An Approach to Obstructive Jaundice
Doctor, my eyes are yellow ! An Approach to Obstructive Jaundice
Introduction
Clinical Approach
Clinical Examination
Causes of Jaundice
Evaluation Priorities
Differential Diagnosis
Context : Casualty / OPD
Introduction
Patients with obstructive jaundice are usually admitted to the hospital. They are vulnerable to sepsis, dehydration, and pose complex diagnostic dilemmas that need to be untangled. They are best admitted and fast-tracked for investigation.
Management depends on the cause of jaundice. In practice, pre-hepatic and hepatic causes of jaundice are managed by a medical team, and the surgical teams take responsibility for the patients with “post hepatic”, cholestatic jaundice. Biliary obstruction is the aetiology in approximately 30% of all patients presenting with jaundice.
Clinical Approach
Try to decide if jaundice is a brand new symptom, or if it reflects a progression of long-standing disease.
ASK ABOUT JAUNDICE THOROUGHLY : define the presenting complaint
Temporal elements | The onset and duration of jaundice are essential Is this a gradual and progressive symptom ? = Neoplastic cause Does jaundice fluctuate, and is of short duration = ? biliary stones |
Associated symptoms | Is there pain? Severe intermittent pain & rigors = cholangitis, stones Painless = early neoplasm Severe persistent pain (often felt in the lower back) and LOW = malignancy Pruritus - this has little relation to the cause of jaundice, but it is a symptom that needs intervention for palliation Is the gut function normal ? Pale stool and dark urine are characteristic of cholestasis, Steatorrhoea may suggest chronic pancreatitis Nausea and vomiting are associated with either hepatitis or early duodenal / gastric outlet obstruction |
Precipitants or aetiological factors | Ask about the use of medications, herbal medications, dietary supplements, and recreational drugs ? any hepatitis risk factors (e.g., travel, possible IV drugs exposure) Exposure to hepatotoxic substances, especially alcohol History of inherited disorders, including liver diseases & haemolytic disorders HIV status NB - history of abdominal operations, including gallbladder surgery |
Clinical Examination
General examination | Jaundice is the dominant sign - it is typically noted in the sclerae and confirmed by a yellow tinge in the frenulum of the tongue Pyrexia = cholangitis, sepsis, hepatitis Anaemia = malignancy , malnutrition Dehydration/malnutrition = malignancy, sepsis Peripheral adenopathy = malignancy Looks for signs of pruritus, and features of chronic liver failure such as spider naevi, bruising, gynecomastia, testicular atrophy, oedema, palmar erythema, Dupuytren’s contracture, hepatic fetor, flap tremor, hepatic enchephalopathy Nutritional deficiencies are common in chronic alcoholics (Pellagra/ Wernicke’s/ Peripheral Neuropathy) |
Abdominal examination | Courvoisier sign (a palpable non-tender gallbladder, caused by obstruction distal to the take-off of the cystic duct by malignancy) Signs of chronic liver failure/portal hypertension such as ascites, distended abdominal wall veins, splenomegaly A palpable mass and ascites may be a sign of advanced malignancy look for scars of previous operations. A laparoscopic incision can be easily missed! Tenderness in the right upper quadrant |
Rectal | Blood PR = malena may be due to bleeding oesophageal varices, bright red blood may be due to haemorrhoids associated with portal hypertension |
Causes of Jaundice
| Unconjugated hyperbilirubinaemia | Mixed hyperbilirubinaemia | Conjugated hyperbilirubinaemia | |
Common causes | Haemolysis Extravasation of blood into the tissue Stress situations (e.g. sepsis) | Viral/ alcoholic hepatitis Non-alcoholic Steatohepatitis Drugs and toxins Cirrhosis | Biliary obstruction (gallstones, pancreatic or biliary malignancy, chronic pancreatitis) typically managed by surgical teams |
Rare causes | Dyserythropoiesis Impaired hepatic bilirubin uptake Impaired bilirubin conjugation (Gilbert syndrome) | Ischemic hepatitis, Liver infiltration, Inherited disorders (e.g. Dubin- Johnson syndrome, Rotor syndrome), TPN, Postoperative jaundice | Biliary obstruction Iatrogenic stricture, sclerosing cholangitis, hilar adenopathy, HIV cholangiopathy, choledochal cyst Cholestasis Severe sepsis, Primary biliary cirrhosis, Viral, Drugs, progressive familial Intrahepatic cholestasis, Intrahepatic cholestasis of pregnancy |
