What are the symptoms of biliary obstruction?

Symptoms of Biliary Obstruction

The most common symptoms of biliary obstruction include jaundice, pale stools, dark urine, pruritus (itching), right upper quadrant pain, and in cases of infection, fever and chills. 1

Clinical Presentation

Primary Symptoms

• Jaundice: Yellowing of skin and sclera due to increased bilirubin levels 1
• Pruritus: Generalized itching due to bile salt accumulation in skin 1
• Pale/clay-colored stools: Due to lack of bile pigments 1
• Dark urine: Due to increased urinary excretion of conjugated bilirubin 1
• Right upper quadrant pain: Often dull and persistent 1, 2

Secondary Symptoms

• Fever and chills: Indicate cholangitis (biliary infection), which is a medical emergency 2
• Malaise and fatigue: Common systemic manifestations, especially with prolonged obstruction 1
• Weight loss: May indicate advanced disease, particularly with malignant obstruction 1

Laboratory Findings

Biliary obstruction typically presents with an obstructive pattern on liver function tests:

• Elevated alkaline phosphatase: Often markedly increased 1
• Elevated gamma-glutamyl transpeptidase (GGT): Confirms biliary origin 1
• Elevated bilirubin: Both direct (conjugated) and total 1, 3
• Relatively normal aminotransferases: May be mildly elevated or normal unless acute obstruction occurs 1
• Prolonged prothrombin time: Due to decreased absorption of vitamin K 1

Complications of Untreated Biliary Obstruction

• Cholangitis: Bacterial infection of the bile ducts presenting with Charcot's triad (fever, RUQ pain, jaundice) in 50-70% of cases 2
• Biliary sepsis: Can progress to septic shock with hypotension and altered mental status (Reynolds' pentad) 2
• Fat-soluble vitamin deficiencies (A, D, E, K): Due to impaired absorption 1
• Secondary biliary cirrhosis: With long-standing obstruction 3
• Hepatic abscesses: Particularly with infected bile 1
• Pancreatitis: When obstruction affects the pancreatic duct 1

Special Considerations

Cholangitis

Cholangitis requires urgent intervention and presents with:

• Fever (>90% of cases)
• Right upper quadrant pain (70% of cases)
• Jaundice (60% of cases) 2

Dominant Strictures

In conditions like primary sclerosing cholangitis (PSC), a dominant stricture (defined as stenosis with diameter ≤1.5 mm in common bile duct or ≤1 mm in hepatic duct) can cause:

• Worsening biochemical indices
• Jaundice
• Pruritus
• Right upper quadrant pain
• Cholangitis 1

Diagnostic Approach

When biliary obstruction is suspected based on symptoms:

1. Laboratory tests: Liver function tests showing obstructive pattern 1
2. Ultrasound: First-line imaging to detect dilated bile ducts and possible stones 3
3. Further imaging: For inconclusive ultrasound with persistent cholestatic profile:
   • MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive with 93% sensitivity and 96% specificity 3
   • ERCP (Endoscopic Retrograde Cholangiopancreatography): Both diagnostic and therapeutic 3

Pitfalls to Avoid

• Missing cholangitis: Failure to recognize fever with jaundice as potential cholangitis requiring urgent intervention 2
• Attributing symptoms to other causes: Pruritus may be mistaken for dermatological conditions 1
• Overlooking biliary obstruction in elderly: May have dilated bile ducts without stones 3
• Delayed intervention: Particularly dangerous in cases of cholangitis or complete obstruction 3

Remember that symptoms of biliary obstruction may vary in presentation and severity depending on the cause, location, and duration of the obstruction. Prompt recognition and appropriate management are essential to prevent serious complications.