EXAMINATION OF SURGICAL

JAUNDICE

PROF THAN WIN

 OBSTRUCTIVE JAUNDICE
• Obstructive jaundice is not a disease in itself

• 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

• But, not all obstructive jaundice are surgical jaundice

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OBSTRUCTIVE JAUNDICE
• In obstructive jaundice, there is the failure of normal
amount of bile to reach the intestine due to the
impediment of bile flow along the hepato-biliary tree
• Surgical jaundice is any jaundice amenable to
surgical treatment
Majority are due to extra-hepatic biliary obstruction
• Not all surgical jaundice is due to obstruction. e.g.
Congenital spherocytosis, here surgical treatment can
be offered as splenectomy

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NORMAL STRUCTURE AND FUNCTION OF THE BILIARY TREE
• Bile is the exocrine secretion of the liver and is produced continuously by hepatocytes
• Contains cholesterol and waste products, such as bilirubin and bile salts, which aid fat digestion
• Catabolism of hemoglobin is a normal function that releases heme molecules, which then
converts to biliverdin, a precursor to bilirubin
• Biliverdin then transforms into unconjugated bilirubin within the reticuloendothelial system
• Being that unconjugated bilirubin is lipid-soluble, the renal system does not eliminate it.
• Unconjugated bilirubin is bound in serum to albumin or exists as free unbound bilirubin
• Unbound bilirubin is taken up by hepatocytes and converted to conjugated bilirubin, which is
water-soluble
• Conjugated bilirubin becomes part of the bile, which is secreted from the hepatocytes in the liver
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NORMAL STRUCTURE AND FUNCTION OF THE BILIARY TREE

• Half the bile produced runs directly from the liver into the duodenum
via the common bile duct
• The remaining 50% is stored in the gallbladder
• In response to a meal, this bile is released from the gallbladder via the
cystic duct, which joins the hepatic ducts from the liver to form the
CBD
• The CBD runs in the hepatodudoenal ligament and then courses
through the head of the pancreas for approximately 2 cm
• It joins the terminal part of the pancreatic duct to form the Ampulla of
Vater before passing through the Papilla of Vater into the duodenum
through the sphincter of Oddi
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 PATHOPHYSIOLOGY
• Biliary obstruction refers to the blockage of any duct that carries bile from the
liver to the gallbladder or from the gallbladder to the small intestine
• This can occur at various levels within the biliary system
• The major signs and symptoms of biliary obstruction result directly from the
accumulation of bilirubin and bile salts in the blood and the failure of bile to
reach its proper destination
• The clinical setting of cholestasis or failure of biliary flow may be due to biliary
obstruction by mechanical means or by metabolic factors in the hepatic cells

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 PATHOPHYSIOLOGY
• Accumulation of bilirubin in the bloodstream and subsequent deposition in the
skin causes jaundice
• Conjunctival icterus is generally a more sensitive sign of hyperbilirubinemia
• Total serum bilirubin values are normally 0.2-1.2 mg/dl
• Jaundice may not be clinically recognizable until levels are at least 3 mg/dl
• Urine bilirubin is normally absent
• When it is present, only conjugated bilirubin is passed into the urine
• This may be evidenced by dark-colored urine
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 PATHOPHYSIOLOGY

• The lack of bilirubin in the intestinal tract is responsible for the pale stools
typically associated with biliary obstruction
• The cause of itching (pruritus) associated with biliary obstruction is not clear
• Some believe it may be related to the accumulation of bile acids/bile salts in the
skin
• Others suggest it may be related to the release of endogenous opioids

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 ETIOLOGY

• Causes of biliary obstruction can be separated

into
• intrahepatic
• extrahepatic
• Most of surgical jaundice are caused by
extrahepatic cause

