68. Obstructive jaundice

1. Definition

• Jaundice → yellow skin and sclera from raised serum bilirubin; seen when bilirubin is over 35–50 µmol/L (normal under 17–21)
• Obstructive (surgical, posthepatic) jaundice → jaundice from mechanical blockage of bile flow in the extrahepatic or large intrahepatic ducts
• Conjugated hyperbilirubinaemia with dilated ducts

2. Epidemiology

• Commonest causes in adults:
  • CBD stones → most common cause
  • Pancreatic head cancer → most common malignant cause
  • Cholangiocarcinoma, ampullary cancer, gallbladder cancer, metastases at the porta
• Stones → younger, women; cancer → older (over 60)
• Children → biliary atresia, choledochal cyst

3. Aetiology and risk factors

Bilirubin metabolism (revision)

1. Haem from old red cells → unconjugated bilirubin (bound to albumin, not water-soluble)
2. Liver takes it up; conjugation with glucuronic acid (UDP-glucuronyl transferase)
3. Conjugated bilirubin excreted in bile
4. Gut bacteria → urobilinogen (some reabsorbed, passed in urine) and stercobilin (colours stool)

Types of jaundice

• Prehepatic → haemolysis, Gilbert's syndrome (unconjugated; no bilirubin in urine)
• Hepatic → hepatitis, cirrhosis, drugs (mixed)
• Posthepatic (obstructive) → blockage of the ducts (conjugated)

Causes of obstruction

• In the lumen:
  • Stones (most common)
  • Parasites (Ascaris, Clonorchis, hydatid daughter cysts), blood clot (haemobilia)
• In the wall:
  • Cholangiocarcinoma (Klatskin tumour at the hilum)
  • Benign stricture → bile duct injury, chronic pancreatitis, PSC, IgG4 disease
  • Biliary atresia, choledochal cyst
  • Ampullary carcinoma, sphincter of Oddi stenosis
• Outside the wall (compression):
  • Pancreatic head carcinoma
  • Chronic pancreatitis, pancreatic pseudocyst
  • Mirizzi syndrome
  • Nodes at the porta hepatis (metastases, lymphoma)
  • Duodenal diverticulum, duodenal tumour
• Drugs (cholestasis without obstruction) → co-amoxiclav, flucloxacillin, chlorpromazine, steroids, oral contraceptives

4. Pathogenesis

• Bile cannot reach the gut:
  • Conjugated bilirubin returns to the blood → water-soluble → dark urine
  • No bilirubin in the gut → pale (clay-coloured) stools; no urobilinogen in the urine
  • Bile salts build up in the skin → itch (pruritus)
  • No bile salts in the gut → fat malabsorption (steatorrhoea), vitamin K deficiency → coagulopathy (prolonged INR)
• Systemic effects (why jaundiced patients are high-risk for surgery):
  • Endotoxaemia → gut barrier fails without bile salts → endotoxin into portal blood
  • Acute kidney injury (hepatorenal: endotoxin, dehydration; bilirubin toxicity)
  • Impaired immunity, poor wound healing, infection (cholangitis)
  • Cardiovascular depression, bleeding
• Long-standing → secondary biliary cirrhosis
• Courvoisier's law → "in the presence of jaundice, a palpable, non-tender gallbladder is unlikely to be due to stones" (stones cause a fibrotic, shrunken gallbladder); suggests pancreatic head or periampullary cancer

5. Classification

• By level:
  • Intrahepatic
  • Hilar (Bismuth-Corlette types I–IV for hilar cholangiocarcinoma)
  • Mid CBD
  • Distal (periampullary) → pancreatic head, ampulla, distal CBD, duodenum
• By cause → benign (stones, strictures, pancreatitis) or malignant
• By course → complete (cancer: continuous, progressive) or incomplete and intermittent (stones: fluctuates)
• By pain → painful (stones) or painless (cancer)

6. Clinical picture

Symptoms

• Jaundice; dark urine; pale stools; itch
• Stones → biliary colic before the jaundice, fluctuating jaundice, fever and rigors (cholangitis)
• Cancer → painless, progressive jaundice; weight loss, anorexia; back pain (pancreatic cancer invading the coeliac plexus); new diabetes, steatorrhoea
• Ampullary cancer → intermittent jaundice (tumour sloughs), melaena (bleeding), "silver stool" (pale stool with blood)
• Ask → alcohol, drugs, travel, transfusions, previous biliary surgery, family history

