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Case 51: Jaundice

A 72 year old man presents with progressive jaundice over 2 weeks. This is associated with dull right upper quadrant pain. His liver function tests are shown below.

1. What are the clinical features of obstructive jaundice?

Obstructive jaundice is characterised by the abscence or reduction of bile flow from the bile canaliculi into the bowel. As such bilirubin and bile salts are reabsorbed into the blood, stain tissues and are excreted in the urine. As such the clinical features are jaundice, pale frothy stools (steatorrhoea), dark urine and generalised pruritus.

2. What is Courvoisier's law and the pathologic basis for it?

Courvoisier's law states that in a jaundiced patient the presence of a palpable gallbladder means that gallstones are unlikely to be the cause. It is important to remember that the converse is not true and an impalpable gallbladder does not mean that stones are the cause.
The basis for this is that a gallbladder containing stones is likely to have been chronically diseased and subject to repeated, although possibly subclinical, episodes of cholesytitis. This results in extensive fibrosis of the gallbladder wall which is then unable to distend when obstructed.

3. What are the differential diagnoses for obstructive jaundice?

As with all hollow tubes obstructive may be related to an intraluminal, intramural or extraluminal pathology. Intraluminal pathology is most commonly gallstones in the common bile duct. In south east Asian populations parasitic worms may infest and obstruct the bile duct. Intramural pathology includes benign and malignant strictures of the bile duct. Benign strictures may relate to previous surgery or other intervention, primary sclerosing cholangitis or ischaemia. Extramural pathology includes benign causes such as compression by a stone in the neck of the gallbladder (Mirizzi syndrome), and malignant causes such as carcinoma of the head of the pancreas or extensive nodal disease at the porta hepatis.

4. What imaging may help determine the diagnosis?

The first line is ultrasound to examine for dilated intra and extrahepatic bile ducts. Ultrasound may also show stones in the gallbladder, liver metastases and occasionally may be able to show pathology in the distal bile duct. CT scans are useful to examine for pancreatic masses, large portal nodes and liver metastases but are not reliable for examining the bile ducts unless performed as a CT cholangiogram. MRCP is an excellent, non-invasive, way of examining the bile ducts and pancreas. ERCP is invasive but allows therapeutic intervention but also gives excellent images of the bile ducts and alows visualisation of the ampulla of Vater.

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