Overview
Jaundice due to bile duct obstruction caused by elevated serum bilirubin skin, mucous membranes in dark yellow, or even yellow-green, and accompanied by white stools, itchy skin and other symptoms of inflammation, parasites, drugs, stones, tumors and so on can cause obstructive jaundice, including symptomatic treatment, causative treatment, etc.
Definition
Obstructive jaundice is the symptom and sign of yellowing of the skin and mucous membranes due to elevated bilirubin in the blood caused by bile duct obstruction.
Obstructive jaundice can be caused by a variety of primary conditions, including obstruction of the extrahepatic or intrahepatic bile ducts.
Classification
Classification according to the site of obstruction
Intrahepatic bile duct obstructive jaundice: bilirubin metabolism disorders caused by intrahepatic stones, tumor embolism, Chinese testicular schistosomiasis, viral hepatitis, cholestasis caused by medications (e.g. chlorpromazine, methyltestosterone, contraceptive pills, etc.), primary biliary cirrhosis, intrahepatic cholestasis in pregnancy, and other intrahepatic causes.
Extrahepatic bile duct obstruction jaundice: stones, inflammation, tumors, roundworms and other parasites of the common bile duct obstruct the extrahepatic bile duct, causing jaundice manifestations.
Causes
Causes
Extrahepatic bile duct obstruction
Obstruction of extrahepatic bile duct
Choledochal stones (most common).
Biliary roundworm disease.
Bile duct obstruction due to bile duct cancer.
Narrowing of the bile duct due to inflammation or after surgery.
Congenital bile duct atresia.
Compression of the extrahepatic bile ducts
Peripheral primary tumors (e.g., pancreatic head cancer, jugular cancer, cholangiocarcinoma, hepatocellular carcinoma), gallbladder stones compressing the extrahepatic bile ducts from the outside in.
Tumor metastasis to lymph nodes (enlarged lymph nodes around hepatoportal or common bile duct) compressing the extrahepatic bile duct.
Intrahepatic bile duct obstruction
Intrahepatic bile duct obstruction
Mud-like stones in the intrahepatic bile ducts, blocking the bile ducts.
Primary sclerosing cholangitis.
Cancer embolus (mostly hepatocellular carcinoma).
Chinese branch testicular schistosomiasis.
Intrahepatic cholestasis
Viral hepatitis.
Pharmacologic cholestasis (e.g., from chlorpromazine, methyltestosterone, birth control pills).
Intrahepatic cholestasis during pregnancy.
Predisposing factors
Unhealthy dietary habits
If you have irregular diet for a long time or eat greasy, high cholesterol food, such as fatty meat, animal offal, egg yolk or drinking alcohol, stones will easily form in your body, which in turn will induce obstructive jaundice.
Inflammation or injury
Such as acute and chronic inflammation of gallbladder and pancreas, liver and gallbladder trauma, bile duct stenosis after surgery.
Pathogenesis
Due to the obstruction of the bile duct caused by various diseases, a large amount of bile is stagnated upstream of the obstructed part of the bile duct, the pressure in the upper bile duct rises, the bile duct dilates, and bile refluxes into the bloodstream through the ruptured small bile ducts and capillary bile ducts, which causes an increase in blood bilirubin and bile acid salts, and jaundice occurs.
Symptoms
Clinical symptoms of obstructive jaundice are mostly characterized by a yellowish color of the skin, mucous membranes and sclera, and white clay-colored stools with itching of the skin.
Main symptoms
Yellowing of skin, mucous membranes and sclera
It is the most important symptom of obstructive jaundice.
Symptoms usually appear when serum total bilirubin exceeds 34.2 μmol/L.
In the early stage, yellowing of the sclera (the white part of the eye) can be seen when the symptoms are mild.
When the symptoms are obvious, the skin and mucous membranes are dark yellow, and in severe cases, even dark yellow or yellowish green.
White clay-colored stools
When the bile duct is blocked and bile cannot enter the intestines, the color of the stool becomes pale or even white clay-colored.
Itchy skin
Increased blood bilirubin and bile acid salts stimulate the nerve endings of the skin, resulting in itching of the skin.
The skin is often marked by scratching.
Yellow urine
Increased bilirubin in urine and deepening of urine color.