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 INTRAHEPATIC CHOLESTASIS
• Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary
canalicular membrane
• Causes include hepatocellular disease (eg, viral hepatitis, drug-induced hepatitis),
drug-induced cholestasis, biliary cirrhosis, and alcoholic liver disease
• In hepatocellular disease, interference in the three major steps of bilirubin
metabolism, ie, uptake, conjugation, and excretion, usually occurs
• Excretion is the rate-limiting step and is usually impaired to the greatest extent
• As a result, conjugated bilirubin predominates in the serum
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 EXTRAHEPATIC OBSTRUCTION
• Extrahepatic obstruction to the flow of bile may occur within the ducts or
secondary to external compression
• Overall, gallstones are the most common cause of biliary obstruction
• Other causes of blockage within the ducts include malignancy, infection, and
biliary cirrhosis
• External compression of the ducts may occur secondary to inflammation (eg,
pancreatitis) and malignancy
• Regardless of the cause, the physical obstruction causes a predominantly
conjugated hyperbilirubinemia
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 EXTRAHEPATIC OBSTRUCTION
• Subdivided into intraductal and extraductal.
• Intraductal causes include stone disease, neoplasms, biliary stricture, parasites,
primary sclerosing cholangitis (PSC), AIDS-related cholangiopathy, and biliary
tuberculosis
• Choledochal cysts cause functional biliary obstruction
• Extraductal obstruction caused by external compression of the biliary ducts may
be secondary to neoplasms, pancreatitis (acute and chronic), pancreatic
pseudocysts, collaterals of portal hypertension (portal biliopathy), or cystic duct
stones with subsequent gallbladder distension (Mirizzi syndrome)
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 CAUSES OF SURGICAL JAUNDICE
A. Non-malignant causes
• Congenital
• Biliary atresia, Caroli’s disease, Choledochal cyst
• Calculous
• Gall stone, biliary calculi, mud or sand
• Benign stricture of bile duct
• Postoperative, inflammatory
• Primary sclerosing cholangitis (PSC)
• Parasitic cholangiopathy
• Clonorchis sinensis, Biliary ascariasis
• Benign tumour of bile duct – papilloma, ampullary adenoma
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 CAUSES OF SURGICAL JAUNDICE
B. Malignant causes
• Carcinoma of head of pancreas
• Periamupllary carcinoma
• Cholangiocarcinoma
• Klaskin tumour
• Carcinoma gall bladder infiltrating CHD & CBD
• External compression on hilum by secondary deposit

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 EPIDEMIOLOGY

RACE-RELATED DEMOGRAPHICS

• Depends on the cause of the biliary obstruction

• Gallstones are the most common cause of biliary obstruction
• Persons of Hispanic origin and northern Europeans have a higher risk of
gallstones compared to people from Asia and Africa
• Gallbladder cancer is more common in central and south America, central and
eastern Europe, the northern Indian subcontinent and east Asia (Japan and Korea)
• Oriental cholangiohepatitis (OCH) is seen in the far east

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 EPIDEMIOLOGY
RACE-RELATED DEMOGRAPHICS
• In developed countries, choledocholithiasis secondary to cholesterol stones is the
most common cause of biliary obstruction,
• Whereas brown pigment stones from infectious etiologies or hemolysis are the
most common etiology in Asia.
• Other etiologies like recurrent pyogenic cholangiohepatitis is characterized by
• recurrent bacterial cholangitis, dilatation, and stricture of the biliary tree,
• the presence of calculi within the intrahepatic bile ducts,

• An increased risk for cholangiocarcinoma is common in Asia but rare in the west
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 EPIDEMIOLOGY

SEX-RELATED DEMOGRAPHICS

• Depends on the specific cause of the biliary obstruction

• Women are much more likely to develop gallstones than men
• By the sixth decade, almost 25% of American women develop gallstones, with as
many as 50% of women aged 75 years developing gallstones
• Gallbladder cancer is also more common in females than in males

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CLINICAL PRESENTATION; HISTORY
• Can have very varied presentation depending on the underlying etiology
• It usually presents as jaundice with clay-colored or acholic stools and dark urine
• Patients can have pruritis with chronic biliary obstruction
• Patients depending on underlying etiology can have right upper quadrant abdominal pain, fever,
nausea and vomiting, and weight loss
• Onset of symptoms can be variable ranging from acute development of symptoms to over months
• The following considerations are important:
• Patients' ages and associated conditions
• The presence or absence of pain
• The location and characteristics of the pain
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CLINICAL PRESENTATION; HISTORY
• The following considerations are important:
• The acuteness of the symptoms
• The course of the jaundice (ie, progressive, intermittent, fluctuating)
• The presence of systemic symptoms (eg, fever, anorexia, weight loss)
• Symptoms of gastric outlet obstruction or stasis (eg, early satiety, vomiting,
belching)
• History of anemia
• Previous malignancy
• Known gallstone disease
• Gastrointestinal bleeding
• Hepatitis 19
surgical jaundice
CLINICAL PRESENTATION; HISTORY
• The following considerations are important:
• Previous biliary surgery
• Diabetes or diarrhoea of recent onset