Evaluation Priorities
How sick is the patient ? Do I need to start a resuscitation protocol? (Needed in cases of cholangitis, or severe pancreatitis) | Hb, blood gas, lactate, U&E, WBC, blood culture Start IV fluid rehydration, IV antibiotics, Vit K |
What is the diagnosis ? exclude “medical causes” of jaundice ? | Check urine Serum U&E, LFT’s, lipase, hepatitis serology, AFP CXR Abdominal US |
Differential Diagnosis
The three key steps are:
| Diagnostic steps | Typical findings of biliary obstruction | |
| 1 | Is jaundice cholestatic? (Or is it mixed or unconjugated?) | Total bilirubin elevated >70% Conjugated transaminases mildly raised or normal ALP and GGT markedly elevated |
| 2 | Differentiate medical causes of Cholestatic Jaundice” (typically Hepatic Diseases) from Biliary Obstruction | US shows biliary dilatation (Intra/extrahepatic) US is very accurate at making this distinction Normal CBD < 7mm |
| 3 | Differentiate “benign” obstructive jaundice (typically caused by biliary calculi) from “malignant” obstructive Jaundice (most commonly caused by carcinoma of the head of the pancreas) | Visible gallstones, shrunken gall bladder, dilated CBD = choledocholithiasis Distended gall bladder, dilated CBD, no gallstones = malignant biliary obstruction |
The patient has unequivocal biliary obstruction - what next ?
Common causes | Clinical clues | Investigations |
Choledocholithiasis | Short history, may be relapsing, associated with rigors of cholangitis No loss of weight, often obese Intermittent severe pain common | Bilirubin moderate to high WBC often raised US – galls stones visible in CBD & in gall bladder |
Periampullary Carcinomas (HOP carcinoma, distal cholangio, ampullary carcinoma) | Loss of weight, progressive jaundice Painless unless advanced disease Courvoisier’s law- palpable gall bladder | Bilirubin high to very high WBC normal may be anaemic US – NO galls stones visible, Intra and extrahepatic biliary dilatation & gall bladder May have liver mets and ascites HOP mass difficult to see on US |
Chronic pancreatitis | Loss of weight, progressive jaundice Recurrent pain due to chronic pancreatitis may have steatorrhea Courvoisier’s law - palpable gall bladder + | Bilirubin high to very high WBC normal, may be anaemic US – NO galls stones visible, Intra and extrahepatic biliary dilatation & gall bladder, pseudocyst in HOP visible HOP mass may be difficult to differentiate from malignancy |
Uncommon causes | Clinical clues | Investigations |
In the lumen ? | Ascaris infestation blocked stent | |
| In the wall ? | HIV cholangiopathy/ Iatrogenic stricture/ Klatskin’s/ adenopathy/sclerosing cholangitis/ choldeochal cyst/ Mirizzi syndrome | |
Outside the wall ? | Portal adenopathy | |
Benign biliary stricture | The commonest cause is Iatrogenic Stricture post biliary surgery | Gall bladder absent Intrahepatic dilatation |
Klatskin tumours (”hilar” cholangiocarcinoma) | Loss of weight, progressive jaundice Painless unless advanced disease No palpable gall bladder | Bilirubin high to very high WBC normal, may be anaemic US – NO galls stones visible, dilated intrahepatic ducts, but CBD & gall bladder normal May have liver mets and ascites |
Portal adenopathy (metastases, lymphoma, rarely TB) | Loss of weight, progressive jaundice Primary carcinoma usually obvious No palpable gall bladder | Intrahepatic biliary dilatation Nodal mass in porta hepatis |
Mirizzi syndrome | Cholangitis, tender gall bladder, recurrent bouts of right UQ pain | Bilirubin moderate WBC elevated US – gall stones visible, gall bladder thick-walled and edematous, Intrahepatic biliary dilatation |
HIV cholangiopathy | RUQ pain, chronic diarrhoea, not always jaundiced, HIV with severe immunosuppression | Multifocal strictures, segmental dilations of the biliary tract Evidence of cytomegalovirus (CMV), cryptosporidium, microsporidium infections |
Sclerosing cholangitis | Intermittent sepsis and jaundice, pruritus, fatigue Associated with ulcerative colitis (75% of cases) | Bile duct wall thickening and focal bile duct dilations may be normal early on |
Ascaris infestation | Children, poor socio-economic background | Intra and extrahepatic biliary dilatation & gall bladder, visible Ascaris in CBD |
Choledochal (Biliary) cyst | Children and young adults, jaundice, pruritus, cholangitis | Intra and / or extrahepatic cystic dilatations of the biliary system |
Does the patient have cholangitis ?
