International Journal of Research in Medical Sciences

Chauhan S et al. Int J Res Med Sci. 2020 May;8(5):1823-1827

www.msjonline.org pISSN 2320-6071 | eISSN 2320-6012

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20201935
Original Research Article

Jaundice in adult patients above 50 years of age: a comparative study of

liver function tests
Suneel Chauhan1, Vijay K. Barwal2, Gopal A. Sharma2, Ajay Vaid3*, Nikhil Sood1,
Naveen Rana1

1
Department of Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
2
Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
3
Department of Paediatric, District Hospital, Kullu, Himachal Pradesh, India

Received: 10 March 2020

Accepted: 01 April 2020

*Correspondence:
Dr. Ajay Vaid,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Diagnosis of jaundice involves a range of tests. The liver function tests are done in all to arrive at a
diagnosis and then manage the case appropriately. With advancing age, the incidence of liver disease increases.
Understanding these changes is important for the management of liver diseases in the elderly. We conducted this
study to find the difference in mean levels of Liver enzymes in younger and older age group of patients suffering with
jaundice.
Methods: It was a prospective observational study. All patients admitted with jaundice in the medicine ward
satisfying inclusion/exclusion criteria were enrolled. The results of liver function tests in younger age and older age
participants were then compared.
Results: Total 100 participants were enrolled during the study period. 53 were enrolled in group one and the rest in
group two. Anorexia (90%) was the most common symptom followed by abdominal distension (54%). The total
bilirubin (8.8±4.7) as well as conjugated bilirubin (3.4±2.8) were higher in group one though they were not significant
statistically (p=0.10 and 0.25 respectively). Mean AST and ALT levels were much higher in group 1 and statistically
significant (p values <0.004 and 0.002 respectively). Conversely the mean PT values were higher in group two
(p=0.02).
Conclusions: Although the symptom severity may be more in elderly, the LFTs are not deranged proportionately. So
there is a need to devise separate cut offs and these have to be lower for the older age group patients with jaundice.
More studies with larger sample size are required to confirm the results.

Keywords: Adult patients, Comparative study, Jaundice, Liver function tests

INTRODUCTION disease or, less often, a hemolytic disorder. An inflamed

liver or obstructed bile duct can lead to jaundice, as well
The word “jaundice” is derived from old French word as other underlying conditions. Diagnosis of jaundice can
“jaundice”, a word rooted in Latin galbinus, meaning involve a range of tests. The presence of scleral icterus
greenish yellow.1 The bilirubin present in serum indicates a serum bilirubin level of at least 3 mg/dL. The
represents a balance between input from the production liver function tests are done in all such cases of jaundice
of bilirubin and hepatic/biliary removal of the pigment. to arrive at a diagnosis and then manage the case
Rise in serum total bilirubin levels indicate jaundice. appropriately. 2-4. The blood flow to the liver gradually
Tissue deposition of bilirubin occurs only in the presence decreases with age. Geriatric populations of many
of serum hyperbilirubinemia and is a sign of either liver countries are growing rapidly and they present major

