Causes of Obstructive Jaundice
Obstructive jaundice is most commonly caused by choledocholithiasis (gallstones in the common bile duct), followed by benign biliary strictures, pancreaticobiliary malignancies (pancreatic cancer, cholangiocarcinoma), and metastatic disease. 1
Primary Etiologic Categories
Benign Causes
- Choledocholithiasis is the single most common cause of obstructive jaundice, representing the majority of cases in clinical practice 1
- Benign biliary strictures can result from prior surgery, chronic inflammation, or trauma to the biliary tree 1
- Chronic pancreatitis causes obstruction through pancreatic fibrosis, edema, or pseudocyst formation compressing the distal common bile duct as it traverses the pancreatic head 2
- Mirrizi's syndrome occurs when an impacted gallstone in the cystic duct or Hartmann's pouch causes extrinsic compression of the common hepatic duct 3
Malignant Causes
- Pancreatic adenocarcinoma is the most common malignant cause, typically presenting with painless jaundice and weight loss 3, 4
- Cholangiocarcinoma (bile duct cancer) can occur at any level of the biliary tree, with hilar tumors (Klatskin tumors) causing proximal obstruction 4
- Hepatocellular carcinoma with bile duct invasion occurs in 1-12% of HCC cases through tumor thrombosis, hemobilia, or direct tumor compression 5
- Metastatic disease to the porta hepatis or pancreatic head from distant primary tumors can cause extrinsic biliary compression 1
Differential Diagnosis Framework
When evaluating obstructive jaundice in chronic pancreatitis specifically, the American College of Radiology identifies three key considerations: choledocholithiasis, pancreatic adenocarcinoma, and Mirrizi's syndrome 3
Clinical Clues to Etiology
- Courvoisier's sign (palpable, non-tender gallbladder with jaundice) has an 87% association with malignancy rather than stone disease 4
- Right upper quadrant pain with fever and rigors indicates cholangitis, most commonly from choledocholithiasis with superimposed infection 4
- Unexplained weight loss and systemic symptoms strongly suggest malignant causes such as cholangiocarcinoma or pancreatic cancer 4
- Age >55 years increases the likelihood of both choledocholithiasis and pancreatic malignancy 4
Mechanisms of Biliary Obstruction in HCC
Hepatocellular carcinoma causes obstructive jaundice through four distinct mechanisms: tumor thrombosis within the bile duct lumen (most common, occurring in 1.2-9% of HCC cases), hemobilia from tumor bleeding, extrinsic tumor compression of bile ducts, and diffuse tumor infiltration of the biliary tree 5
Important Diagnostic Pitfall
A normal common bile duct caliber on ultrasound does NOT exclude obstruction—the negative predictive value is only 95-96%, meaning 4-5% of patients with truly normal-appearing ducts on ultrasound will still have obstruction 4