• Abdominal pain may be misleading;

• Some patients with common bile duct calculi have painless jaundice,
• Whereas some patients with hepatitis have distressing pain in the right upper quadrant
• Malignancy is more commonly associated with the absence of pain and tenderness
during the physical examination

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CLINICAL PRESENTATION; PHYSICAL EXAMINATION
• Patient may display signs of jaundice (skin and icterus)
• Look for signs of dissemination of cancer (eg, left supraclavicular lymph node,
umbilical nodule, pelvic deposits on per rectal [P/R] or per vaginal [P/V]
examination)
• When the abdomen is examined, the gallbladder may be palpable (Courvoisier
sign)
• This may be associated with underlying pancreatic malignancy
• Look for signs of weight loss, adenopathies, and occult blood in the stool,
suggesting a neoplastic lesion
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surgical jaundice
CLINICAL PRESENTATION; PHYSICAL EXAMINATION

• Note the presence or absence of splenomegaly, ascites, and collateral circulation

associated with cirrhosis
• Nodular enlarged liver suggests metastases in malignant biliary obstruction
• A high fever and chills suggest a coexisting cholangitis
• Xanthomata are associated with primary biliary cirrhosis (PBC)

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HISTORY
MODE OF ONSET OF JAUNDICE
• Over a few days to a week implies hepatitis, whether drug or toxin induced, viral or bacterial (i.e.,
Leptospirosis)
• Over the course of weeks implies a subacute hepatitis or extrahepatic obstruction due to
malignancy, gallstone, chronic pancreatitis, or stricture in the common bile duct
• Fluctuating intensity implicates gallstones, ampullary carcinoma, or possible drug hepatitis
• Past history of jaundice, although potentially unrelated to the immediate problem, may implicate
chronic hepatitis, cirrhosis, benign recurrent intrahepatic cholestasis, or a genetic nonhemolytic
hyperbilirubinemeia (i.e., Gilbert's or dubin–johnson syndrome) as the cause.

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HISTORY
DOSE THE DISCOLORATION CHANGE WITH TIME ?

• With fasting, stress, menstruation? Gilbert syndrome

IS YOUR URINE DARK?

• Hepatitis

• Alcoholic liver

• Hepatotoxicity

• Biliary obstruction

• Hemolysis (by hemoglobinuria)

ARE YOUR STOOLS PALE ?

• Pale, bulky and oily stool - Biliary obstruction (with dark urine )
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ASSOCIATED SYMPTOMS
PAIN
• Right upper quadrant abdominal pain occurring episodically over months to years, and especially when radiating
to the right scapular area, right shoulder, or around the upper abdomen and back in a girdle distribution, suggests
gallstones
• Persistent epigastric or right upper quadrant pain possibly radiating to the back suggests carcinoma of the head of
the pancreas
• Although hepatocellular jaundice is usually painless, a dull ache or "heavy sensation" in the right upper quadrant
may attend acute hepatitis of any cause
• Painless progressive jaundice – possible malignant jaundice( Ca head of pancreas, periampullary Ca)
• Character of the pain – biliary colic in gall stone disease, persistent dull aching in cholecystitis/ empyaema of gall
bladder
• Does anything increase the pain? – Fatty food - Choledocholithiasis

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ASSOCIATED SYMPTOMS
FEVER
• Frequently accompanies jaundice caused by acute hepatitis, although it usually lasts no more than a
few days.
• Fever associated with chills usually points to biliary obstruction, especially due to stones or stricture
and, less frequently, to malignancy

PRURITUS
• Generalized pruritus usually points to biliary tract obstruction
• Recent onset localizes the level to the large ducts (i.e., Neoplasm) or canaliculi (intrahepatic
cholestasis, most commonly due to drug toxicity or stone)
• A long-standing history of pruritus extending over months to years in a middle-aged woman suggests
primary biliary cirrhosis
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ASSOCIATED SYMPTOMS
PRODROMAL SYMPTOMS BEFORE JAUNDICE
• History of arthralgias and myalgias before yellowing indicates hepatitis, either due to drugs or viral
infections
• Arthritis may also accompany or precede autoimmune hepatitis
WEIGHT LOSS
• Cancer in the head of the pancreas , Alcoholic liver, Hepatobiliary cancer
ANAEMIA OR SPLENOMEGALY

• Pre hepatic – Haemolytic disease

HAEMATEMESIS AND MELAENA
• Cirrhosis of liver
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ASSOCIATED SYMPTOMS