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problems to healthcare infrastructures from both medical versus the older age participants. For this purpose authors
and economic perspectives. The elderly are predisposed divided the patients into two age groups: up to 50 years
to a variety of diseases, which contribute to a marked and above 50 years of age i.e. Group one and Group two
increase in morbidity in this sub population. With respectively. The clinical, biochemical and socio-
advancing age, the incidence of liver disease increases in demographic details of the patients were collected in a
the elderly, but the cellular and sub cellular perturbations self-designed, pretested and structured format. Clinical
that underlie this suspected predisposition to pathology objectives were achieved by noting down a detailed
remain unresolved.5 Morphology and functions of the history, general physical examination, chest X-ray PA
liver as well as other organs change with aging. view, abdominal ultrasonography, upper gastrointestinal
Understanding these changes is important for the endoscopy, final diagnosis and outcome at discharge.
management of liver diseases in the elderly. There is Biochemical objectives were achieved by doing
limited data available regarding comparison of liver investigations like complete blood count, liver function
function of the younger age group patients with those tests, Renal function tests alongwith tests for other
patients above the age of 50 years. So authors conducted serological markers of hepatitis and PT-INR. In this study
this study to find the difference in mean levels of Liver authors limit this findings to the socio demogarphic
enzymes in younger and older age group of patients profile and liver function tests of the cases enrolled.
suffering with jaundice.
Statistical analysis
METHODS
The data of all the enrolled patients was cleaned and
The study was conducted in the department of medicine, entered in Microsoft Excel software spreadsheet. It was
at Dr Rajendra Prasad Government Medical College, then analyzed using Epi info version 7.2.0.1 and the
Kangra, Himachal Pradesh. It was part of a larger results are presented as means, standard deviations,
prospective observational study and was conducted for a frequencies and percentages along with various tables.
period of one year from 1st June 2016 through May 2017. The two groups were compared using Independent t-test
The necessary permission from the institutional ethical and a p value of <0.05 was considered as statistically
committee was taken before commencing the study. A significant.
total of 100 patients having jaundice and admitted in the
department of medicine, who satisfied the inclusion and RESULTS
exclusion criteria and also who gave their consent, were
enrolled in the study. A total of 100 participants were enrolled during the study
period. Out of these 77% were males and the average age
Inclusion criteria of presentation was 47.5 years. Maximum patients were
in the age group of 51-60 years (32%). 53 patients were
 All the patients with jaundice and admitted in the below 50 years of age and were enrolled in group one
medicine ward of the medical college during the while the rest were allotted group two (Table 1).
study period.
Table 1: Age and sex distribution.
Exclusion criteria
Age group (Years) Males Females Total (%)
 Those who were not willing to participate in the 18-20 3 2 5(5.0)
study and were below 18 years of age. 21-30 8 2 10(10.0)
31-40 2 4 6(6.0)
A total of 100 patients who satisfied the inclusion and 41-50 22 10 32(32.0)
exclusion criteria were enrolled by doing consecutive 51-60 32 5 37(37.0)
sampling for a period of one year. Authors wanted to >60 10 0 10(10.0)
compare the results of liver function tests in younger age Total 77 23 100(100.0)

Table 2: Distribution of signs and symptoms.

Number of patients Number of patients

Signs Symptoms
(n=100) (n=100)
Ascites 60 Anorexia 90
Pedal edema 44 Abdominal distension 54
Hepatic encephalopathy 43 Altered sensorium 41
Splenomegaly 36 Fever 33
Stigmata of chronic liver disease 21 Pain abdomen 31
Enlarged liver 03 Nausea 17

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The most common cause of jaundice in hospitalized followed by abdominal distension (54%). With regard to
patients was found to be decompensation of cirrhosis. the signs, ascites was the commonest finding in 60%
Anorexia (90%) was the most common symptom while pedal edema was present in 44% cases (Table 2).

Table 3: Comparison of liver function tests between Group 1 and Group 2.

Group 1 Group 2 p value

Parameter
Mean±SD (range) Mean±SD (range) (*<0.05 is significant)
Age (years) 36.9±10.4 (18-49) 56.9±4.5 (50-70) 0.00*
Liver span (cm) 14.7±1.6 (12-18) 14.2±1.5 (11-18) 0.12
Duration of jaundice (days) 70.4±160.2 (2-900) 56.8±76.9 (2-365) 0.59
Serum bilirubin (T) mg/dl 8.8±4.7 (3.3-26.0) 7.2±5.0 (1.4-21.0) 0.10
Serum bilirubin(C) mg/dl 4.1±2.9 (0.35-15.0) 3.4±2.8 (1.0-10.7) 0.25
Aspartate transaminase (AST) (u/l) 625±846.1 (25-3337) 233±265.3 (46-1697) 0.004*
Alanine transaminase (ALT) (u/l) 788.9±1359.0 (21-5672) 140.2±193.1 (26-1200) 0.002*
Alkaline phosphatase (ALP) (u/l) 306.9±306.0 (55-1844) 237.8±169.2 (31-719) 0.17
Prothrombin time (PT)- prolonged
6.7±4.6 (0.0-20.0) 8.9±4.4 (0.0-20.0) 0.02*
(control-12.5)
International normalized ratio (INR) 2.1±1.7 (0.9-12.0) 2.0±0.55 (1.3-3.6) 0.78
Serum protein (T) gm/dl 6.3±0.67 (5.0-8.4) 6.1±0.98 (4.0-8.4) 0.19
Serum albumin (gm/dl) 3.1±0.72 (1.8-4.7) 2.7±0.54 (1.8-5.0) 0.001*

