Phys · gastrointestinal
Obstructive (Surgical) Jaundice
Also known as obstructive jaundice · surgical jaundice · post-hepatic jaundice · extrahepatic biliary obstruction · cholestatic jaundice · choledocholithiasis · malignant biliary obstruction · ascending cholangitis
Consultant-physician-depth guide to obstructive (surgical) jaundice — bilirubin above 50 micromol per litre with predominant conjugated hyperbilirubinaemia, elevated alkaline phosphatase and gamma-GT, pale stools, dark urine, and pruritus. Causes classified by the level of obstruction: extrahepatic (choledocholithiasis as the most common cause, pancreatic head cancer, cholangiocarcinoma, ampullary cancer, biliary stricture, parasitic obstruction, biliary atresia, Mirizzi syndrome, pancreatitis) and intrahepatic cholestasis (drugs, PBC, PSC, viral hepatitis, sepsis, Dubin-Johnson and Rotor, intrahepatic cholestasis of pregnancy). The diagnostic approach from history (biliary colic versus painless jaundice, weight loss, Charcot triad) and examination (Courvoisier sign, scratch marks, asterixis) through investigations (LFT pattern, GGT, coagulation, CA 19-9, ultrasound first-line, MRCP gold-standard, CT for pancreatic mass, EUS-FNA, ERCP therapeutic). Management of the underlying cause, biliary drainage, the Tokyo Guidelines 2018 for cholangitis, pre-operative optimisation with vitamin K, and palliative care for advanced malignancy. Structured for FRACP DWE and DCE, MRCP, and ABIM preparation.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Painless progressive jaundice with weight loss and a palpable gallbladder (Courvoisier sign) — pancreatic or periampullary malignancy until proven otherwise
- Fever, jaundice, and right upper quadrant pain (Charcot triad) with hypotension and confusion (Reynolds pentad) — acute ascending cholangitis requiring urgent biliary drainage
- A rising bilirubin with a non-dilated biliary tree on ultrasound in a patient on flucloxacillin, chlorpromazine, anabolic steroids, or amoxicillin-clavulanate — drug-induced intrahepatic cholestasis
- Obstructive jaundice with markedly elevated amylase — gallstone pancreatitis with ampullary obstruction requiring urgent ERCP
- Prolonged prothrombin time that fails to correct with vitamin K — evolving hepatocellular failure, not simple obstruction
Obstructive (Surgical) Jaundice
[1]Meet the patient
A 68-year-old man presents with two weeks of painless, deepening jaundice, pale stools he cannot flush, and dark urine the colour of strong tea. He has lost six kilograms and his pruritus keeps him awake. On examination his gallbladder is palpable and non-tender. He has no fever and no pain.[1][5]
The three questions that frame his workup are the three that frame every jaundiced patient: is this extrahepatic or intrahepatic? (imaging — ultrasound first, then MRCP), what is the cause? (painless progressive jaundice with a palpable gallbladder is malignancy until proven otherwise — Courvoisier sign), and does he need drainage now? (only if Charcot triad or coagulopathy demands it). The history is the compass — painless and progressive points one way, painful and febrile points another.[1][3]
References8ShowHide
- [1]Kiriyama S, Kozaka K, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos) J Hepatobiliary Pancreat Sci, 2018.PMID 29032610
- [2]Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis Gastrointest Endosc, 2019.PMID 30979521
- [3]Vincent A, Herman J, Schulick R, Hruban RH, Goggins M Pancreatic cancer Lancet, 2011.PMID 21620466
- [4]Ballehaninna UK, Chamberlain RS The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: An evidence based appraisal J Gastrointest Oncol, 2012.PMID 22811878
- [5]Fitzgerald JE, White MJ, Lobo DN Courvoisier's gallbladder: law or sign? World J Surg, 2009.PMID 19190960
- [6]van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ Preoperative biliary drainage for cancer of the head of the pancreas N Engl J Med, 2010.PMID 20071702
- [7]Lindor KD, Kowdley KV, Harrison ME; American College of Gastroenterology ACG Clinical Guideline: Primary Sclerosing Cholangitis Am J Gastroenterol, 2015.PMID 25869391
- [8]Thornton GD, McPhail MJ, Nayagam S, et al. Endoscopic ultrasound guided fine needle aspiration for the diagnosis of pancreatic cystic neoplasms: a meta-analysis Pancreatology, 2013.PMID 23395570