Management of Obstructive Jaundice

Management of Obstructive Jaundice:

Yellowing of the skin and whites of the eyes, light-colored stools, and dark urine could be signs of obstructive jaundice – a condition where normal drainage of bile from the liver to the small intestines is blocked.

Obstructive jaundice is not a disease in itself but a symptom of an underlying condition involving the liver, the gallbladder, or the pancreas. It will usually require surgical intervention, and is also known as surgical jaundice. The most common cause of obstructive jaundice here is gallstones causing a blockage in the drainage of the pathway of bile.

The liver produces bile to digest food and deliver waste products to the intestines for elimination. When bile drainage is obstructed, bilirubin – a byproduct of red cell recycling – builds up in the liver and spills over to the bloodstream, causing the skin and whites of the eyes to turn yellowish.

What are the causes of Obstructive Jaundice?

It is important to distinguish between the possible causes of obstructive jaundice. While the common causes are related to gallstone disease, the more sinister causes are related to cancer (pancreatic cancer, ​bile duct cancer, or less commonly liver cancer).

Painful obstructive jaundice is usually related to gallstones, while painless obstructive jaundice tends to be related to tumours. The reason for this difference is that stones tend to harbour bacteria and cause bile duct infection, resulting in pain and fever.

Interestingly, as pain is not a key feature for malignant causes, patients with tumours tend to seek expert help later. These patients may also have worrisome symptoms of weight loss and loss of appetite.

Two types of jaundice (surgical and medical jaundice):

Obstructive or surgical jaundice is different from medical jaundice. Patients with medical jaundice will have yellowing of the skin, without dark urine or light-colored stools.

Medical jaundice can be related to:

  • Hepatocellular jaundice – caused by a liver condition such as hepatitis and liver cirrhosis; and
  • Haemolytic jaundice (blood disorder) – a result of increased breakdown of red blood cells due to underlying conditions such as thalassemia, autoimmune disease, or malaria.

All these types of jaundice lead to an abnormal increase of bilirubin, causing the yellowing of the skin.

What causes obstructive jaundice (surgical jaundice)?

As mentioned above, there are both benign and malignant causes of obstructive jaundice.

  • Benign causes: Gallstones or cysts in the bile ducts (choledochal cyst), narrowing of the bile ducts (bile duct strictures), and pancreatitis (inflammation of the pancreas).
  • Malignant causes: Cancerous tumors in the pancreas, bile duct, gallbladder, and liver.

Malignancy causing complete blockage of bile can result in significant itching due to accumulation of bile pigments within the skin, and malnutrition as bile is part of the digestive system.​

Signs of obstructive jaundice:

Watch out for yellowing of the skin and the whites of the eyes, which may be followed by itching of the skin. As the condition worsens, other symptoms may appear:

  • Severe abdominal pain
  • ​​​Fever
  • Chills
  • Vomiting and nausea

Treatment of obstructive jaundice:

Depending on the underlying cause, the doctor may initially prescribe pain medications and antibiotics to treat the infection if the cause is related to gallstone disease. Diagnostic imaging and blood tests will usually be able to distinguish the various causes of jaundice. Definitive treatment will depend on the cause of jaundice.

If gallstones are diagnosed, endoscopic removal of the stones obstructing the bile duct is recommended. Endoscopic stenting is sometimes necessary as a temporary measure to relieve the bile duct obstruction and clear any bacterial infection before definitive surgery. Thereafter, laparoscopic (keyhole surgery) cholecystectomy is advised to remove the gallbladder, from which most gallstones originate.

If the root cause of obstructive jaundice is a malignant tumour, the long-term outcome of such patients is best served if the tumour can be surgically removed.

Such surgery is a major undertaking and patients should be managed by hepato-pancreato-biliary surgeons (surgeons specialising in liver, pancreas and biliary problems). The outcomes of such major surgeries are also better when they are performed in a high-volume and dedicated surgical centre.