On comparing participants of group one and group two Bangladesh it was 3.16:1 which is comparable with this
authors found that the mean age of cases in group one study.8,11
was 36.9±10.4 and it was 56.9±4.5 in group two. The
mean duration of jaundice was higher in group one as Authors found anorexia the most common symptom
compared to group two, though it was not statistically (90%) followed by distension of abdomen (54%).
significant (p=0.59). With regard to their liver function Maskey et al, and Suthar et al, found abdominal
tests it was found that the total bilirubin (8.8±4.7) as well distension as a presenting complaint in 84%, and 60% of
as conjugated bilirubin (3.4±2.8) were higher in group their patients respectively.8,9 In another study conducted
one than group two, though they were not significant in Peru, the main clinical presentation was upper
statistically (p=0.10 and 0.25 respectively). Again the gastrointestinal bleeding, followed by ascites and
mean AST and ALT levels were much higher in group encephalopathy.12 Hajiani et al, also found abdominal
one as compared to group two and were statistically distension as the chief complaint in most of their
significant also at p values of 0.004 and 0.002 patients.13
respectively. Conversely the mean PT values were higher
in group two and were also statistically significant As per Deetman et al, and Dong et al, Liver enzyme
(p=0.02) (Table 3). levels can increase due to factors such as liver damage
and injury, and can decrease due to factors such as
DISCUSSION hepatic ageing, frailty and reduced hepatic blood
circulation.14-15 Authors found that all the liver enzymes
The average age of patients was 47.7±12.7 years, increased due to various factors which had led to jaundice
majority between 41-60 years (69%). Hung et al, reported in the study participants. The mean increase in the liver
mean age of 53.8±16.9 years and maximum cases were enzymes was proportionately more in younger age group
also in the range of 40-59 years (41%).5 Similarly, in as compared to the older age group.
Chacko and Chacko, Sarin et al, and Maskey et al,
studies, average age of patients was 48±11 years, 43±8.7 According to Kim H et al, aging is associated with the
years and 49.06±11.27 years respectively.6,7,8 Other vulnerability to acute liver injury, severity and poor
studies conducted on alcoholic liver disease by Hemang prognosis of various liver diseases.16 Tietz NW et al,
Suthar et al, in India, and Pathak et al, in Nepal, mean age found that the liver enzymes are well preserved in elderly
was 41 years and 52 years respectively.9,10 while bilirubin levels may decline due to decreased
muscle mass and haemoglobin concentrations.17 In this
The male: female ratio in this study was 3.3:1 while L.N. study also the mean bilirubin levels of jaundice patients
Hung et al, reported a male: female ratio of 1.3:1.5 were lower at 7.2±5.0 in group 2 as compared to group 1
Maskey et al, reported a ratio of 2.1:1, while in (8.8±4.7. Dong et al, found that the albumin, ALT and
gamma-gluatmyl transferase levels decrease with aging