Epigastric pain
Biliary obstruction caused by stones is often accompanied by pain in the right upper abdomen, the nature of the pain is persistent vague pain, dull pain or colic. It is often accompanied by nausea, vomiting, abdominal distension and other digestive symptoms.
Obstructive jaundice caused by biliary roundworms is mainly characterized by drilling pain in the upper abdomen.
Other symptoms
Steatorrhea
Blockage of the bile duct leads to lack of bile in the intestines, and the intestines malabsorb lipids and fat-soluble vitamins, so that a large amount of yellow fat is discharged in the stools in the form of an oily pattern, which is often accompanied by a bad odor.
Fat-soluble vitamin malabsorption, coagulation factor reduction, skin mucous membranes under the easy appearance of bleeding spots.
Lipid malabsorption also leads to osteoporosis.
Fever
Obstructive jaundice caused by acute purulent cholangitis and sclerosing cholangitis can also be characterized by fever, and the body temperature is often above 39℃.
The temperature fluctuates widely, with a range of more than 2℃ within 24h.
Sclerosing cholangitis often persists with low-grade fever for several days.
Wasting, anemia, fatigue
Obstructive jaundice caused by tumor etc. is often accompanied by weight loss, emaciation, anemia and weakness.
Complications
Infection
Stones, roundworms and tumors obstruct the bile ducts and are easily complicated by bacterial infections.
Liver cirrhosis, liver failure
Prolonged obstruction of bile excretion will cause cholestatic cirrhosis, which will eventually lead to liver failure.
Consultation
Department of Medicine
Gastroenterology
When yellowing of the skin and sclera or itching of the skin occurs, it is recommended to consult the Gastroenterology Department in order to find out the cause of the disease.
General Surgery
When there is fever, right upper abdominal pain, yellowing of the skin and sclera, itching of the skin, or the presence of gallbladder stones or common bile duct stones, it is recommended to consult the General Surgery Department or the Department of Hepatobiliary Surgery in a timely manner.
Obstetrics and Gynecology
If itching, jaundice, or skin scratching occurs during pregnancy, it is recommended to consult an obstetrician and gynecologist.
Preparation
Preparing for your visit: registering, preparing documents, FAQs
Tips for seeking medical treatment
Try to keep a record of the symptoms, duration, and information about previous treatment for liver and gallbladder diseases and obstetrics and gynecology, so that you can give your doctor more information.
Take photos of abnormal skin symptoms, such as skin color changes and scratches.
Preparation Checklist for Doctor’s Visit
Symptom list
Particular attention should be paid to the time of symptom onset, special manifestations, etc.
Is there any manifestation of dark urine, yellow sclera, yellow skin, etc.?
Is there skin itching?
Is there fatigue, poor appetite, abdominal pain?
Is there any excess oil, grayish-white stools?
Is there fever?
When did these symptoms appear and how long did they last?
Medical History Checklist
Any gallstones, hepatitis, cirrhosis, cancer?
Is there a history of hepatobiliary surgery?
Is there a history of drug use, with specific names, dosages, and durations?
Is there any alcohol abuse, how much and how long has it lasted?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: urine routine, liver function, etc.
Examination reports: abdominal ultrasound, CT, MRCP, etc.
Medication list
Medication in the last 3 months, if there is a medicine box or package, you can bring it to the doctor
Drugs for lowering bile acids: ursodeoxycholic acid, S-adenosylmethionine.
Drugs for itching: calamine.
Diagnosis
Diagnosis is based on
Medical history
History of gallbladder stones, viral hepatitis, liver and bile duct tumors.
Clinical manifestations
Symptoms
The clinical manifestations of obstructive jaundice are mostly yellow color of skin, mucous membrane and sclera, white clay color of feces, dark urine, and itching of skin.
Physical signs
In case of malignant tumors, a swollen mass can be palpated in the abdomen.
Gallstones and cholecystitis may present with abdominal pressure pain and abdominal muscle tension.
If the disease progresses to cirrhosis, there may be hepatosplenomegaly, and the liver may shrink in the advanced stage, and the abdomen may be positive for mobile turbid sounds.
Laboratory Tests
Liver function
Serum total bilirubin (STB) is elevated (>34.2 μmol/L), conjugated bilirubin (CB) is significantly elevated, and the ratio of conjugated bilirubin to total bilirubin (CB/STB) is >50%.
