Surgical Jaundice: Clinical Features, Investigation, and Management

1. Classification of Jaundice

2. Causes of Surgical (Extrahepatic) Jaundice

Malignant

• Pancreatic carcinoma (most common malignant cause - painless, progressive)
• Cholangiocarcinoma (hilar = Klatskin tumour; distal)
• Gallbladder carcinoma
• Ampullary carcinoma

Benign

• Choledocholithiasis (most common overall cause - typically painful, fluctuating)
• Primary or secondary sclerosing cholangitis
• Benign biliary strictures (post-operative, traumatic)
• Choledochal cyst / Caroli's disease
• Pancreatic pseudocyst / chronic pancreatitis
• Parasites (Ascaris, Clonorchis)
• Haemobilia
• Ampullary scarring / duodenal diverticulum

3. Clinical Features

History

• Icterus (yellow skin/sclerae)
• Dark urine (bilirubinuria - conjugated bilirubin)
• Pale/clay-coloured stools (absent urobilinogen - bile not reaching gut)
• Pruritus (bile salt deposition in skin)
• Fatigue
• Malabsorption of fat-soluble vitamins (A, D, E, K) with prolonged obstruction

• Fluctuating jaundice - characteristic of CBD stone
• Progressively deepening, painless jaundice - typical of malignancy (especially pancreatic carcinoma)

• Painful obstructive jaundice - most commonly CBD stones (biliary colic - RUQ, colicky, may radiate to back/shoulder)
• Painless obstructive jaundice - most often malignancy

Examination

4. Investigation

A. Biochemical (Liver Function Tests)

B. Additional Blood Tests

• FBC: Leucocytosis (cholangitis); spherocytosis/reticulocytosis (haemolytic); anaemia in malignancy/cirrhosis
• U&E/Creatinine: Baseline renal function (risk of hepatorenal syndrome)
• Coagulation screen: PT, APTT - guide for vitamin K therapy
• Tumour markers: CA 19-9 (cholangiocarcinoma, pancreatic cancer), CEA, AFP (hepatocellular carcinoma)
• Serology: Hepatitis A/B antigens/antibodies, anti-mitochondrial antibodies (primary biliary cholangitis), smooth muscle antibodies, ANA

C. Imaging

• Initial modality of choice
• Reliably demonstrates biliary dilation and level of obstruction
• Sensitivity for CBD stones: only 21-63%
• Can identify: gallstones, dilated CBD (>6 mm with gallbladder in situ = strong predictor of choledocholithiasis), liver mass, pancreatic head lesions

• ERCP: Visualises the biliary and pancreatic ducts; diagnostic and therapeutic in same session; preferred for distal lesions; can obtain brush cytology, bile/pancreatic juice for cytology; successful in >90% of attempts; complications include pancreatitis, cholangitis, duodenal perforation
• PTC (Percutaneous Transhepatic Cholangiography): Visualises proximal biliary tree (above obstruction); preferred for hilar/proximal tumours; >90% success with dilated ducts; complications include bleeding and bile leakage; contraindicated in coagulopathy and significant ascites

ERCP of a patient with obstructive jaundice caused by a malignant hilar tumour - intrahepatic ducts are dilated. (Pye's Surgical Handicraft 22e)

5. Management

A. Resuscitation and Preoperative Preparation

• Bile salt absence impairs fat-soluble vitamin absorption (including Vit K)
• Vit K1 (phytomenadione) 10-20 mg IV/IM daily until operation
• PT should normalise within 12-24 h if liver synthetic function intact
• If PT does not respond to IV Vit K - implies hepatocellular damage; fresh frozen plasma (FFP) may be required

• Surgery in jaundiced patients carries ~20% mortality risk; risk factors include old age, malnutrition, ongoing biliary infection, malignancy, high serum urea
• Adequate IV fluid hydration to prevent hepatorenal syndrome
• Avoid nephrotoxic drugs (NSAIDs, aminoglycosides if possible)
• Monitor urine output

• Malabsorption is common; enteral or parenteral nutrition if indicated

• If cholangitis present: IV broad-spectrum antibiotics (cephalosporins or aminoglycosides) - given before ERCP/intervention
• Prophylactic antibiotics for biliary surgery

B. Management of Cholangitis

• IV fluids + IV antibiotics immediately
• ERCP with biliary decompression within 48 hours - a systematic review (Iqbal et al.) showed ERCP < 48 h was associated with a nearly twofold reduction in mortality; delay >72 h significantly worsens outcome
• Tokyo 2018 Guidelines used for diagnosis and severity stratification of acute cholangitis

C. Non-Operative (Endoscopic/Percutaneous) Treatment

• Treatment of choice for CBD stones (choledocholithiasis)
• Selective cannulation achieved in >90%
• Stent insertion for strictures (plastic or self-expanding metal stents - SEMS)
• For malignant obstruction: SEMS (10 mm or 12 mm) for palliation - a recent meta-analysis (Prata et al., Dig Dis Sci 2025, PMID: 39614024) compared stent calibres for malignant biliary obstruction

• For proximal/hilar lesions or failed ERCP
• Endoprosthesis 2-3.5 mm diameter can be inserted percutaneously
• Mainly used for inoperable malignant obstruction with limited life expectancy

• Indicated when bilirubin >6 mg/dL anticipated for major liver resection (hyperbilirubinaemia impairs hepatic regeneration)
• Allows biliary infection to subside, nutritional correction before surgery
• Note: evidence does not consistently show reduction in operative mortality/morbidity from routine preoperative drainage

D. ASGE Risk Stratification for Choledocholithiasis

E. Operative (Surgical) Management

6. Summary Algorithm

Jaundice
   |
   ├── History & Exam → Painful? Fluctuating? (stone) vs. Painless? Progressive? (malignancy)
   |                  → Courvoisier's sign? Charcot's triad?
   |
   ├── LFTs: Conjugated bili↑, ALP↑↑, GGT↑ → consistent with obstructive
   |    └── PT prolonged → IV Vit K → Corrects: surgical; Does not: hepatocellular
   |
   ├── Ultrasound → Biliary dilatation? Level? Stones?
   |
   ├── CT / MRCP / EUS → Level, cause, staging, FNA
   |
   ├── Cholangitis? → IV fluids + antibiotics + ERCP within 48 h
   |
   ├── Benign obstruction → ERCP + stone extraction / sphincterotomy
   |                      → Surgical CBD exploration if ERCP fails
   |
   └── Malignant obstruction
        ├── Resectable → Surgery (Whipple / extended hepatectomy)
        └── Inoperable → ERCP stenting / PTC / surgical bypass (palliative)

• Current Surgical Therapy, 14th ed. - Obstructive Jaundice: The Role of Endoscopic Intervention (pp. 574-578)
• Pye's Surgical Handicraft, 22nd ed. - Management of patients with obstructive jaundice (pp. 285-290)
• Bailey and Love's Short Practice of Surgery, 28th ed. - Cholangiocarcinoma clinical features
• Sleisenger & Fordtran's GI and Liver Disease - Obstructive Jaundice overview
• Harrison's Principles of Internal Medicine, 22nd ed. - Choledocholithiasis