Obstructive jaundice

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Obstructive Jaundice

Definition

Obstructive (post-hepatic / surgical) jaundice is the clinical manifestation of impaired flow of conjugated bilirubin through the biliary tree into the duodenum. The obstruction may be intraluminal, mural, or extramural and can occur anywhere from the intrahepatic bile ducts to the ampulla of Vater.

Current Surgical Therapy 14e, p. 574

Pathophysiology

When bile flow is obstructed:

Conjugated (direct) bilirubin backs up into the bloodstream - it exceeds 50% of total bilirubin.
Bile salts are absent from the gut, impairing fat-soluble vitamin (A, D, E, K) absorption.
Vitamin K deficiency reduces hepatic synthesis of prothrombin, factor V, and factor VII - elevated PT/INR results.
Cholestasis impairs clotting and immunologic responses, raising the risk of cholangitis (Charcot's triad / Reynolds' pentad).
Absent bilirubin in the gut leads to clay/pale stools (acholia) and absent urobilinogen.
Bilirubin filtered by the kidneys produces dark urine.
Accumulation of bile salts in skin causes pruritus.

Causes

Malignant

Tumour	Feature
Pancreatic carcinoma	Most common malignant cause; painless progressive jaundice, Courvoisier's sign
Cholangiocarcinoma	Hilar (Klatskin) or distal
Gallbladder carcinoma	Jaundice usually late
Ampullary carcinoma	Earlier jaundice, relatively better prognosis

Benign

Choledocholithiasis - most common overall cause; painful, fluctuating jaundice, fever (Charcot's triad)
Primary/secondary sclerosing cholangitis
Benign biliary strictures (post-operative)
Choledochal cyst, Caroli's disease
Parasites (e.g., Clonorchis, Ascaris)
Hemobilia, pancreatic pseudocyst, pseudotumoral chronic pancreatitis
Duodenal diverticulum, ampullary scars

Congenital

Biliary atresia
Caroli's disease

Clinical clue: A fluctuating jaundice is characteristic of a stone in the bile duct; a progressively deepening jaundice is typical of carcinoma.

Pye's Surgical Handicraft, p. 285

Clinical Features

Feature	Obstructive Jaundice	Parenchymal Liver Disease
History	Abdominal pain, fever/rigors, prior biliary surgery, acholic stools	Viral prodrome, drug/alcohol exposure, family history of jaundice
Examination	High fever, abdominal tenderness, palpable mass (Courvoisier's gallbladder in pancreatic Ca)	Ascites, spider naevi, gynecomastia, asterixis, encephalopathy, Kayser-Fleischer rings
Labs	Elevated ALP (>3-4x), direct hyperbilirubinemia; PT normalises with vitamin K	Elevated ALT/AST; PT does NOT correct with vitamin K

Goldman-Cecil Medicine, Table 133-3

Laboratory Findings

Test	Finding in Obstructive Jaundice
Serum bilirubin	Direct (conjugated) elevated; >50% of total
Alkaline phosphatase (ALP)	Markedly elevated (3-4x normal) in up to 75% of patients
GGT	Elevated (from bile duct mucosal cells); confirms hepatobiliary origin of ALP rise
5'-nucleotidase	Elevated; correlates with hepatobiliary disorder, not elevated in bone disease
ALT/AST	May be modestly elevated depending on duration
PT/INR	Prolonged due to vitamin K malabsorption; responds to IV vitamin K (distinguishes from hepatocellular disease)
Urobilinogen	Absent in urine (no bilirubin reaching gut to form urobilinogen)
Urine bilirubin	Present (bilirubinuria) - dark urine

Pye's Surgical Handicraft, p. 286; Current Surgical Therapy 14e, p. 574

Investigation and Imaging

Step 1 - Ultrasound (First-line)

The initial imaging modality of choice for suspected bile duct obstruction.
Demonstrates biliary dilation and the level of obstruction in most cases.
If obstruction is at the lower CBD: entire biliary system including gallbladder is dilated.
If obstruction is at the hilar region: only intrahepatic ducts are dilated.
Sensitivity for intraductal stones is limited (21-63%), so further imaging is usually needed.