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suggesting decrease in liver function.18 Authors also REFERENCES

found that though all the patients were suffering from
Jaundice and had markedly raised levels of liver 1. Sherlock S. Dubey J. Diseases of Liver and Biliary
enzymes, but the mean levels of ALT, AST and ALP system. 11th ed. Cholestatsis. London: Blackwell
were lower in older age group. But in chronic liver science; 2001: 223.
disease as found by Roche et al, these can be normal or 2. Chopra S, Griffin PH. Laboratory tests and
slightly elevated as there is little parenchyma left to diagnostic procedures in evaluation of liver disease.
damage. Similar findings were observed by Fargo MV et Am J Medi. 1985 Aug 1;79(2):221-30.
al.19,20 According to them Elevated alanine transaminase 3. Schenker S, Balint J, Schiff L. Differential diagnosis
and aspartate transaminase levels can indicate of jaundice: report of a prospective study of 61
hepatocellular damage. However, levels may be normal proved cases. Am J Digest Dis. 1962 May
in chronic liver disease (e.g., cirrhosis). In such cases, 1;7(5):449-63.
there may not be enough normal liver parenchymal tissue 4. O'Connor KW, Snodgrass PJ, Swonder JE,
to release elevated levels of these enzymes. Mahoney S, Burt R, Cockerill EM, et al. A blinded
prospective study comparing four current
Shah AA et al, observed that the development of jaundice noninvasive approaches in the differential diagnosis
in elderly patients was associated with better prognosis.21 of medical versus surgical jaundice.
This result may represent robust immunity in these Gastroenterology. 1983 Jun 1;84(6):1498-504.
elderly patients with sepsis, which may be responsible for 5. Schmucker DL. Age-related changes in liver
their survival. Premoli et al, state that a cautious structure and function: implications for disease?.
individual evaluation is therefore required in aged Experim Gerontol. 2005 Aug 1;40(8-9):650-9.
patients. No significant differences in diagnostic 6. Chacko RT, Chacko A. Serum & muscle
investigations or treatment options occur between the magnesium in Indians with cirrhosis of liver. Indian
elderly and the young.22 But authors found that the liver J Medi Res. 1997 Nov 1;106:469-74.
enzymes were markedly lower in older age group. The 7. Sarin SK, Dhingra N, Bansal A, Malhotra S, Guptan
AST, ALT, PT and Serum albumin levels were found to R. Dietary and nutritional abnormalities in alcoholic
be significantly lower than the younger age group. liver disease: a comparison with chronic alcoholics
without liver disease. Am J Gastroenterol. 1997
Boland BS et al, found that the Bilirubin levels increased May 1;92(5).
significantly (p<0.0001) with advancing age.23 But the 8. Maskey R, Karki P, Ahmed SV, Manandhar DN.
reverse was seen in this study where the increase in mean Clinical profile of patients with cirrhosis of liver in
total bilirubuin as well as the conjugated bilirubin levels a tertiary care hospital, Dharan, Nepal. Nepal Med
were found to be lower in the elderly age group. Coll J. 2011 Jun;13(2):115-8.
According to Neki NS, the prothrombin time may be 9. Suthar H, Suthar K, Mewada B. Clinical profile of
prolonged because of vitamin K malabsorption in cases of alcoholic liver disease. Int J Med Sci Public
elderly.24 Here also authors found that the mean PT levels Health. 2013 Apr 1;2(2):408-12.
in group two were 8.9±4.4 and were significantly higher 10. Pathak OK, Paudel R, Panta OB, Pant HP, Giri BR,
than the younger age group. Adhikari B. Retrospective study of the clinical
profile and prognostic indicators in patients of
CONCLUSION alcoholic liver disease admitted to a tertiary care
teaching hospital in Western Nepal. Saudi J
It is known fact that liver function decreases with age, but Gastroenterol: Offi J Saudi Gastroenterol Assoc.
although the symptom severity may be more in elderly 2009 Jul;15(3):171.
the LFTs are not proportionately deranged. These 11. Ahsan T, Ahsan M, Kamal MM, Hossain KJ, Haque
findings suggest that there is a need to devise separate cut ME, Islam SN. Lifestyle, nutritional status and
offs of liver function tests in the elderly. These cut offs seroclinical profile of liver cirrhotic patients.
need to be lower for the older age group patients of Banglad Medi J. 2007;36(2):44-7.
jaundice because here there may be a decrease in levels 12. Hajiani E, Hashemi S, Masjedizadeh R,
due to damage to the liver tissue due to some chronic Ahmadzadeh S. Liver cirrhosis seen in GI clinics of
ailment. More studies with larger sample size are Ahvaz, Iran. Govaresh. 2012 Oct 3;17(3):178-82.
required to confirm the results. The elderly patients show 13. Bustíos C, Dávalos M, Román R, Zumaeta E.
different changes of the liver that may affect the clinical Clinical and epidemiological profile of cirrhosis in
presentation and further the management of liver the liver unit at Edgardo Rebagliati Martins
pathology in these patients. National Hospital. Rev Gastroenterol Del Peru:
Organo Ofi La Soc Gastroenterol Del Peru.
Funding: No funding sources 2007;27(3):238-45.
Conflict of interest: None declared 14. Deetman PE, Alkhalaf A, Landman GW, Groenier
Ethical approval: The study was approved by the KH, Kootstra‐Ros JE, et al. Alanine
Institutional Ethics Committee aminotransferase and mortality in patients with type

