What are the symptoms and management of obstructive jaundice?

Symptoms and Management of Obstructive Jaundice

Obstructive jaundice presents with yellowing of the skin and sclera, darkening of the urine, acholic (pale) stools, and pruritus that can manifest out of proportion to serum bilirubin levels, significantly impairing quality of life. 1

Common Symptoms

Primary Symptoms

• Jaundice (yellowing of skin and sclera) (84-90% of cases) 1
• Darkening of the urine 1
• Acholic (pale) stools 1
• Pruritus (itching) - can be severe and disproportionate to bilirubin levels 1

Secondary Symptoms

• Weight loss (35%) 1
• Abdominal pain (30%) - more common in benign obstruction (71%) than malignant obstruction (34%) 1, 2
• Nausea and vomiting (12-25%) 1
• Fever (10%) - may indicate cholangitis 1

Diagnostic Approach

Initial Laboratory Evaluation

• Complete liver profile:
  • Total and fractionated bilirubin (to determine conjugated vs. unconjugated hyperbilirubinemia)
  • AST/ALT (ratio >1.5 suggests alcoholic liver disease)
  • Alkaline phosphatase and GGT (elevated in cholestasis)
  • Albumin and prothrombin time/INR (indicating synthetic function) 3
• Tumor markers: CA19-9 and CEA (supportive for cholangiocarcinoma diagnosis) 1

Imaging Studies

1. Abdominal Ultrasound - First-line imaging:

   • Detects bile duct dilation (sensitivity 32-100%, specificity 71-97%)
   • May identify site of obstruction
   • Can detect gallstones, liver masses, or signs of cirrhosis 1, 3

2. CT Abdomen with Contrast:

   • Better visualization of potential malignancies
   • Helps determine tumor resectability by showing relationship to major vessels 1

3. MRI with MRCP:

   • Superior for visualizing biliary anatomy
   • Higher sensitivity for detecting small stones than CT or US
   • For CBD stones: sensitivity 77-88%, specificity 50-72% 1

4. Endoscopic procedures:

   • ERCP: Reserved primarily for therapeutic intervention rather than diagnosis 3
   • EUS: Useful for detecting small CBD stones (<4mm) and for tissue sampling 1

Management

Biliary Decompression

• Endoscopic biliary drainage (preferred first-line approach):

  • Less invasive and preserves quality of life 1
  • Options include:
    • Plastic stents: Good for short-term use (<3 months) or when response to chemotherapy/radiation is expected
    • Metal stents: Preferred for longer survival (>4 months) with 6-month patency of 81% vs 20% for plastic stents 1

• Percutaneous transhepatic biliary drainage (PTBD):

  • Second-line procedure for patients who have failed ERCP or have difficult anatomy
  • May require temporary external drain if obstruction cannot be easily traversed 1

• EUS-guided biliary drainage (EUS-BD):

  • Alternative when conventional approaches fail
  • Useful after failed ERCP, in altered anatomy, or when tumor occludes access to biliary tree 1

Cause-Specific Management

Malignant Obstruction (64% of cases) 2

• Pancreatic cancer (46% of malignant cases):

  • Palliative stenting for unresectable disease
  • Surgical resection when possible 2
  • Consider palliative radiotherapy or chemotherapy for pain management 1

• Cholangiocarcinoma (29% of malignant cases):

  • Surgical resection if resectable
  • Palliative stenting for unresectable disease 2

Benign Obstruction (36% of cases) 2

• Choledocholithiasis (65% of benign cases):

  • ERCP with sphincterotomy and stone extraction 3

• Biliary strictures (8% of benign cases):

  • Dilation and stenting via ERCP 3

Supportive Care

• Pruritus management:

  • Cholestyramine or other bile acid sequestrants
  • Antihistamines for symptomatic relief

• Nutritional support:

  • Consider pancreatic enzyme replacement for patients with exocrine pancreatic insufficiency 1
  • Dietary consultation for nutritional assessment and support 1

• Pain management:

  • Consider neurolytic sympathectomy for pain control in pancreatic cancer 1

Prognosis

• Malignant obstruction carries a poor prognosis with 2-year mortality rate of 95% 2
• Benign obstruction has a much better prognosis with 78% survival 2

Common Pitfalls and Caveats

• Elevated CA19-9 can occur in non-malignant obstructive jaundice; persistent elevation after decompression is more suggestive of malignancy 1
• Injection of contrast under pressure during PTBD should be avoided as it may lead to cholangio-venous reflux and exacerbate septicemia 1
• Visual estimation of jaundice severity is unreliable, especially in patients with dark skin 3
• Patients with obstructive jaundice may present with painless jaundice (52% of cases), especially with malignant obstruction 2