TRAVEL TO ENDEMIC AREA

• Malaria

CHARCOT'S TRIAD
• Charcot's triad consists of intermittent fever, Right Upper Quadrant pain, and fluctuating
jaundice
• It is reported in up to 50-70% of patients with cholangitis
• However, recent studies believe it is more likely to be present in 15-20% of patients
surgical jaundice 28
PAST MEDICAL AND SURGICAL HISTORY

• Similar symptoms (pain) - choledocholithiasis

• Any history of existing liver disease – Cirrhosis of liver
• Sickle cell, thalassemia – Haemolytic jaundice
• IBD such as ulcerative colitis - Primary Sclerosing Cholangitis
• Any autoimmune diseases – Autoimmune hepatitis
• Recently exposed to anyone with hepatitis - hepatitis A or B
• Recent blood transfusion – Haemolysis, Hepatitis B

• Known history Gallstones - choledocholithiasis

• Any surgeries ( especially biliary surgery ) - stricture , retained stone , choledocholithiasis

• Started any new medications recently - TB medication or herbal hepatotoxicity

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FAMILY HISTORY
• Family history of liver disease
• Implicate the genetically transmitted nonhemolytic hyperbilirubinemias (i.e., Crigler–najjar,
Gilbert’s, Dubin–Johnson, or Rotor's syndromes),
• Benign recurrent intrahepatic cholestasis, Wilson's disease, hemochromatosis, alpha-1 antitrypsin
deficiency or hereditary spherocytosis
• Family history of haemolytic disease
• Family history of hepatitis B and C
• Family history of ulcerative colitis

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PERSONAL HISTORY

• Alcohol intake should be documented - How much? How long? – alcoholic liver disease
• Intravenous drugs using history – Hepatitis B, C
• High-risk sexual behaviour
• Any tattoos
• Travelled recently

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SOCIAL HISTORY

• Occupation
• Occupational exposure to barnyard animals, slaughterhouses, or stagnant water may
implicate leptospirosis
• A patient who is immunologically compromised is a potential target for cytomegalovirus or
herpes virus infection, while work in an institution (i.e., Prison, day care center) or health
care facility may implicate hepatitis A or B virus infection
• Water source
• Sanitary system

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DRUG HISTORY

• Hepatotoxic drugs
• Frequent taking history of paracetamol
• Anti TB – Rifampincin

• Herbal medicine

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IMMUNIZATION HISTORY

• Immunization for Hepatitis B

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SYSTEMATIC REVIEW

• Patients with inflammatory bowel disease are predisposed to primary sclerosing cholangitis,
cholangiocarcinoma, chronic hepatitis, cirrhosis, and hepatic amyloid
• A patient with bacterial sepsis due to a wide variety of bacteria may have jaundice without
cholangitis or biliary obstruction
• Pregnancy
• Joint pain and swelling (autoimmune or viral hepatitis, hemochromatosis, primary sclerosing
cholangitis, sarcoidosis)

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PHYSICAL EXAMINATION
GENERAL EXAMINATION
• General appearance is noted, particularly for cachexia and lethargy
• Evaluation of body habitus and nutritional status - Temporal and proximal muscle wasting
suggests malignancy or cirrhosis
• Vital signs are reviewed for fever and signs of systemic toxicity (eg, hypotension, tachycardia)
• Inspection of the sclerae and tongue for icterus and the eyes for kayser-fleischer rings (best seen
with slit lamp).
• Mild jaundice is best seen by examining the sclerae in natural light; it is usually detectable when
serum bilirubin reaches 2 to 2.5 mg/dl (34 to 43 micromol/L)

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GENERAL EXAMINATION
• Well-known stigmata of chronic liver disease, which includes spider nevi, palmar erythema,
gynecomastia, caput medusae, Dupuytren contractures, parotid gland enlargement, and testicular
atrophy

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GENERAL EXAMINATION
• Fetor hepaticus, flapping tremors, personality changes-impending hepatic coma
• Men are checked for testicular atrophy and gynecomastia
• Skin is examined for jaundice, palmar erythema, needle tracks, vascular spiders, excoriations,
xanthomas (consistent with primary biliary cholangitis), paucity of axillary and pubic hair,
hyperpigmentation, ecchymoses, petechiae, and purpura, scratch marks

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Signs of chronic liver insufficiency

