Introduction
Obstructive-icteric syndrome is a set of clinical and laboratory changes caused by mechanical interruption of bile flow from the liver to the duodenum. This topic covers its definition, causes and classification, clinical picture, diagnostic approach with differential diagnosis, and the principles of surgical and endoscopic treatment.
Definition and pathophysiology
Obstructive jaundice (also called cholestatic jaundice) is a yellow discolouration of skin and sclera caused by retention of conjugated bilirubin due to blockage of the bile ducts. When the outflow is obstructed, conjugated bilirubin and bile acids regurgitate into the blood. Conjugated bilirubin is water-soluble, so it appears in the urine, while stercobilinogen no longer reaches the intestine, so the stool becomes pale. Bile acid retention causes intense pruritus. Rising pressure in the biliary tree can lead to infection and damage to the liver parenchyma.
Classification and causes
The syndrome is classified by the site of obstruction. Extrahepatic causes are the most common in surgical practice.
Clinical features
- Jaundice with dark urine and pale (acholic) stools
- Pruritus, often severe and worse at night, caused by bile salts in the skin
- Pain in the right upper quadrant: colicky with stones, dull or absent with malignancy
- Painless, enlarged palpable gallbladder (Courvoisier sign), which suggests a malignant cause of obstruction
- Weight loss, anorexia and weakness in malignant disease
- Hepatomegaly and bleeding tendency from vitamin K malabsorption
- Charcot triad of ascending cholangitis: fever with chills, jaundice and right upper quadrant pain
- Reynolds pentad, Charcot triad plus hypotension and altered mental status, indicates severe septic cholangitis, a surgical emergency