Obstructive Jaundice: Causes, Symptoms and Treatment
Obstructive jaundice is the type of jaundice resulting from obstruction of bile flow to the duodenum from the biliary tract. Also called mechanical, cholestatic jaundice or surgical jaundice.
As a reminder, Jaundice, or icterus refers to the yellowish discoloration of the skin, sclerae, and mucous membranes caused by retention of bilirubin and/or its conjugates.
Classification of obstructive jaundice
Etiologic classification of obstructive jaundice
1.Site of the lesion in relation to the liver.
2. According to the site of obstructing lesion
- Intraluminal causes
- Biliary stones
- Parasites (e.g. Ascaris lumbricoides, liver flukes
- Intramural causes
- Benign stricture (may be iatrogenic)
- Malignant strictures (e.g. cholangiocarcinoma)
- Extramural causes
3. According to the cause of lesion and time of onset
- A choledochal cyst (weakness in the wall of CBD)
- Caroli’s disease (Dilatation of intrahepatic ducts)
- Pancreatic pseudocysts
- Inflammatory causes like cholecystitis, sclerosing cholangitis,
- Malignancies; cancer of the pancreas, Cholangiocarcinoma
- Malignant lymph nodes at the Porta hepatis; non-Hodgkin lymphoma, Hodgkin Lymphoma.
- Iatrogenic due to previous surgical interventions e.g. ERCP
- Gall stones
- Drugs such as oral hypoglycemics, anticonvulsants, antithyroid, cytotoxics, anesthetic agents.
- Total parenteral nutrition may cause cholestasis
Causes of obstructive jaundice
- Cholelithiasis/choledocholithiasis. Gall Stones- the most common cause. There are cholesterol stones or mixed stones that form in the gall bladder, migrate via the cystic duct
- Pancreatic head carcinoma
- Common bile duct strictures are mostly iatrogenic-ERCP and cholecystectomy.
- Choledochocele, Choledochal cysts, and congenital atresia
- Infections- Parasitic-Clonorchis Sinensis and Ascaris Lumbricoides- Opportunistic infections in HIV-Cryptosporidium, cytomegalovirus, Microsporidia, tuberculous adenitis
- Other Tumours- Hepatoma, lymphomas, stomach cancer, Colorectal cancer, Ampullary cancer of Duodenum, Gallbladder Adenocarcinoma
- Pancreatic pseudocysts
Clinical Presentation of a patient with obstructive jaundice:
The patient will present with history of;
- The yellowness of the eyes
- Skin irritation- pruritus
- Dark urine (bilirubinuria)
- Pale stools (Acholic stools)
- Abdominal pain; You need to determine the character if it is colicky, intermittent or continuous. Dull aching vs. sharp pain.
- Fever with rigors
- Anorexia, weight loss, vomiting.
- History of the pre-existing hepatobiliary disease; gall stones recur
- History of previous hepatobiliary interventions
Rule out Viral Hepatitis; fever, arthralgias, history of contact with a patient with yellowing of eyes, history of blood product transfusion.
Enquire about medication history such as chlorpromazine, anabolic steroids, isoniazid, acetaminophen toxicity,
Rule out possible malignancies; diabetes mellitus or diarrhea (Steatorrhea) of recent onset, metastasis; a mass, weight loss, anemia, chest or abdominal symptoms
The patient may also report a smoking and alcohol intake history.
Liver function tests will indicate raised conjugated (direct) bilirubin (normal 0- 0.2 mg/dl).
Alkaline phosphatase markedly elevated (38-230uL)
Serum aminotransferases are elevated (mildly)
Albumin is normal in acute obstructive jaundice (decreased albumin indicates prolonged liver disease or malignancy)
A full hemogram will show anemia in malignancies and leucocytosis in cholecystitis.
Carcinoembryonic antigen test& Alpha-fetoprotein. If the results are above normal suspect liver carcinomas
Liver biopsy is required for Primary sclerosing cholangitis, Caroli’s disease and fine needle aspiration for cytology
Blood cultures in cholecystitis may be positive for enteric organisms
Clotting panel to check for Prothrombin Time which is mostly prolonged. Chest Vitamin K dependent clotting factors A, D, E & K, APTT, International normalized ratio are altered.