Serum total bile acids (TBA) were elevated.
Elevated glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP) reflecting bile duct obstruction.
Tumor marker screening
May be slightly elevated and greater than 3 times the upper limit suggests possible biliary malignancy.
Urine routine
Strongly positive urine urobilirubin and decreased or absent urobilinogen.
Imaging
Ultrasound of abdomen
Safe, economical and non-invasive, it can detect the presence of bile duct dilatation and provide preliminary localization and characterization of the site of obstruction.
However, the accuracy of ultrasound can be affected by the interference of duodenal gas in the lower part of the common bile duct.
Abdominal CT examination
CT examination of the upper abdomen is of great significance in the diagnosis of biliary obstruction, especially extrahepatic obstruction.
The CT image of the obstruction site shows a dendritic distribution of low density in strips, and the morphology of the dilated bile ducts is withered, stumpy, and soft vine-like, and there is no enhancement in the enhanced CT image.
Magnetic resonance cholangiopancreatography (MRCP) examination
MRCP is a non-invasive cholangiopancreatography technique utilizing the principle of water imaging.
MRCP can non-invasively show the morphology of the bile ducts and pancreatic ducts inside and outside the liver, which is important for clarifying the site of obstruction and evaluating the surgical approach.
MRCP can make a more objective diagnosis and is especially suitable for patients who have positive initial screening results on ultrasound or CT, but cannot make a definitive diagnosis.
Endoscopic retrograde cholangiopancreatography (ERCP)
ERCP can directly observe the lesions in the jugular abdomen and duodenal papilla through endoscopy, and biopsy can be taken after the lesions are found, which can show whether there are abnormal lesions in the bile ducts and pancreatic ducts.
ERCP can also assist in the incision and extraction of stone surgery, and the placement of stent drainage.
Liver puncture biopsy and laparoscopy
It is an important aid in the diagnosis of difficult jaundice cases.
Hepatic puncture biopsy has the risk of causing bleeding in patients with poor coagulation function, so it should be considered with caution.
Percutaneous Transluminal Cholangiography (PTC)
It can clearly show the entire biliary system and can distinguish between extrahepatic obstructive jaundice and intrahepatic cholestatic jaundice.
It provides an understanding of the site, degree and extent of biliary obstruction.
Endoscopic ultrasound (EUS)
It improves the sensitivity and specificity of ultrasonography by avoiding the interference of open abdomen and intestinal gas.
Ultrasound endoscopy is an option when the ultrasound scan shows dilated intra- and extrahepatic bile ducts or combined pancreatic duct dilatation, but no lesion can be found.
Differential diagnosis
Obstructive jaundice is mainly differentiated from hemolytic jaundice and hepatocellular jaundice.
Jaundice is a symptom with the same points of yellowing of the skin, mucous membranes and sclera, but the degree of yellowing varies with different types of jaundice.
Hemolytic jaundice
The degree of jaundice is less severe than obstructive jaundice, and is often accompanied by anemia such as pale skin.
Acute hemolysis can have fever, chills, headache, vomiting, back pain, and in severe cases, acute renal failure. Chronic hemolysis is mostly congenital, with splenomegaly in addition to anemia.
Laboratory examination: serum iron content is increased, bone marrow smear shows exuberant proliferation of myeloid red system, liver function is normal.
Imaging of the liver and gallbladder may show no abnormal lesions.
Hepatocellular jaundice
Most commonly seen in viral hepatitis, toxic liver injury, cirrhosis, etc., manifested by jaundice, malaise, nausea, loss of appetite, pain or discomfort in the hepatic region, with or without fever.
Laboratory examination of liver function in addition to elevated bilirubin, serum transaminases are often also significantly elevated.
Imaging may show no obstruction.
Treatment
Treatment objective: early relief of obstruction, relief of bile duct pressure, smooth bile drainage, so as to relieve jaundice.
Principle of treatment: choose appropriate medication and surgery according to the symptoms and etiology.
Drug treatment
Analgesic
Antispasmodic and analgesic drugs such as magnesium sulfate, atropine, scopolamine; non-steroidal anti-inflammatory drugs such as diclofenac sodium; opioid analgesic drugs such as tramadol, morphine and so on.