Step 2 - Advanced Imaging

Modality	Role
MRCP	Non-invasive gold standard; 95% sensitivity for biliary obstruction; best for CBD stones (non-therapeutically); differentiating benign vs. malignant stricture can be challenging
CT scan	Highly sensitive for pancreatic tumours >2 cm; good for metastases
EUS	Excellent for hilar tumours, ampullary region, pancreatic head; allows FNA (sensitivity 84-91%, specificity 71-100% for malignant stricture)
ERCP	Primarily therapeutic; >90% selective cannulation success; gold standard for stone extraction and stenting
PTC	Used when ERCP fails or anatomy is altered

ASGE Risk Stratification for Choledocholithiasis

Predictor Strength	Clinical Signs	Probability
Very strong	CBD stone on US, clinical cholangitis, bilirubin >4 mg/dL	High (>50%)
Strong	Dilated CBD on US (>6 mm), bilirubin 1.8-4 mg/dL (both needed)	High (>50%)
Moderate	Abnormal LFTs, age >55, dilated CBD on cross-sectional imaging	Intermediate (10-50%)

Current Surgical Therapy 14e, p. 575-577

Management

Preoperative Preparation

Correct coagulopathy: Vitamin K1 20 mg IV - normalises PT within 12-24 hours if liver is intact. Repeat PT after vitamin K before operating.
Nutritional correction - obstructed patients are often malnourished.
Treat cholangitis before elective surgery (sepsis control with IV antibiotics, urgent biliary drainage).
Note: surgical mortality in jaundiced patients is ~20%; risk factors include old age, malnutrition, biliary infection, malignancy, and elevated serum urea.

Non-Operative / Endoscopic Drainage

ERCP is the primary non-surgical intervention:

Stone extraction via sphincterotomy + balloon/basket
Dilation of benign strictures
Plastic or self-expanding metal stent (SEMS) placement for malignant obstruction
Indicated for choledocholithiasis, cholangitis, biliary strictures, periampullary tumours

Percutaneous Transhepatic Biliary Drainage (PTBD):

Used when ERCP fails or anatomy precludes endoscopic access
Definitive palliation for malignant obstruction not amenable to surgery

EUS-guided biliary drainage (EUS-BD):

Alternative when ERCP fails; 10-20% adverse event rate (mostly mild-moderate)
Lower cost vs. PTBD with fewer reinterventions

Surgical Management

Directed by location and cause:
- Choledocholithiasis: laparoscopic cholecystectomy + CBD exploration or ERCP stone clearance first
- Hilar strictures/cholangiocarcinoma: biliary-enteric bypass or resection (Whipple for periampullary)
- Distal lesions (pancreatic head tumour): ERCP/stenting for palliation; pancreaticoduodenectomy if resectable
- Focal intrahepatic strictures: interventional radiologic approach preferred
Sleisenger & Fordtran's GI and Liver Disease: for neoplasms - surgery if feasible; for distal lesions amenable - endoscopic (sphincterotomy for choledocholithiasis)

Complications of Untreated Obstruction

Ascending cholangitis (Charcot's triad: fever, RUQ pain, jaundice; Reynolds' pentad adds hypotension + altered consciousness)
Secondary biliary cirrhosis (chronic obstruction)
Hepatorenal syndrome
Septicaemia
Coagulopathy / bleeding

Key Differentiating Points: Obstructive vs. Hepatocellular Jaundice

Parameter	Obstructive	Hepatocellular
Bilirubin	Conjugated (direct) predominant	Both, but unconjugated may be higher
ALP	Markedly elevated	Mildly elevated
ALT/AST	Mildly elevated	Markedly elevated
Urine urobilinogen	Absent	Increased
Urine bilirubin	Present	Present
Stools	Pale/clay	Normal or pale
PT response to Vit K	Yes	No
Pruritus	Common	Less common