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ABDOMINAL EXAMINATION
INSPECTION
• Shape of abdomen – distension – generalised(ascites) / localised(HCC, Ca head
of pancreas, distended gall bladder)
• Note any striae, bruising or scratch marks
• Abnormally prominent veins on the abdominal wall suggest portal
hypertension or vena-caval obstruction - Caput Medusae
• Abdominal mass – distended GB, GOO
• Umbilicus may appear bluish and distended due to an umbilical varix
• Umbilical hernia is a distended and everted umbilicus which does not appear
vascular and may have a palpable cough impulse
• Umbilical nodule - Sister Mary Joseph’s Nodule
• Surgical scars – laparotomy / laparoscopic scars

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ABDOMINAL EXAMINATION
PALPATION
• Tenderness and guarding
• Underlying inflammation and infection – cholangiohepatitis, acute pancreatitis, cholangitis
• Palpable Swellings / Mass
• Palpable gall bladder( Courvoiser’s Law), hepatic nodules, Ca head of pancreas, dilated stomach GOO,
Umbilical hernia, Umbilical nodule(Sister Mary Joseph’s Nodule)
• Palpable liver enlargement
• Hepatitis, HCC
• Splenomegaly
• Portal hypertension– Cirrhosis of liver, Hypersplenism
• Malaria

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ABDOMINAL EXAMINATION

PERCUSSION
• Ascites – cirrhosis of liver, HCC
• Upward enlargement of liver - HCC
• Dilated stomach – Ca head of pancreas, Ca Stomach

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ABDOMINAL EXAMINATION

AUSCULTATION
• Bruit over HCC
• Succussion splash - GOO

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ABDOMINAL EXAMINATION

• Per-rectal examination
• Secondary deposit in rectal shaft, rectal growth
• Examination of genital organ – testicular atrophy

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GENERAL SYSTEMIC EXAMINATION

• Examination of Neck
• Cervical lymph node enlargement, left supraclavicular lymph node enlargement

• Examination of Chest
• Pleural effusion

• Central Nervous System examination

• GCS

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 COMMON CAUSES OF OBSTRUCTIVE JAUNDICE
Suggesting Ca head of pancreas obstructing CBD
• An older patient
• Vague epigastric pain
• Usually painless obstructive jaundice. (Presents with jaundice then later pain. Pain is due
to; involvement of the retropancreatic nerve, obstruction of pancreatic duct, or
disruption of the nerve sheeth by tumour )
• Weight loss
• Progressive deepening jaundice associated with ca pancreas.
• Gall-bladder is palpably enlarged, strongly suggests a malignant obstruction at the lower
end of the common bile-duct, but its absence does not exclude this.

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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

Suggesting Peri-ampullary Carcinoma

• Fluctuating obstructive jaundice (necrosis of the tumour with sloughing with temporary relief of
jaundice)
• Silver coloured stools
• Weight loss and pain is a late feature

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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

Suggesting gallstones / CBD stone

• Severe intermittent colicky pain (painful jaundice- develop pain before jaundice)
• A long history of intermittent varying jaundice (fluctuating jaundice)
• Fever, chills, and rigors (suggesting cholangitis, often complicate the jaundice of gallstones)
• Little or no weight loss,
• Flatulent dyspepsia
• A non-palpable gall-bladder
• A raised white count suggests cholecystitis
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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

Suggesting a Carcinoma of Stomach with secondaries to porta hepatis

• Pain – constant epigastric pain not associated with meal
• Anorexia,
• Vomiting,
• An upper abdominal mass(GOO), and
• Visible peristalsis of pyloric obstruction
• Anaemia is common

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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

Suggesting hepatoma
• A large, hard, irregular liver
• A bruit is often present,
• Ascites is common, and is often bloodstained

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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE

• Ascending cholangitis/ Cholangiohepatitis

• Acute cholangitis results from bacterial superimposed infection on biliary obstruction
• The infection ascends into the hepatic duct causing serious infection
• The classical triad - Charcot triad- RUQ pain, fever, and jaundice
• A pentad - Raynold's pentad- in which alter sensorium and hypotension is added to the triad

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COMMON CAUSES OF OBSTRUCTIVE JAUNDICE
Suggesting carcinoma of the gall-bladder
• The patient is a woman with an enlarged liver and a hard, irregular mass in her right
hypochondrium

Other causes
• Cirrhosis - alcohol intake
• Hepatitis - injections and transfusions
• Hereditary spherocytosis - family history of anaemia, splenectomy and gallstones

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