Eyes are a beautiful part of our body that helps us visualize the world. Everyone knows eyes speak a lot more than words. Same works here. Any defects in the liver and biliary system will be reflecting in our eyes by changing its white color to yellow color. Yes, it is jaundice.
Jaundice - the word itself has yellow (jaunisse) in it. It is the yellowish discoloration of the sclera, mucous membrane, and the skin as a result of increased bilirubin levels in the blood. Let us see how it occurs
Before hitting our brain with causes, we will have a quick review of bilirubin metabolism. As we already saw, bilirubin is the only culprit that turns our eyes yellowish.
What happens?
Usually, when red blood cells after their lifespan, will go and commit suicide in the spleen. That time, it will be lysed into heme and globin. This heme part has iron and biliverdin. This biliverdin will be reduced to unconjugated bilirubin. All these things take place in the reticuloendothelial system. Now, this biliverdin will join with albumin and make its ride towards the liver. Here, with the help of UDP- glucuronosyltransferase it will be changed to conjugated bilirubin(water-soluble). Again it starts its journey to the biliary system and at last enters the small intestine. Due to its large size, the colonic bacteria will change this into urobilinogen and stercobilinogen. This will render the yellow color to the stool. Enterohepatic circulation occurs. Some amount of urobilinogen will be absorbed and lost in urine as it is water-soluble. Anything which alters this condition will lead to the state of hyperbilirubinemia. Based on the condition which alters this jaundice are classified into 3 types.
Types of jaundice
Jaundice can be classified as
- Pre-hepatic jaundice: It is also known as hemolytic jaundice. In this type, due to increased hemolysis of RBC, there will be an increased bilirubin level.
- Hepatic jaundice: This type is due to failure of the liver to conjugate the bilirubin.
- Post-hepatic jaundice: This is due to the obstruction to the flow of bile from the liver to the small intestine.
Another entity, neonatal jaundice is also there. Jaundice in the newborn will be either physiological or pathological. Pathological jaundice occurs within 24 hrs of birth. It will be due to syndrome such as Crigler Najjar syndrome, Dubin Johnson syndrome, etc. More concern will be given to obstructive jaundice in this article.
Surgical jaundice
Surgical jaundice is the name given to obstructive jaundice. Because treatment of this jaundice mainly depends on the surgery. Bilirubin along with bile will enter the common bile duct and at the second part of the duodenum, it will join with the pancreatic duct forming an ampulla of Vater and pour its contents into the duodenum. Lesions occurring in this pathway will result in obstructive jaundice.
Conditions causing obstructive jaundice
Causes can be either congenital or acquired. They are
- Congenital causes such as biliary atresia, a choledochal cyst.
- The most common acquired causes are common bile duct stones and periampullary tumors.
- Luminal causes are biliary stricture, any parasitic infestation.
- Extrinsic causes such as the head of the pancreas tumor, lymph node enlargement, klatskin tumor, etc.
- Inflammatory conditions such as sclerosing cholangitis and ascending cholangitis are also responsible for obstructive jaundice.
Complaints of patients
Yellowish discoloration of the sclera is the usual complaint by the patient. The sclera is the first one to get the yellow color as it has elastin( high affinity to bilirubin). By seeing this we should not jump into the diagnosis of jaundice. Carotenemia due to increased consumption of carrots and sweet potatoes will produce yellowish discoloration of the eyes. Skin will be yellowed when bilirubin is increased above 6 mg/dl.
- If the jaundice is intermittent in course, we can make our diagnosis towards the periampullary carcinoma. Because there will be on and off sloughing of the central necrotic part of the tumor.
- Pruritus: The patient will have disturbed sleep due to the constant itching. And their body will have scratch marks.
- Loss of weight and loss of appetite: this complaint directs our diagnosis towards any tumor.
- Sometimes, the patient will experience pain in the right hypochondrium.
- Fever will be present in case of any inflammatory cause such as cholangitis. In cholangitis, there will be Charcot’s triad( intermittent fever, intermittent jaundice, intermittent pain).
- History of any pale-colored stools(lack of stercobilinogen) and high colored urine(due to increased bilirubin) should be asked.
- Steatorrhoea due to fat malabsorption. Here the stools will be difficult to flus
- On examination, if the doctor finds any palpable mass, the cause will be mostly tumor according to Courvoisier’s law
What is the law?
In the patient with jaundice, if there is a palpable gallbladder, it is not due to stones.
In the case of stones, chronic inflammation in the gallbladder will produce fibrotic change and make it non-distensible. So there will be no palpable gallbladder.
In malignancy, the gallbladder will be distended due to obstruction.
There will be some exceptional cases. They are double impacted stones, large stones in Hartmann’s pouch, empyema gallbladder with CBD stones.
Sequale of obstructive jaundice
- Bile is the one responsible for fat absorption. In the case of obstructive jaundice, bile will be not available. So, fat-soluble vitamins are deficient( A, D, E, and K).
- Vitamin-A deficiency produces visual problems, vitamin-D deficiency produces bone weakness, vitamin-E deficiency produces peripheral neuropathies.
- Vitamin-K dependent clotting factors will be reduced. So there will be prolonged Prothrombin time.
- Bile stasis itself produces cholangitis.
Hepatorenal syndrome is an important complication of obstructive jaundice.
Work up
Following things are to be performed,
- Blood investigation such as Hb, TBC is done.
- Van den berg test can be performed. Here the result will be direct positive due to increased conjugated bilirubin.
- Coagulation profile can be done. Here prothrombin time will be increased.
- Serum alkaline phosphatase level will be increased in obstructive jaundice.
- Ultrasound abdomen is the main investigation to be done. Gallstones will show posterior acoustic shadow.
- CECT can help identify the tumor and its extent.
- ERCP or MRCP can be done. The stones will appear as filling defects in the CBD and tumors will have an irregular filling.
- Tumor markers such as CA19/0 will be increased in the case of the head of the pancreas tumor.
- Other investigations such as Endoscopic Ultrasound(EUS), urine tests are performed.
Steps to make patients happy
- Once causes are treated, jaundice will disappear.
- We can help the patient to have a nice sleep by advising the warm bath or oatmeal bath for pruritus. If it is not working, we can provide them with bile acid sequestrants such as Cholestyramine or colestipol.
- In the case of CBD stones, we can go with ERCP stone removal.
- If it is not done with ERCP, we can do choledocholithotomy with cholecystectomy followed by insertion of T- tube to maintain the patency of the tube.
- With the above procedure, there will be a chance of a biliary leak. The best solution is combining the above procedure with choledochoduodenostomy.
- Periampullary carcinoma can be surgically treated with Whipple’s procedure. In this operation, the growth along with the C loop of the duodenum, proximal jejunum, head of the pancreas, and partial gastrectomy is done. And this is followed by anastomosis. It will be created as pancreaticojejunal, gastrojejunostomy, and choledochojejunostomy anastomosis.
- Another technique is the triple bypass procedure. This is a palliative surgery. Cholecystojejunostomy, gastrojejunostomy, entero-enterostomy are done.
- For biliary stricture cases, stenting can be done.
- In the case of non-operable cases of tumor, stenting can be done for drainage of bile as palliative care.
Reference
- SRB’s Manual of Surgery 6th edition page no:646 to 649
- https://www.ncbi.nlm.nih.gov/books/NBK532930
Authors footnote
Feel free to click on the references for a more in-depth reading if you so desire.
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