JAUNDICE

JAUNDICE – DISEASE MARKER OF LIVER DISORDERS – GENERAL AND HOMEOPATHIC APPROACH

Jaundice is a yellowish discoloration of the skin, mucous membranes and of the white of the eyes caused by elevated levels of the chemical bilirubin in the blood (hyperbilirubinemia). The term jaundice is derived from the French word jaune, which means yellow. Jaundice is typically seen when the level of bilirubin in the blood exceeds 2.5-3 mg/dL (milligrams per deciliter).

Jaundice is not a disease but rather a sign that can occur in many different diseases. Jaundice is often seen in liver disease such as hepatitis or liver cancer. It may also indicate leptospirosis or obstruction of the biliary tract, for example by gallstones or pancreatic cancer, or less commonly be congenital in origin (e.g., biliary atresia).

Jaundice is a yellowy tinge to the skin and the whites of the eyes. It is caused by a buildup of the chemical bilirubin in the blood. Bilirubin is made when redblood cells are broken down. The body is usually able to get rid of it easily unless there is something wrong with your liver or biliary system (this releases bile to help with digestion).

Neonatal jaundice often affects newborn babies during the first few weeks of life. This is because their livers take a while to get working properly. Jaundice in adults and older children is not related to neonatal jaundice; it is usually the sign of a health problem.

AETIOLOGY

When red blood cells break down naturally in a 120-day cycle, bilirubin is produced as a waste by-product. The journey bilirubin takes out of the body's waste disposal systems takes it carried by blood to the liver. There is it combined with bile (digestive fluid) from the gallbladder. This mixture exits the body through faeces and urine. If everything is working well, faeces should be brown and urine light yellow. Infections or damage can disrupt this process, leading to jaundice.

Jaundice is classified into three categories, depending on which part of the physiological mechanism the pathology affects. The three categories are:

Pre-hepatic jaundice

If an infection or medical condition makes the red blood cells break down sooner than usual, bilirubin levels rise. This is known as pre-hepatic jaundice.

In tropical countries, malaria can cause jaundice in this manner. Certain genetic diseases, such as sickle cell anemia, spherocytosis and glucose 6phosphate dehydrogenase deficiency can lead to increased red cell lysis and therefore hemolytic jaundice. Commonly, diseases of the kidney, such as hemolytic uremic syndrome, can also lead to coloration. Defects in bilirubin metabolism also present as jaundice. Jaundice usually comes with high fevers.

Laboratory findings include: Urine: no bilirubin present, urobilirubin > 2 units (except in infants where gut flora has not developed). Serum: increased unconjugated bilirubin.

Intra-hepatic (Hepatic) jaundice

If the liver is damaged, it may be less able to process bilirubin.  Hepatic jaundice causes include acute hepatitis, hepatotoxicity and alcoholic liver disease, whereby cell necrosis reduces the liver's ability to metabolise and excrete bilirubin leading to a buildup in the blood. Less common causes include primary biliary cirrhosis, Gilbert's syndrome, CriglerNajjar syndrome and metastatic carcinoma.

Jaundice seen in the newborn, known as neonatal jaundice, is common, occurring in almost every newborn as hepatic machinery for the conjugation and excretion of bilirubin does not fully mature until approximately two weeks of age

Laboratory Findings include: Urine: Conjugated bilirubin present, Urobilirubin > 2 units but variable (Except in children)

Post-hepatic jaundice

Post hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct, and pancreatic cancer in the head of the pancreas. Also, a group of parasites known as "liver flukes" live in the common bile duct, causing obstructive jaundice. Other causes include strictures of the common bile duct, biliary atresia, ductal carcinoma, pancreatitis and pancreatic pseudocysts. A rare cause of obstructive jaundice is Mirizzi's syndrome.

The presence of pale stools and dark urine suggests an obstructive or post hepatic cause as normal feces get their color from bile pigments. Patients also can present with elevated serum cholesterol, and often complain of severe itching or "pruritus".