Sources: Current Surgical Therapy 14e; Pye's Surgical Handicraft 22nd ed.; Sleisenger & Fordtran's GI and Liver Disease; Goldman-Cecil Medicine International Edition

General examination

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General Examination

General examination is the first and most critical step in clinical assessment. It is a systematic head-to-toe survey performed before regional/systemic examination. The goal is to gain an overall impression of the patient's health status, identify immediately life-threatening problems, and gather clues that guide the focused examination.

1. First Impression (General Appearance)

Before even touching the patient, observe:

Age - stated vs. apparent age (premature ageing suggests chronic illness or malnutrition)
Build and Nutrition - obese / overweight / normal / thin / cachectic / wasted
Posture and Gait - antalgic posture (pain), stooped posture (Parkinson's, ankylosing spondylitis), waddling gait (proximal myopathy/hip disease)
Decubitus (position in bed) - active, passive, or preferential (e.g., patient leans forward in pericarditis, sits upright in acute pulmonary oedema, lies still in peritonitis)
Facial expression - distress, pain, anxiety, depression, blunted affect
Level of consciousness / alertness - conscious, oriented, drowsy, confused
Mood and demeanour - agitated, cooperative, anxious
Speech - dysarthria, aphasia, hoarseness

The examination begins with an assessment of the general appearance: age, posture, demeanour, and overall health status. Is the patient in pain or resting quietly, dyspnoeic or diaphoretic?

Harrison's Principles of Internal Medicine 22e, p. 1903

2. Vital Signs (Always Record)

Parameter	Normal Range	Significance
Temperature	36.5-37.5°C	Fever (infection, malignancy, connective tissue disease); hypothermia (shock, sepsis, hypothyroidism)
Pulse rate	60-100/min	Tachycardia / bradycardia; also note rhythm and character
Blood pressure	<120/80 mmHg	Hypertension, hypotension, postural drop; compare both arms
Respiratory rate	12-18/min	Tachypnoea (commonest sign of physiological deterioration)
SpO₂	≥95%	Hypoxia
Weight + BMI	BMI 18.5-24.9	Underweight (<18.5), overweight (25-29.9), obese (≥30)
Waist circumference	M <94 cm; F <80 cm	Predicts cardiovascular and metabolic risk

3. Facies

Specific facial appearances suggest diagnoses:

Facies	Associated Condition
Hippocratic facies	Peritonitis, near death (sunken eyes, cold sweaty skin, cyanotic lips)
Mitral facies	Bilateral malar flush + cyanosis - mitral stenosis
Cushingoid facies	Moon face, plethora - steroid excess / Cushing's
Acromegalic facies	Enlarged jaw, prognathism, wide nose, coarse features
Myxoedematous facies	Puffy, coarse, periorbital oedema, loss of outer 1/3 eyebrows
Thyrotoxic facies	Staring eyes, exophthalmos, lid lag
Parkinsonian facies	Expressionless (mask-like), reduced blinking
Leonine facies	Leprosy (infiltration gives lion-like appearance)
Mongoloid facies	Down syndrome (trisomy 21) - upward slant, epicanthal folds
Potter's facies	Renal agenesis - wide-set eyes, low ears, beaked nose
Marfanoid habitus	Tall, long limbs, high arched palate, arachnodactyly

4. Skin

Examine for:

