OBSTRUCTIVE JAUNDICE LONG CASE

What should I gather from patient evaluation?

• First confirm whether it is jaundice or not
• If jaundice, whether it is OJ or medical jaundice
• If OJ, find out whether it is hepatic or extra hepatic OJ
◦ Hepatic OJ can be due to
‣ functional obstruction - drugs, cholestatic phase of hepatitis
‣ organic obstruction - intrahepatic obstruction from HCC/mets
• If extra hepatic
◦ Level of obstruction (at liver hilum or below the cystic duct, if below is it in the CBD or periampullary)
◦ Cause of obstruction
◦ If malignant - extension of the disease
• Complications of OJ

History
• Jaundice - yellowish discolouration of sclera
◦ Onset - sudden, insidious
◦ Duration (short history - benign, relatively long history - likely to be malignant)
◦ Differentiate surgical and medical jaundice
‣ Surgical jaundice - deep jaundice, tea colour urine, pale stool, pruritus
◦ Progressively worsening? (Pancreatic cancer) Intermittent? (Gallstones) Waxing and waning
(fluctuating) jaundice that never reaches the non-jaundice level? (Periampullary cancer)
◦ Has there been previous episodes of jaundice like this?
• Associated with pain or not
◦ Painful? (gallstones, chronic pancreatitis)
◦ painless? (pancreatic cancer)
• If painful
◦ Gallstone pain - biliary colic → acute onset, severe, persistent, RHC pain, radiating along the costal margin to the
back and tip of the right shoulder, increased with meals, associated with nausea and vomiting
◦ Chronic pancreatitis pain - insidious onset, moderately severe, persistent, epigastric pain, radiating to the back,
increased with meals, reduced with bending forwards, generally in a patient with a history of chronic alcohol abuse (but
pancreatitis can occur due to gallstone disease also, just as CP can give rise to OJ. Keep that in mind!)
◦ Differentiate this pain from GORD pain which is commonly present
• Aetiology
◦ Gallstones
‣ If biliary colic pain wasn't asked above, ask it here
‣ Dyspeptic symptoms
‣ PHx of gallstones
‣ H/o haemolytic anaemia
◦ Chronic pancreatitis
‣ If CP pain wasn't asked above (if patient has painless jaundice, no point of asking about CP's pain) ask it here
‣ PHx of CP
‣ Check whether patient is in pancreatic failure or not
• Steatorrhoea (pale foul smelling floating frothy stool) - exocrine failure
• DM - endocrine failure
◦ Mitotic lesion
‣ Significant LOW, LOA and anaemia?
• Ascertain how much of a significant LOW, whether it is intentional or unintentional LOW (>5% of
unintentional weight loss in 3-6 months is significant)
• Ascertain it is truly LOA and not aversion of food due to pain (CP, biliary colic, gastric ulcer patients avoid
food due to fear of pain)
◦ What is the favourite food? do you not like it anymore?
◦ Do you get nausea at the sight or thought of food?
• Anaemia - has it ever been found that you have low haemoglobin? do you have easy fatiguability?
‣ Possible malignancy causes for OJ
• Periampullary cancer
◦ Melaena (they will have fluctuating jaundice) - if black coloured stool, always ask if patient is on iron
tablets or not!
• Cholangiocarcinoma
◦ H/o choledochal cysts
◦ IBD history - h/o alteration of bowel habits, blood and mucous diarrhoea, use of sulphasalazine
 ◦ H/o hepatitis B or C
◦ Liver fluke infection (how to ask this?)
• Porta hepatic LN compression
◦ GOJ tumour - dysphagia with early satiety
◦ Gastric cancer - early satiety, haematemesis
◦ Bowel cancer - PR bleeding, alteration of bowel habits, tenesmus
• HCC
◦ H/o cirrhosis
◦ H/o hepatitis B and C
◦ Consumption of alcohol
◦ Stricture
‣ H/o ERCP and instrumentation
‣ H/o biliary tract surgery
‣ H/o TB - chronic cough, evening pyrexia, contact history of TB
◦ Primary sclerosing cholangitis - insidious onset of fatigue, then marked pruritus, which is then followed by
jaundice (in a middle aged woman with a history of IBD is the classic presentation)
◦ Medical causes
‣ Viral hepatitis
• Blood transfusions
• IV drug abuse
• Tattooing
• Travel to a foreign country
‣ Haemolytic anaemias (by now already asked above)
‣ H/o malaria
‣ H/o parasitic infections
‣ Drug induced
• Anti TB drugs
• Antibiotics - flucloxacillin, sulphas, erythromycin, nitrofurantoin
• OCP
• Paracetamol
• Steroids
• Anti psychotics
‣ Auto immune diseases (primary biliary cirrhosis) - ask whether patient has photosensitive
rashes, joint pains, oral ulcers
◦ Family history of jaundice (Wilson's disease, alpha-1-antitrypsin deficiency, Gilbert, haemolysis)
• Presuming it's a malignancy - ask about metastatic symptoms
◦ Liver
◦ Lung
◦ Bone
• Complications of jaundice
◦ Cholangitis
‣ Fever with chills and rigours, hospital admissions, IV antibiotics'
◦ Hepatorenal syndrome
‣ Hepatic failure
• Bleeding varices - haematemesis (already asked)
• Day time sleepiness (alteration of sleep pattern)
‣ Renal failure
• Reduced urine output
• Body swelling
◦ Disrupted enterohepatic circulation of bile salts
‣ Fat malabsorption - steatorrhoea (already asked as a complication of CP)
‣ Bleeding manifestations - easy bleeding
‣ Night blindness
‣ Osteomalacia - bone pain, muscle pain
• What has been done so far?
◦ ERCP?
◦ Stenting?
◦ CT?
◦ MRCP?
◦ Tumour markers?
• Assess fitness
◦ ASA with PMHx
◦ ECOG score
• PSHx
◦ Cholecystectomy
already asked during 'stricture' part
◦ Bile duct exploration
◦ Ileal resection
• Allergies
◦ Drug, food, plaster, contrast allergy
• Social history
◦ If stent is required - family support is important
◦ Alcohol - has already been asked
◦ Smoking