Signs

• Yellow sclera and skin; scratch marks (excoriation)
• Palpable gallbladder (Courvoisier's sign) → distal malignant obstruction
• Hepatomegaly → metastases, congestion
• Epigastric mass, Virchow's node, ascites → advanced cancer
• Fever, RUQ tenderness → cholangitis
• Signs of chronic liver disease (spider naevi, palmar erythema) → point to a hepatic cause
• Migratory thrombophlebitis (Trousseau's sign) → pancreatic cancer

7. Diagnosis

Blood and urine

• LFT:
  • Raised conjugated bilirubin
  • ALP and GGT raised much more than transaminases (cholestatic pattern)
  • Transaminases high with acute stone impaction (can briefly reach the hundreds)
• Urine → bilirubin positive, urobilinogen absent
• INR (prolonged; corrects with vitamin K, unlike liver failure)
• FBC, U&E (renal function), albumin, CRP
• Tumour markers → CA 19-9 (pancreas, cholangiocarcinoma; falsely high in jaundice and cholangitis), CEA
• Hepatitis serology, autoantibodies, IgG4 → hepatic causes

Imaging (stepwise)

1. Ultrasound → first test: dilated ducts (obstruction) or not (hepatic cause); level of block; stones; liver metastases
2. CT (pancreatic protocol, triple phase) → mass, staging, vascular involvement, resectability
3. MRCP → biliary tree map, stones, strictures, hilar tumours (non-invasive)
4. EUS → small pancreatic or ampullary tumours, distal CBD stones; fine-needle biopsy
5. ERCP → therapy (stones out, stent), brushings for cytology; ampullary biopsy
6. PTC (percutaneous transhepatic cholangiography) → hilar obstruction, failed ERCP; drainage
7. PET-CT, staging laparoscopy → selected cancers

8. Differential diagnosis

• Hepatic jaundice → viral, alcoholic or drug hepatitis, cirrhosis, autoimmune hepatitis
• Intrahepatic cholestasis → primary biliary cholangitis, PSC, pregnancy, sepsis, TPN, drugs
• Prehepatic → haemolysis, Gilbert's syndrome
• Carotenaemia (yellow skin, white sclera)
• Within obstructive causes → stone vs cancer vs stricture

9. Treatment

Conservative

• Preparation of the jaundiced patient (before any procedure):
  1. IV fluids; keep good urine output (over 0.5 mL/kg/h); avoid nephrotoxins (aminoglycosides, NSAIDs, contrast if possible) → prevents hepatorenal failure
  2. Vitamin K IV (10 mg daily for 3 days); FFP if urgent
  3. Antibiotic prophylaxis before ERCP or surgery (or treatment if cholangitis)
  4. Nutrition support
  5. Itch → cholestyramine, antihistamines, sertraline, rifampicin; drainage is the real cure
  6. Glucose control; check for new diabetes
• Treat the cause:
  • Hepatic and prehepatic → medical
  • Drug cholestasis → stop the drug

Surgical: biliary drainage

• ERCP → stones: sphincterotomy and extraction; stent for strictures and tumours
  • Plastic stent → benign, temporary
  • Self-expanding metal stent (SEMS) → malignant obstruction (longer patency); covered or uncovered
• PTBD → hilar tumours, failed ERCP, altered anatomy
• EUS-guided drainage → failed ERCP
• Preoperative biliary drainage before a Whipple → not routine; more infection without benefit (DROP trial); drain only if cholangitis, very high bilirubin (over 250 µmol/L), itch, or delay for neoadjuvant therapy

Surgical: definitive

• Stones → ERCP clearance plus laparoscopic cholecystectomy, or one-stage laparoscopic CBD exploration
• Resectable periampullary or pancreatic head cancer → pancreaticoduodenectomy (Whipple) or pylorus-preserving form
• Hilar cholangiocarcinoma → hepatectomy with bile duct resection and hepaticojejunostomy; liver transplantation in selected patients
• Distal cholangiocarcinoma → Whipple
• Benign strictures → endoscopic stents; Roux-en-Y hepaticojejunostomy for bile duct injury and failed stenting
• Choledochal cyst → excision and hepaticojejunostomy
• Unresectable cancer (palliation):
  • Metal stent (first choice)
  • Surgical bypass (hepaticojejunostomy plus gastrojejunostomy) if found at laparotomy or duodenal obstruction
  • Duodenal stent for gastric outlet obstruction
  • Coeliac plexus block for pain; chemotherapy

10. Complications

• Cholangitis, liver abscess
• Acute kidney injury (hepatorenal syndrome)
• Coagulopathy, bleeding
• Malabsorption, weight loss, vitamin deficiencies (A, D, E, K)
• Secondary biliary cirrhosis, liver failure
• Wound breakdown, infection after surgery
• Procedures → post-ERCP pancreatitis, perforation, stent occlusion or migration, bile leak, haemobilia (PTBD)