CLINICAL MANIFESTATION

As well as the classic yellow tinge to the skin and whites of the eyes, someone with jaundice may also have yellowing of mucous membranes in the mouth and nose.

Stools (faeces) can be pale in colour and urine dark in colour.

Some underlying conditions, which lead to jaundice, may feel like flu, and may also result in fever, chills, stomach pain, itching or weight-loss or be without an explanation such as a diet.

DIAGNOSIS

Many tests are available for determining the cause of jaundice, but the history and physical examination are important as well.

History

The history can suggest possible reasons for the jaundice. For example, heavy use of alcohol suggests alcoholic liver disease, whereas use of illegal, injectable drugs suggests viral hepatitis. Recent initiation of a new drug suggests drug induced jaundice. Episodes of abdominal pain associated with jaundice suggests blockage of the bile ducts usually by gallstones.

Physical examination

The most important part of the physical examination in a patient who is jaundiced is examination of the abdomen. Masses (tumors) in the abdomen suggest cancer infiltrating the liver (metastatic cancer) as the cause of the jaundice. An enlarged, firm liver suggests cirrhosis. A rockhard, nodular liver suggests cancer within the liver.

Blood Test

Measurement of bilirubin can be helpful in determining the causes of jaundice. Markedly greater elevations of unconjugated bilirubin relative to elevations of conjugated bilirubin in the blood suggest hemolysis (destruction of red blood cells). Marked elevations of liver tests (aspartate amino transferase or AST and alanine amino transferase or ALT) suggest inflammation of the liver (such as viral hepatitis). Elevations of other liver tests, e.g., alkaline phosphatase, suggest diseases or obstruction of the bile ducts.

Ultrasonography

Ultrasonography is a simple, safe, and readily available test that uses sound waves to examine the organs within the abdomen. Ultrasound examination of the abdomen may disclose gallstones, tumors in the liver or the pancreas, and dilated bile ducts due to obstruction (by gallstones or tumor).

Computerized tomography (CT or CAT scans)

Computerized tomography or CT scans are scans that use xrays to examine the soft tissues of the abdomen. They are particularly good for identifying tumors in the liver and the pancreas and dilated bile ducts, though they are not as good as ultrasonography for identifying gallstones.

Magnetic resonance imaging (MRI)

Magnetic Resonance Imaging scans are scans that utilize magnetization of the body to examine the soft tissues of the abdomen. Like CT scans, they are good for identifying tumors and studying bile ducts. MRI scans can be modified to visualize the bile ducts better than CT scans (a procedure referred to as MR cholangiography), and, therefore, are better than CT for identifying the cause and location of bile duct obstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) provides the best means for examining the bile duct. ERCP is particularly good at demonstrating the cause and location of obstruction within the bile ducts. A major advantage of ERCP is that diagnostic and therapeutic procedures can be done at the same time as the xrays.

For example, if gallstones are found in the bile ducts, they can be removed. Stents can be placed in the bile ducts to relieve the obstruction caused by scarring or tumors. Biopsies of tumors can be obtained.

Ultrasonography can be combined with ERCP by using a specialized endoscope capable of doing ultrasound scanning. Endoscopic ultrasound is excellent for diagnosing small gallstones in the gallbladder and bile ducts that can be missed by other diagnostic methods such as ultrasound, CT, and MRI. It also is the best means of examining the pancreas for tumors and can facilitate biopsy through the endoscope of tumors within the pancreas.

Liver biopsy

Biopsy of the liver provides a small piece of tissue from the liver for examination under the microscope. The biopsy most commonly is done with a long needle after local injection of the skin of the abdomen overlying the liver with anesthetic. The needle passes through the skin and into the liver, cutting off a small piece of liver tissue. When the needle is withdrawn, the piece of liver comes with it. Liver biopsy is particularly good for diagnosing inflammation of the liver and bile ducts, cirrhosis, cancer, and fatty liver.