Pallor - conjunctival, palmar, nail bed pallor (anaemia)
Jaundice - best seen in sclera (sclerae icterus), skin, and under the tongue in fair skin; seen in sclera before skin
Cyanosis:
- Central - bluish discolouration of lips, tongue, mucous membranes; indicates right-to-left shunt or severe respiratory failure (SpO₂ <85%)
- Peripheral - acrocyanosis of fingertips/toes; reduced peripheral flow (heart failure, shock)
- Differential cyanosis - cyanosis of lower but not upper limbs: patent ductus arteriosus (PDA) + pulmonary hypertension
Pigmentation - increased (Addison's disease, haemochromatosis, pernicious anaemia); decreased (vitiligo, albinism)
Purpura / Petechiae / Bruising - thrombocytopenia, vasculitis, coagulopathy
Xanthomas - tendon xanthomas (hypercholesterolaemia, familial hypercholesterolaemia); eruptive xanthomas (hypertriglyceridaemia)
Spider naevi - >5 on upper body: liver disease (portal hypertension)
Rashes - distribution pattern is diagnostic (butterfly rash of SLE, dermatitis herpetiformis, etc.)
Wounds, scars, ulcers - healed surgical scars (previous operations), leg ulcers (venous vs. arterial)

5. Lymph Nodes

Examine all accessible lymph node groups systematically:

Group	Method	Significance
Cervical (anterior + posterior)	Palpate with patient sitting	Infection (EBV, TB), lymphoma, head/neck malignancy
Submandibular / Submental	Bimanual	Dental infection, oral malignancy
Supraclavicular	Right side: lung/oesophagus; Left side (Virchow's node / Troisier's sign)	Intra-abdominal malignancy (gastric, pancreatic, colonic)
Axillary	Arm supported, examine apex + walls	Breast cancer, lymphoma, arm infections
Inguinal	Horizontal (external iliac drainage) + vertical chain	Genital/anal infection, lower limb melanoma, lymphoma

Characters of lymph nodes to describe: size, shape, surface, consistency (hard, firm, soft, rubbery), tenderness, mobility/fixity, matting, overlying skin changes.

Character	Suggests
Hard, irregular, non-tender, fixed	Metastatic malignancy
Rubbery, firm, non-tender	Lymphoma
Soft, tender, mobile	Reactive (infection)
Matted, fluctuant ± sinus	TB lymphadenopathy

6. Hands

The hands are a "window to systemic disease":

Sign	Location	Significance
Pallor	Palmar creases / nail beds	Anaemia
Clubbing	Fingers (loss of nail angle, Schamroth's sign, fluctuant nail)	Lung Ca, ILD, bronchiectasis, cyanotic heart disease, liver cirrhosis, IBD
Koilonychia	Spoon-shaped nails	Iron deficiency anaemia
Leukonychia	White nails	Hypoalbuminaemia (cirrhosis, nephrotic syndrome)
Lindsay's nails (half-and-half)	Proximal white, distal brown	Chronic kidney disease
Muehrcke's nails	Paired white transverse bands	Hypoalbuminaemia
Splinter haemorrhages	Nail bed linear streaks	Infective endocarditis (also trauma)
Palmar erythema	Thenar/hypothenar redness	Liver disease, pregnancy, RA
Dupuytren's contracture	Palmar fascial thickening	Alcoholic liver disease
Janeway lesions	Non-tender, haemorrhagic, palms/soles	Infective endocarditis
Osler's nodes	Tender nodules on finger pads	Infective endocarditis (immune complex)
Xanthomas	Tendon / dorsum	Hypercholesterolaemia
Arachnodactyly	Long spider fingers	Marfan syndrome
Tremor	Fine resting/intention/postural	Parkinson's, thyrotoxicosis, benign essential
Asterixis	Flapping tremor on wrist extension	Hepatic encephalopathy, uraemia, CO₂ retention

7. Eyes

Sign	Significance
Conjunctival pallor	Anaemia (lower palpebral conjunctiva)
Scleral icterus (jaundice)	Hyperbilirubinaemia (appears when bilirubin >2-3 mg/dL)
Exophthalmos / Proptosis	Graves' disease, retro-orbital tumour
Lid lag / Lid retraction	Thyrotoxicosis
Xanthelasma	Periorbital yellow plaques - hyperlipidaemia (may occur with normal lipids)
Arcus senilis	Corneal lipid ring - normal >60 yrs; hyperlipidaemia if <45 yrs
Kayser-Fleischer rings	Greenish-brown limbal ring (slit lamp) - Wilson's disease
Periorbital oedema	Hypothyroidism, nephrotic syndrome, SLE, angio-oedema
Horner's syndrome	Ptosis, miosis, anhidrosis - apical lung tumour (Pancoast), carotid dissection