Urinary bilirubin can be detected at 0.05mg/dl
Serology for viral hepatitis; Hepatitis B, C
Antimitochondrial antibodies are elevated in Peripheral Blood Count & absent in PSC
Ultrasound is an essential non-invasive imaging technique. It will indicate:
- Duct dilatation, pancreas, kidney, and blood vessels are seen.
- Presence of gall stones, tumors, Ascites
On a plain Radiography
- 10% of gall stones are radio-opaque, may be seen
- A chest x-ray can be done for lung metastasis in staging cancer cases
CT scan with contrast will indicate
- Duct dilatation, most organs & tumor masses well illustrated
- Radiolucent stones may be missed
MRCP (Magnetic Resonance Cholangiopancreatography)
Radionuclide biliary scintigraphy (HIDA Scan)
ERCP (Endoscopic Retrograde CholangioPancreatography)
- Combines endoscopic & radiologic modalities
- It is a contrast utilized, invasive technique.
- It is diagnostic and therapeutic
PTHC (Percutaneous TransHepatic Cholangopancretography) is also contrast utilized, invasive, diagnostic and therapeutic
The differential diagnosis that you may think of are;
- Ampullary Carcinoma
- Bile duct stricture
- Bile duct tumors
- Biliary colic
- Biliary trauma
- Choledochal Cyst
- Cirrhosis of the Liver
- Gall bladder Carcinoma
- Hepatocellular Carcinoma
- Secondary Hepatic Ca
- Pancreatic cancer
- Chronic Pancreatitis
- Acute Pancreatitis
- Primary Biliary Cirrhosis
- Primary Sclerosing Cholangitis
- Drug reactions Infections
Treatment of Obstructive jaundice
Treatment for obstructive jaundice can be supportive or specific.
Supportive management entails:
Correction of dehydration, Fluid and Electrolyte abnormalities.
- Intravenous Fluids; normal isotonic saline alternate with 5% dextrose.
- Monitor Input-Output by catheterization.
- Plasma expanders can also be used when necessary.
- Frusemide diuretic is used with intravenous fluids.
- Electrolyte replacements; Urea/Electrolyte monitoring is key in the management
- Inotropic support if in endotoxic shock: Dopamine 3mg/kg/d
Correction of clotting disorders
Intramuscular Vit. K 10mg/day until international normalized ratio or Prothrombin Tine are normal and for preoperative optimization.
Monitor INR, APTT, PT
Control of sepsis using appropriate antibiotics. Broad-spectrum spectrum such as Ceftriaxone + Gentamycin. Add Metronidazole in patients with previous biliary surgical procedures
Treat pruritus with Cholestyramine which is bile acid-binding resins, Antihistamines such as chlorpheniramine
Discontinue causative drugs in pt with drug-induced obstructive Jaundice (oral hypoglycemics, anticonvulsants, antithyroid, cytotoxics, anesthetic agents.
The patient should reduce the dietary intake of saturated fats, increase the intake of a high fiber diet.
Encourage regular exercise tailored to support healing postoperatively.
The specific treatment uses Ursodeoxycholic Acid that dissolves cholesterol stones at a dose of 10mg/kg/day orally.
Stones recur within 5 yrs once the drug is stopped
Gallstones are managed surgically by;
- Cholecystectomy by open or laparoscopic surgery
- Cholecystotomy and stone removal
- Contact or Laser Lithotripsy – endoscopic
- Endoscopic guided ultrasound shattering of stone
- Choledochotomy and exploration
- ERCP and stone removal, or ERCP and balloon dilatation
Malignant Strictures are treated by;
- Staging for resectability using CT-scan, ultrasound, and angiography
- Surgical Resection
- Surgical Bypass surgery such as cholecystojejunostomy and choledochojejunostomy.
- ERCP and Stenting
- Whipple’s operation also known as a pancreaticoduodenectomy.
Benign Strictures are treated by; Balloon dilatation, Stenting, and Hepaticojejunostomy.
Treatment of the underlying cause
Liver Transplantation in Patients with Primary biliary cholangitis& PSC