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Distribution of bilirubin in tissues in jaundice
Last reviewed: 04.07.2025
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Circulating protein-bound bilirubin has difficulty penetrating into tissue fluids with low protein content. If the protein content increases, jaundice becomes more pronounced. Therefore, exudates are usually more icteric than transudates.
Cerebrospinal fluid xanthochromia is more likely in meningitis; a classic example is Weil's disease (icteric leptospirosis) with a combination of jaundice and meningitis.
In newborns, icteric staining of the basal ganglia of the brain (nuclear jaundice) may be observed, caused by high levels of unconjugated bilirubin in the blood, which has an affinity for nervous tissue.
In jaundice, the bilirubin content of the cerebrospinal fluid is small: one tenth or one hundredth of the bilirubin level in the serum.
With severe jaundice, the intraocular fluid may become yellow, which explains an extremely rare symptom - xanthopsia (patients see surrounding objects in yellow).
In severe jaundice, bile pigment appears in urine, sweat, seminal fluid, and milk. Bilirubin is a normal component of synovial fluid and may be present in the norm.
The skin color of paralyzed and swollen areas of the body usually does not change.
Bilirubin easily binds to elastic tissue. It is found in large quantities in the skin, sclera, and walls of blood vessels, so these formations easily become icteric. This also explains the discrepancy between the severity of jaundice and the level of bilirubin in the serum during the recovery period in hepatitis and cholestasis.
Normal bilirubin content in the blood: total - 0.5-20.5 μmol/l; conjugated (direct) - 0-4.3 μmol/l; unconjugated (indirect) - 0-16.2 μmol/l;
Visible jaundice appears with bilirubinemia of 34 μmol/l. Jaundice first appears on the sclera, on the palate and under the tongue. Upon examination, the following shades of jaundice can be distinguished:
- orange-red (rubinicterus) or saffron-yellow in hepatic (parenchymatous) jaundice;
- lemon yellow (flavinicterus) for suprahepatic (hemolytic) jaundice;
- green (verdinicterus) in subhepatic (mechanical) jaundice;
- dark olive (icterus melas) in very long-term cholestasis.
It is necessary to remember about false jaundice due to the disruption of carotene metabolism and its deposition in the skin (in diabetes mellitus, hypothyroidism, excessive consumption of carrots, oranges), as well as yellowing of the skin due to acriquine, rivanol. In these cases, there is no jaundice of the sclera, and mainly the palms and soles become yellow.
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