8. Mouth and Tongue

Sign	Significance
Central cyanosis	Tongue and mucous membranes blue
Glossitis	Smooth red tongue - B12, folate, iron deficiency
Geographic tongue	Benign migratory glossitis
Angular stomatitis	Iron / B2 (riboflavin) deficiency
Leukoplakia	White patch - premalignant
Gum hypertrophy	Phenytoin, cyclosporin, amlodipine
Telangiectasia	Osler-Weber-Rendu syndrome
Bifid uvula	Loeys-Dietz syndrome
High arched palate	Marfan syndrome
Parotid enlargement	Alcoholism, mumps, Sjögren's

9. Neck

JVP (Jugular Venous Pressure) - elevated in right heart failure, cardiac tamponade, SVC obstruction; measured at 45° (normal <4.5 cm above sternal angle)
Trachea - central or deviated (towards: collapse/fibrosis; away: tension pneumothorax/large effusion)
Thyroid - enlarged (goitre), nodules, bruit over a toxic goitre
Lymphadenopathy (see above)
Carotid pulse - character and bruits

10. Oedema

Type	Location	Cause
Pitting oedema	Ankles/sacrum	Heart failure, hypoalbuminaemia, venous insufficiency, drugs (CCBs)
Non-pitting oedema	Any area	Hypothyroidism (myxoedema), lymphoedema
Sacral oedema	Sacrum (bedridden patients)	Dependent - always check in recumbent patients
Anasarca	Generalised	Severe hypoalbuminaemia, nephrotic syndrome, right heart failure

Testing: Apply firm pressure for 5 seconds over the bony prominence. Pitting = depression remains.

11. Temperature (Body Habitus / Build)

Finding	Interpretation
Obese / overweight	Metabolic syndrome, T2DM, OSA, cardiovascular risk
Thin / cachectic	Malignancy, TB, hyperthyroidism, chronic infection, malabsorption
Short stature	Hypothyroidism, GH deficiency, Turner syndrome, achondroplasia
Tall stature	Marfan, acromegaly (if tall + coarse features), Klinefelter

Sequence of General Examination (Mnemonic: ABCDEFGHIJ)

Letter	Aspect
A	Appearance (general impression, build, nutrition)
B	Behaviour (level of consciousness, mood, cooperation)
C	Colour (pallor, jaundice, cyanosis, pigmentation)
D	Deformities / Dysmorphic features
E	Eyes, Ears, Oropharynx
F	Facies (specific facies)
G	Gait and posture
H	Hands and nails (clubbing, koilonychia, asterixis)
I	Integument (skin, rashes, oedema, hair, nails)
J	JVP + Jugular area; Jugular lymph nodes

Key Points in Surgical Context (Bailey & Love's)

The examination should be performed sequentially, beginning with general inspection looking for evidence of:

Weight loss and dehydration
Pedal oedema
Anaemia (conjunctival pallor, pallor of palmar creases)
Jaundice or abnormal pigmentation
Hands - anaemia or chronic liver disease
Head and neck - liver disease features or cervical lymphadenopathy, particularly left supraclavicular (Virchow's node), suggestive of intra-abdominal malignancy
Vital signs (heart rate, BP, RR, temperature)
Weight and BMI in elective settings
Bailey and Love's Short Practice of Surgery 28e, p. 1076

Sources: Bailey & Love's Short Practice of Surgery 28e; Harrison's Principles of Internal Medicine 22e; Pye's Surgical Handicraft 22e; Textbook of Family Medicine 9e

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