Dissociated jaundice

Dissociated jaundice (ictere dissociee) refers to a dissociation of bilirubin and bile salt excretion in which bilirubin is retained, leading to jaundice, but bile salts are excreted in a normal manner so that such patients are icteric but do not have pruritus and no bile salts are detected in blood or urine. The concept was held that only the hepatic cell could selectively retain bilirubin but excrete bile salts and that bile ducts or gallbladder cells could not. The observation of dissociated jaundice was therefore regarded as useful in distinguishing jaundice due to hepatitis or cirrhosis from that caused by bile duct obstruction (74-76). 

TABLE VII. Incidence of Dissociated Jaundice in Various Disease Groups... 

Thus when the concept of dissociated jaundice is examined by modern analytical techniques it is found to be true only to a very limited extent (i.e., more patients with cirrhosis or hepatitis will have dissociated jaundice than will those with bile duct disease), and the incidence of dissociated jaundice is so low in all groups as to be of little diagnostic usefulness—for the fact remains that more jaundiced patients (65 % or more) will have increased serum bile salt concentrations regardless of the type of disease. Dissociated jaundice is of limited diagnostic value only when it is present. 

Jaundice does not necessarily accompany cholestasis. In severe and prolonged cholestasis, particularly if obstructive, jaundice is generally always in evidence. In cholestasis, the third fraction, known as delta bilirubin, can largely be detected by means of the diazo method. This fraction is firmly bound to albumin and can therefore only be dissociated and excreted slowly. For this reason, jaundice occurring together with cholestasis tends to subside at a significantly slower rate than the increased bile acid level in the serum. In this case, jaundice is due to a reflux of bilirubin from the canaliculus into the blood or a bidirectional transport of bilirubin via the sinusoidal membrane. Sometimes jaundice is caused by metabolic dysfunction of the liver cells. Bilirubin also acts as an antioxidant. 

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