International Journal of Research in Medical Sciences | May 2020 | Vol 8 | Issue 5 Page 1826
 Chauhan S et al. Int J Res Med Sci. 2020 May;8(5):1823-1827

2 diabetes (ZODIAC‐38). Eur J Clini Investig. 2015 21. Shah AA, Patton M, Chishty WH, Hussain A.
Aug;45(8):807-14. Analysis of elevated liver enzymes in an acute
15. Dong MH, Bettencourt R, Brenner DA, Barrett- medical setting: Jaundice may indicate increased
Connor E, Loomba R. Serum levels of alanine survival in elderly patients with bacterial sepsis.
aminotransferase decrease with age in longitudinal Saudi J Gastroenterology: Offi J Saudi
analysis. Clini Gastroenterol Hepatol. 2012 Mar Gastroenterol Assoc. 2010 Oct;16(4):260-3.
1;10(3):285-90. 22. Premoli A, Paschetta E, Hvalryg M, Spandre M, Bo
16. Kim H, Kisseleva T, Brenner DA. Aging and liver S, Durazzo M. Characteristics of liver diseases in
disease. Curr Opini Gastroenterol. 2015 the elderly: a review. Minerva Gastroenterol E
May;31(3):184. Dietol. 2009 Mar;55(1):71-8.
17. Tietz NW, Shuey DF, Wekstein DR. Laboratory 23. Boland BS, Dong MH, Bettencourt R, Barrett-
values in fit aging individuals-sexagenarians Connor E, Loomba R. Association of serum
through centenarians. Clini Chem. 1992 Jun bilirubin with aging and mortality. J Clini Experim
1;38(6):1167-85. Hepatol. 2014 Mar 1;4(1):1-7.
18. Dong MH, Bettencourt R, Barrett-Connor E, 24. Neki NS. Jaundice In Elderly. JK Scie. 2013 Jul
Loomba R. Alanine aminotransferase decreases with 1;15(3):113-6.
age: the Rancho Bernardo Study. PloS One.
2010;5(12).
19. Roche SP, Kobos R. Jaundice in the adult patient. Cite this article as: Chauhan S, Barwal VK, Sharma
Am Family Physici. 2004 Jan 15;69(2):299-304. GA, Vaid A, Sood N, Rana N. Jaundice in adult
20. Fargo MV, Grogan SP, Saguil A. Evaluation of patients above 50 years of age: a comparative study
jaundice in adults. Am Family Physici. 2017 Feb of liver function tests. Int J Res Med Sci
1;95(3):164-8. 2020;8:1823-7.

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