Yellowing of the whites of the eyes is most often due to a rise in a substance in the blood called bilirubin. When the bilirubin rises further, yellowing can be noticed in the skin as well. This is called jaundice (icterus).
Jaundice is not a disease in itself. It can arise from causes as varied as liver disease, blockage of the bile ducts, and certain diseases in which the blood cells are broken down faster than normal.
In an adult, newly developed yellowing of the eyes or skin should have its cause investigated.
What is bilirubin?
Bilirubin is a substance formed during the breakdown of ageing red blood cells.
Under normal conditions bilirubin is processed in the liver, passed into the bile and sent on to the bowel.
When a problem arises at any stage of this process, bilirubin can build up in the blood and lead to yellowing of the eyes or the skin.
What are the principal causes of yellowing of the eyes?
The causes of jaundice can broadly be assessed in three groups:
1. Causes arising before the liver
In certain diseases in which red blood cells are broken down faster than normal, the amount of bilirubin the liver has to process can increase.
This may be associated with the processes known as haemolysis.
2. Liver diseases
If the liver cannot process bilirubin sufficiently, or cannot pass it into the bile, jaundice can develop.
The principal causes include:
- Acute or chronic hepatitis
- Drug-induced liver damage
- Alcohol-related liver disease
- Advanced liver disease
- Certain metabolic and inherited diseases
3. Blockage of the bile ducts
If the bile formed in the liver cannot reach the bowel, bilirubin can pass back into the blood and jaundice can develop.
The causes of this may include:
- Stones dropping into the bile duct
- Narrowings of the bile duct
- Diseases of the bile ducts
- Diseases of the pancreas
- Certain tumours of the pancreas, the bile duct or the surrounding tissues
Can a gallstone turn the eyes yellow?
Yes.
If a stone from the gallbladder drops into the main bile duct and obstructs the flow of bile, jaundice can develop.
This may be accompanied by:
- Pain in the upper right or upper abdomen
- Nausea and vomiting
- Dark urine
- Pale stools
Where a stone is found in the bile duct, ERCP may be required in some patients to remove it.
What causes dark urine?
In certain types of jaundice where the flow of bile is disturbed, bilirubin begins to be excreted in the urine.
The urine may therefore appear the colour of tea or dark amber.
Newly developed dark urine together with yellowing of the eyes is an important finding in particular.
Why do the stools become pale?
When bile does not reach the bowel in sufficient amount, the substances that give the stool its normal brown colour can diminish.
The stool may appear:
- Pale,
- Grey,
- Clay-coloured.
Jaundice + dark urine + pale stools together suggest that there may be a problem with the flow of bile, and should be assessed.
Can jaundice cause itching?
Yes.
In certain diseases where the flow of bile is disturbed in particular, widespread and sometimes quite severe itching can develop over the body.
In some people the itching may begin before the jaundice is noticed.
Does painless jaundice matter?
Yes.
Jaundice being painless does not mean that it is unimportant.
Where painless jaundice starts in later life in particular, together with dark urine, pale stools, loss of appetite or weight loss, the causes that can lead to obstruction — including the bile ducts and the pancreas — should be investigated.
Painless jaundice does not by itself mean cancer, however.
Is yellowing of the eyes always a serious disease?
No.
In Gilbert’s syndrome, for example — a quite common and generally harmless inherited condition — the bilirubin can rise slightly from time to time.
Slight yellowing of the eyes may be noticed during periods of fasting, infection, intense exercise or stress.
Where the person does not already know the cause, however, they should not put newly developed jaundice down to Gilbert’s syndrome on their own.
How is jaundice investigated?
The doctor first assesses when the jaundice began, and whether there is abdominal pain, fever, weight loss or itching, along with the medicines being taken.
Blood tests generally assess:
- Total and direct bilirubin
- ALT and AST
- Alkaline phosphatase (ALP)
- GGT
- A full blood count
together with any other tests required.
Depending on the patient’s condition, methods such as:
- Ultrasound
- Computed tomography
- MRI/MRCP
- Endoscopic ultrasound (EUS)
- ERCP
may be used.
ERCP is not carried out in every patient with jaundice. It is used particularly in selected patients who have an obstruction of the bile ducts requiring treatment.
When is urgent assessment required?
Medical assessment is required without delay, particularly if jaundice is accompanied by any of the following:
- Fever and shivering
- Severe or steadily increasing abdominal pain
- Persistent vomiting
- Confusion or drowsiness
- A marked deterioration in general condition
- Signs of bleeding
Jaundice + fever/shivering + upper right abdominal pain may be a sign of a serious infection of the bile ducts (acute cholangitis) and requires urgent assessment.
When should I see a doctor?
In an adult, newly developed yellowing of the whites of the eyes or of the skin should be assessed even if there is no other complaint.
Where the jaundice is accompanied by:
- Dark urine
- Pale stools
- Itching
- Abdominal pain
- Fever
- Loss of appetite
- Unexplained weight loss
in particular, seeing a doctor should not be delayed.
Remember
Jaundice is not a disease; it is a finding.
The problem may sometimes lie in the liver, sometimes in the bile ducts, and sometimes in the process by which bilirubin is formed.
In newly developed jaundice the aim is not merely to bring the bilirubin down, but to establish why it has risen and what has led to the jaundice.
Sources
- Prof. Ali Tüzün İnce, MD