Any of the above causes of biliary obstruction can be complicated by sepsis, typically with gram –'ve organisms.
Cholangitis Commonest precipitant :
Requires biliary obstruction and infected bile | Charcot’s triad- rigors, pain, jaundice It is a clinical diagnosis Need to have a high index of suspicion (do not delay starting treatment while waiting for investigations) Can develop septic shock | Bilirubin moderate to high WBC very high US – depends on the primary cause of biliary obstruction, but may have cholangitic liver abscesses |
I am not quite sure what is going on, and I need more information
HPB conditions are heavily reliant on high-quality imaging, and through multidisciplinary review. A lot of conditions are inaccessible and do not allow histological confirmation of the diagnosis, so therapeutic decisions are frequently based on a clinical and radiological evaluation only.
Different units adopt protocols to the availability of equipment, local skill and expertise.
Most diagnoses, other than obvious CBD stones, need more imaging than the US alone.
It is important to recognize and treat cholangitis early. Avoid dehydration and correct coagulopathy while awaiting further investigations.
Imaging investigations in obstructive jaundice
Test | Ideal context | Issues to consider |
Abdominal US | Best in thin patients, excellent to confirm calculi, biliary dilatation, gall bladder inflammation | The most widely used FIRST imaging test Operator dependent, but easily available and relatively cheap. Not good to image pancreas or retroperitoneum. |
Abdominal CT | Best for obese patients, or suspected retroperitoneal or pancreatic pathology | Essential investigation in cases of suspected malignancy; moderately expensive, uses IV contrast |
MRCP | A non-invasive way of imaging biliary system No risk to the patient | Not therapeutic (diagnostic information only) Increasingly available Expensive, often unnecessary if a PTC or ERCP is clearly indicated |
ERCP | Excellent imaging of biliary and pancreatic system& allows therapeutic intervention. Ideal to extract CBD stones or to palliate jaundice in advanced peri-ampullary malignancy | Invasive, potential complications include pancreatitis, bleeding, perforation and cholangitis. Requires advanced endoscopic expertise & hospital admission |
PTC | Excellent imaging of intrahepatic biliary system & allows therapeutic intervention Best to palliate jaundice in advanced Klatskin tumours | Invasive, potential complications include cholangitis and bleeding Requires advanced radiological expertise & hospital admission. |
Endoscopic US | Excellent visualization of pancreas and distal CBD Best tool to guide directed biopsy of suspicious lesions in the pancreas | Limited availability and skill Invasive potential complications include pancreatitis, bleeding, perforation Requires advanced endoscopic expertise |
Laparoscopy | Useful to look for early peritoneal metastases in suspected malignant disease | Commits patient to surgery, uses theatre resources, requires surgical expertise |
The role of the junior surgeon on this context is the ward care of the patients (highly prone to intermittent sepsis, renal failure and nutritional deficit), and to manage sensibly all the complex permutations of investigations available. Always discuss with the senior consultant prior to booking investigations, particularly invasive procedures like ERCP and PTC.
SHOULD I OPERATE OR NOT ?
The decision to intervene surgically, or endoscopically is complex and always requires senior supervision.
You have to know when to intervene and when not to. There is no substitute for clinical experience, and the heterogeneity of clinical conditions makes a one-size-fits-all approach impossible.
All cases need thorough review, and great harm comes from inappropriate surgery, especially in advanced malignancy.
These are some thoughts to guide your decision making
Common diagnosis | Early intervention | Definitive treatment |
Choledocholithiasis | ERCP & stone extraction | Laparoscopic cholecystectomy, once CBD is cleared |
Cholangitis | Initial resuscitation with IV antibitiotics and IV fluids. Correct coagulopathy. If not improving may require organ support and ICU referral. | Adequate biliary drainage (e.g. stone extraction or stenting, usually via ERCP) |
Periampullary carcinomas (HOP carcinoma, distal cholangio, ampullary carcinoma) | ERCP & stent ...but inappropriate deployment of CBD stent can trigger sepsis and delay curative surgery | A proportion of cases with early disease may be cured by surgical resection (pancreaticoduodenectomy or Whipple’s procedure. Incurable cases are well palliated by ERCP stent |
Chronic pancreatitis | ERCP only if cholangitis present | Persistent jaundice requires intervention Inflammatory mass or stricture
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