It can be used to reduce the abdominal pain symptoms of obstructive jaundice.
Precautions:Active peptic ulcer, perioperative period of coronary artery bypass graft surgery, and severe heart failure are prohibited.
Anti-infection
Antibiotics:Cefoperazone sodium, ampicillin, etc.
Indicated for obstructive jaundice with bacterial infection.
Hepatoprotection
Commonly used drugs: reduced glutathione, S-adenosylmethionine, silymarin, polyenylphosphatidylcholine and bicyclic alcohol.
Suitable for patients with jaundice caused by impaired bile secretion from hepatocytes.
Anti jaundice
Commonly used drugs: ursodeoxycholic acid, Injenjirubicin and so on.
Used in patients with high bilirubin for choleretic and anti-yellowing treatment.
Anthelmintics
Commonly used drugs: albendazole, chloroquine, etc..
Used in the treatment of biliary ascariasis and trematode.
Chemotherapeutic drugs
Commonly used drugs: Gemcitabine, Fluorouracil, etc.
It can be used in the treatment of pancreatic head cancer and liver cancer. According to the pathological diagnosis of malignant tumor patients, staging, tumor cell division cycle, physical condition of patients, economic situation and other comprehensive selection.
Drugs for itching
Commonly used drugs: kolestenamide, rifampicin.
By reducing the absorption of bile acids, reduce itching symptoms.
Surgical treatment
After the cause of obstructive jaundice is clarified, endoscopic or surgical treatment can be chosen according to the condition, and the surgical method needs to be determined according to the patient’s specific situation.
For obstructive jaundice caused by gallbladder stones or biliary tract infection, cholecystectomy or cholecystectomy and lithotripsy can be used.
For obstructive jaundice caused by malignant tumors, radical surgery or extended radical surgery can be used. For patients who are old, have metastases, have unresectable tumors, or have significant cardiopulmonary dysfunction and cannot tolerate large operations, percutaneous transhepatic puncture choledochotomy and drainage (PTCD), endoscopic nasobiliary drainage (ENBD) and other palliative surgeries may be used to alleviate the symptoms of patients with obstructive jaundice and improve the quality of their survival.
Choledochotomy and exploration and T-tube drainage may be used for those with obstructive jaundice caused by parasites.
Prognosis
Cure
Benign obstructive jaundice due to stones, inflammation, parasites, etc. can usually be cured after medication or endoscopic or surgical treatment.
Tumor-induced obstructive jaundice can be cured by surgical treatment if not metastasized; if metastasis occurs, the quality of life can be improved by active surgical treatment or palliative surgery.
If obstructive jaundice is not treated in time, it is easy to induce hemorrhage and perforation at the obstruction site, as well as liver failure and other complications, which may lead to death in serious cases.
Daily
Daily Management
Dietary management
Regular eating, diet should be low fat, high protein, light and easy to digest.
Reduce the intake of high cholesterol food.
Consume more fresh vegetables and fruits.
Stop smoking and drinking.
Life Management
For pregnant women, rest appropriately, left lateral lying position mainly to increase placental blood flow.
Keep the skin of itchy area clean and dry, avoid scratching and infection.
Change underwear frequently to increase comfort, and the itchy part can be washed with warm water.
Live a regular life, avoid staying up late.
Pay attention to rest, before the condition is not effectively controlled, exercise is not recommended. Patients who have recovered reasonably well after surgery can exercise appropriately and gradually return to the activity level before the onset of the disease.
Psychological management
Listen carefully to the patient’s complaints, advise the patient to distract his/her energy according to his/her own interests such as listening to music, reading books, watching TV, etc., provide positive psychological support and reduce anxiety.
Maintain a positive and optimistic state of mind and avoid adverse emotions such as mental tension and anxiety.
Prevention
In daily life, pay attention to balanced nutrition, regular diet, avoid long-term large amount of high cholesterol, greasy food, can to a certain extent to avoid the formation of gallstones, cholecystitis.
Paying attention to personal hygiene and washing hands before and after meals can prevent obstructive jaundice caused by biliary ascariasis to a certain extent.
Regular medical checkups and timely treatment of early lesions can also help prevent the formation of gallstones and cholecystitis.