Table of diagnostic tests

Function test	Prehepatic Jaundice	Hepatic Jaundice	Posthepatic Jaundice
Total bilirubin	Normal / Increased	Increased	Increased
Conjugated bilirubin	Normal	Increased	Increased
Unconjugated bilirubin	Normal / Increased	Increased	Normal
Urobilinogen	Normal / Increased	Decreased	Decreased / Negative
Urine Color	Normal	Dark (urobilinogen +conjugated bilirubin)	Dark (conjugated bilirubin)
Stool Color	Normal	Normal/Pale	Pale
Alkaline phosphatase levels	Normal	Increased	Increased
Alanine transferase and Aspartate transferase levels	Normal	Increased	Increased
Conjugated Bilirubin in Urine	Not Present	Present	Present
Splenomegaly	Present	Present	Present

MANAGEMENT

Jaundice cannot be treated or better said, treatment of jaundice is usually unnecessary. The correct approach is to cure Jaundice is to treat the underlying disease. A balanced diet with plenty of fruits, vegetables, animal protein with a fat, carbohydrate & protein ratio of 30%, 50% &20% unless specific problems such as diabetes, kidney disease etc dictate otherwise.

·        Plenty of fluids, avoidance of excess alcohol, pack diet with antioxidants

·        Antioxidants protect against free radical (produced in all of us due to body’s metabolic processes) injury.

·        Antioxidants are abundant in fruits and vegetables, as well as other foods including nuts, grains and some meats, poultry, fish

Best food sources of Anti oxidants are

·      BetaCarotene - Found in many foods that are orange in color, including sweet potatoes, carrots, apricots, pumpkin, and mangos. Some green leafy vegetables such as spinach and kale are also rich in betacarotene.

·      Lycopene: A potent antioxidant found in tomatoes, watermelon, guava, papaya, apricots, oranges.

·      Selenium: Selenium is a mineral, not an antioxidant nutrient. However, it is a component of antioxidant enzymes. The amount of selenium in soil, which varies by region, determines the amount of selenium in the foods grown in that soil. Plant foods like rice and wheat are the major dietary sources of selenium in most countries.

·      Vitamin A - Foods rich in vitamin A include liver, sweet potatoes, carrots, milk, egg yolks and mozzarella cheese.

·      Vitamin C – This can be found in abundance in citrus fruits (lemons, oranges etc.), cereals, poultry and fish.

·      Vitamin E - This is found in almonds, in many oils including safflower, corn and soyabean oils, and also found in mangos, nuts, broccoli and other foods.

Natural Home Remedies

·        Tomato juice: One glass of tomato juice, mixed with a pinch of salt and pepper, taken on empty stomach in the morning is a very effective home cure for jaundice.

·        Radish leaves: Radish leaves contain compounds which induces appetite and regularises the bowel movements. Take some radish leaves and extract juice from it, with the help of a sieve. Drink about half a litre of the extracted juice daily, in about ten days the patient should get relief from the disease.

·        Papaya leaves: Add one tablespoon of honey to one teaspoon of papaya leaves paste. Eat this regularly for about one or two weeks. This is a very effective home cure for jaundice.

·        Sugarcane: The properties in sugarcane helps in proper digestion and proper liver functioning, thereby helping the patient to recover quickly from jaundice. Take a glass of sugarcane juice and add some lime juice to this. Drink this juice twice daily for better results. Ensure to clean sugarcane

·        Gooseberry: Gooseberry is rich in vitamin C and is a very useful in alleviating the symptoms of jaundice.

·        Barley: Boil a cup of barley water in about three litres of water and allow it to simmer for about three hours. Drink this water as frequently as possible throughout the day for treatment of jaundice.

·        Lemon: The anti-inflammatory property in lemon helps in treating jaundice. Lemon also unblocks the bile ducts, thereby making it the most effective home remedy for jaundice. Squeeze the juice of 2 lemons and add it to a glass of water. Drink this minimum thrice a day, as it protects the liver cells from damage.