Examination
• General
◦ BMI
◦ Whether patient is comfortably lying or not
◦ Skin - panniculitis, bullies phemphigous - pancreatitis
◦ Wasting - temporal fossa
◦ Icterus
◦ Pallor
◦ LN - Virchow
◦ Hands
‣ Liver flaps
‣ Palmar erythema
‣ white nails, shiny nails
‣ clubbing
‣ dupuytren's contracture
◦ Gynaecomastia
◦ Extensive scratch marks
◦ Migratory thrombophlebitis
◦ Edema
• Abdomen
◦ Sister Joseph's nodule
◦ Previous surgical scars (laparoscopic cholecystectomy/open Kocher incision)
◦ Dilated veins/spider naevi (liver failure)
◦ Epigastric masses (pancreatic cancer, pseudocyst, porta hepatic LN, gastric cancer)
◦ Liver - HCC, secondary deposit
◦ Palpable gallbladder (obstruction is due to a malignancy and it is below the level of the cystic duct)
◦ Check for spleen (hypersplenism can occur in haemolytic anaemias, splenomegaly can occur in portal hypertension)
◦ Ascites
◦ DRE
‣ Blumer's shelf (finding felt in DRE in pancreatic and gastric cancer)
‣ Check the colour of the stool (pale stool)

SUMMARY
• A 48 year old male with a performance score of ECOG 1 and ASA 1, has come with the complaint of features suggestive of
OJ for a period of 3 months, which is insidious in onset, progressive in nature without a history of intermittency or
fluctuation. Jaundice is painful, where the pain is more of chronic pancreatitis in origin rather than a biliary colic, although his
pancreas is presently not in exocrine or endocrine failure.
• Aetiologically, other than the possibility of CP, I could not find features suggestive of a mitotic lesion, choledocholithiasis, a
biliary stricture, cholestatic jaundice due to medical causes like hepatitis, cirrhosis, drugs, autoimmune conditions or familial
jaundice syndromes.
• His OJ is not complicated by ascending cholangitis, hepatorenal syndrome, or sequale of disrupted enterohepatic circulation
of bile salts such as coagulopathy, fat malabsorption, night blindness, neuromuscular weakness or osteomalacia
• So far he has been investigated with an USS, CECT.
• On examination, he is deeply jaundiced with scratch marks over his body and shiny nails to show for it. He has no features of
liver decompensation or chronic liver disease for that matter.Virchow's node is not present. Abdomen has never been
previously operated on, and there was no intra-abdominal mass. His gallbladder isn’t palpable. His spleen is not enlarged. DRE
did reveal pale stool, but no evidence of Blumer's shelf.