phosphatase are raised, rather to a bile congestion. Usually an ultrasound examination of liver and bile ducts follows, which makes gallstones, congestion or abnormalities of the liver visible. The ultrasound is painless, fast and often already provides the decisive clue as to whether the bile is congested. Depending on the suspicion, further examinations are added, for example a hepatitis examination, a determination of haemolysis values or a special imaging of the bile ducts. From all these building blocks a clear picture usually emerges quickly, so that targeted treatment is possible.
Some medications can strain the liver, and with liver diseases the right, regular intake is important. brite helps you manage your medications, be reminded of the intake and keep possible interactions in view. This way you have all the important information together when you need it at the doctor.
The bottom line: jaundice is always a serious signal and not a purely cosmetic problem. It shows that something in the interplay of blood, liver and bile is not right, and should never simply be waited out with home remedies. Some causes are easily treatable, such as gallstones, others need quick help. What is decisive is that the cause is found at all, because only then can targeted treatment take place. Therefore: a new yellowing of skin or eyes should be assessed by a doctor, and with warning signs such as fever, strong pain or confusion you must not wait but need help immediately. Those who know the accompanying signs and describe them precisely to the practice help to find the cause quickly. So note as far as possible since when the yellowing has existed, how stool and urine look and which further symptoms appear.
Well prepared for the appointment
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This article is for general information and does not replace medical advice, diagnosis or treatment. With jaundice with fever, strong abdominal pain, vomiting or confusion, please call the emergency number immediately.
