Obstructive Jaundice

Obstructive jaundice is conjugated hyperbilirubinaemia caused by impaired drainage of bile from the liver into the duodenum.

The obstruction may be intrahepatic or extrahepatic, benign or malignant.

Important surgical causes include:

• Choledocholithiasis
• Acute cholangitis
• Benign biliary stricture
• Mirizzi syndrome
• Pancreatic head cancer
• Cholangiocarcinoma
• Ampullary tumour
• Gallbladder cancer

Management requires identification of the level, cause and urgency of obstruction before drainage is performed.

Typical features are:

• Jaundice
• Dark urine
• Pale stool
• Pruritus
• Fat malabsorption with prolonged obstruction

Fever and right upper quadrant pain suggest superimposed cholangitis.

Progressive painless jaundice, weight loss and anorexia should raise concern for malignant obstruction.

Longstanding obstruction can produce vitamin K deficiency and coagulopathy.

Laboratory testing usually demonstrates predominantly conjugated hyperbilirubinaemia with a cholestatic rise in alkaline phosphatase and gamma glutamyl transferase.

Right upper quadrant ultrasound: first investigation; determine whether the biliary tree is dilated and identify the approximate level of obstruction.

MRCP: define biliary anatomy and the obstruction noninvasively.

Contrast CT: particularly important when pancreatic or biliary malignancy is suspected.

Endoscopic ultrasound is useful for distal common bile duct, ampullary and pancreatic lesions and permits tissue acquisition.

ERCP should principally be used when therapy is expected, rather than as a routine diagnostic investigation.

Treat the cause rather than the bilirubin value alone.

Cholangitis

Infection plus obstruction requires urgent antibiotics and biliary decompression.

ERCP is preferred when the obstruction is endoscopically accessible.

Choledocholithiasis

Perform ERCP with sphincterotomy and stone extraction, or operative common bile duct exploration depending on local expertise.

Follow gallbladder derived duct stones with definitive cholecystectomy.

Malignant obstruction

Do not automatically place a biliary stent before potentially curative surgery.

Preoperative drainage is appropriate when there is:

• Acute cholangitis
• Severe symptomatic jaundice with significant organ dysfunction
• Renal impairment attributable to obstruction
• Planned neoadjuvant treatment
• Significant delay before surgery
• Need to optimise a future liver remnant before major hepatectomy

For unresectable malignant obstruction causing jaundice, pruritus, cholangitis or liver dysfunction, internal endoscopic drainage is generally preferred when technically feasible. Percutaneous drainage is used when endoscopic access fails or the anatomy makes it more effective.

Coagulopathy

Check INR in prolonged cholestasis or before invasive procedures.

When vitamin K deficiency is suspected:

Vitamin K 10 mg IV slowly or orally once, then reassess coagulation according to urgency and clinical response.

Failure of INR to correct should prompt consideration of significant hepatic synthetic dysfunction rather than simply escalating vitamin K.

Do not delay urgent biliary drainage in septic cholangitis merely to normalise bilirubin. The immediate objective is decompression of the infected obstructed system.