·        Natural home remedy using almonds, dates, cardamoms, sugar and butter: Take 7 almonds, add 2 dried dates, add 3 small cardamoms, soak them in water overnight, crush them to make fine paste the next morning, add 2 tsp sugar, add 1 tsp butter, mix well and eat once every day

·        Turmeric powder: Take 1 glass water, add 2 tsp turmeric powder, drink the mixture 3 times a day

HOMOEOPATHIC MANAGEMENT

Homoeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homoeopathy is not only to treat jaundice but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several remedies are available to treat jaundice and liver diseases that can be selected on the basis of cause, sensations and modalities of the complaints.  For individualized remedy selection and treatment, the patient should consult a qualified homoeopathic doctor in person. There are following remedies which are helpful in the treatment of jaundice and liver diseases:

Indicated Remedies	Indications
Carica Papaya	It is used commonly in liver complications and disorders of digestion, very efficacious in helping digestion of very weak patients. It is best spleen and liver, dyspepsia and indigestion. It acts best in jaundice.
Carduus Marianus	Liver-Engorged, especially left lobe, swelled laterally in the transverse direction painful to pressure [Chelidomium- liver enlarges in vertical direction]. -Pain in liver most marked when lying on left side. < deep inspiration. < motion. Liver disease affects lungs, and causes vomiting of blood from lungs
Chionanthus	LIVER-SORE, ENLARGED, Jaundice and constipation. Jaundice occuring every summer, caused by drinking too much cider. JAUNDICE WITH ARREST OF MENSES. Bilious symptoms, sore liver and headache at every menstrual period.
Chelidonium	Chelidonium is to be used in the homeopathic treatment of patients with symptoms such as the presence of an intense pain under the right shoulder symptoms also include the presence of a dull or stitching pain in the abdominal remedy can also be used to treat related liver problems such as jaundice.
China	Fullness and FLATULENCE-whole abdomen is enormously distended not > from eructations or only temporary>. Everything eaten turns into gas. GALL STONE colic periodic bending double.
Ferrum Phosphoricum	For those who are tall, irritable, graceful with delicate transparent skin. Congestion with cold extremities. Plethoric, rapid growth, easy exhaustion, of sanguinous and nervous temperament. -Considered for first stage of inflammatory and non-inflammatory conditions.
Hydrastis	Hydrastis, though most effective in gastric disorders, is valuable in certain affections of the accessory digestive organs. It is of unquestioned worth in catarrhal states of the intestines and gall duct, in duodenal catarrh aggravated by neighboring biliary concretions, and in chronic constipation due to debility and imperfect action of the intestinal glands. Its use must be persisted in for a long period.
Kalmegh	Kalmegh extract is a potent Liver stimulant, and cures a number of liver aliments
Lycopodium	Lycopodium is to be used in the homeopathic treatment of all individuals suffering from liver problems including disorders such as cirrhosis of the liver, the presence of a persistent chronic jaundice and all other forms of hepatitis and related conditions such as jaundice. Physical symptoms include the presence of extreme and cutting painful sensations running from the right to the left side of the body. The individual’s abdominal region and the area above the liver become extremely sensitive to touching and even slight pressure may cause pain.
Mercurius Sol	Liver enlarged, sore to touch, indurated. Jaundice. Bile secreted deficiently
Natrum Phosphoricum	A sour taste in the mouth, an acid or burning sensation in the stomach, sour vomiting, regurgitated bits of food, and a yellow coating on the tongue are all indications for this remedy. The person may have problems after consuming dairy products or too much sugar.
Natrum Sulph	Diarrhoea from vegetables, farinaceous, fat food. Diarrhoea with flatus. Pain in the liver region. Desire to lie on right side with legs curled up. Colic > rubbing abdomen > lying on sides.
Taraxacum	Jaundice with enlargement and induration of liver. White stools. Bilious diarrhoea