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All about Obstructive Jaundice you need to know - Part 1

In-depth review of the concepts around obstructive jaundice

Continuing with the MCQ which I posted yesterday, today let's go through the answers and in-depth review of the concepts around obstructive jaundice. Here I would try and cover as many surgery viva questions on Obstructive jaundice as I can.

If you want to go through the question again, here is the link.

Firstly in relation to the the picture which was attached to the last post showing the yellow stained sclera of a jaundice person. The first question was

What is the lowest level of bilirubin to detect jaundice in the sclera? 

Answer: At a total serum bilirubin of 42.8 mmol/l (2.5 mg/dl) and 53.0 mmol/l (3.1 mg/dl), 58% (95% confidence interval [CI] 33-80%) and 68% (95% CI 46-85%) of examiners detected the presence of scleral icterus, respectively [1]

Q.2: What can be the cause of this presentation.
1. Liver cirrhosis with spontaneous bacterial peritonitis
2. Carcinoma of periampullary region with spontaneous bacterial peritonitis
3. Acute Fulminant Viral Hepatitis
4. Carcinoma Stomach with liver metastasis and peritoneal seeding

 Answer: 2. Carcinoma of periampullary region with spontaneous bacterial peritonitis

Points in favour of Periampullary Ca
  • Painless progressive jaundice with clay colored stools
  • SAP was found to elevated more than 3 times the normal value and mildly elevated ALT/AST
  • He does not report any fever at the onset of jaundice. The onset of jaundice was Insidious. History of 2 days of fever can be attributed to SBP. 
  • He is a young individual, though he is an alcoholic, but alcoholic liver disease and liver cirrhosis would take quite a long time of exposure to heavy drinking to present.
  • Obstructive jaundice due to metastasis will be seen in advanced stages and usually jaundice will not be the first presenting symptom
To confirm our diagnosis we would do a CECT of the abdomen.

Obstructive Jaundice: Points to remember

Differential Diagnosis of Obstructive Jaundice

Intrahepatic cholestasis.
  1. PBC.
  2. Drugs (for example, phenothiazines).
  3. Primary sclerosing cholangitis
  4. Dubin-Johnson syndrome: autosomal recessive disorder characterised by conjugated hyperbilirubinaemia and deposition of pigment in hepatocytes.
  5. Rotor's syndrome.
Extrahepatic Cholestasis

From within the lumen, in the wall of the duct or from external compression
  1. Choledocholithiasis
  2. Periampullary Ca
  3. Ca Gallbladder
  4. Cholangiocarcinoma involving bile duct
  5. Lymph node mass in the porta causing biliary obstruction
  6. Bile duct stricture
  7. Sclerosing Cholangitis
  8. Chronic Pancreatitis with duct obstruction

What is Courvoisier's Law?

In cases of jaundice:

  • If Gall bladder is palpable, it is not due to choledocholithiasis (Secondary CBD Stone), as it will get fibrosed due to cholecystitis by ongoing disease process and not get distended.

What are exceptions of Courvoisier's Law?

  • Double impact action of stone- one at common bile duct and another at cystic duct
  • Primary CBD stone
  • Distended Gall bladder due to large stone load

---To Be Continued---




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