Painless Jaundice

I saw an older male patient yesterday who had painless jaundice.  This is one of the conditions every medical student learns has cancer until proven otherwise.  Although there is a big list of causes of jaundice, in older adults who develop jaundice without having significant abdominal pain a less than acute cause of obstruction of the outflow of bile is the most common cause.  Unfortunately the cause of this obstruction is most often a cancer that blocks the outflow of bile.

This patient had presented to our same day clinic three days previously, and had liver function tests as well as testing for hepatitis A,B and C, as well as an abdominal ultrasound ordered.  The LFTs showed significant elevation of the transaminases, a bilirubin of 5.6, and the tests for viral hepatitis were all negative.  The ultrasound added some hope with a gall bladder full of stones, but no common bile duct stone seen on the scan, and the common bile duct was dilated to 16 mm, far larger than normal.

The anatomy of the outflow of bile from the liver and gall bladder is fairly simple to think about, and the pancreatic duct empties into the common bile duct near where the cystic duct from the gall bladder joins the common bile duct.  The head of the pancreas is near this area, and cancer of the head of the pancreas can cause obstructive jaundice of the bile duct.  Cancers of the gall bladder or common bile duct can also cause jaundice as a presenting symptom.  Cancers metastatic to the liver can also cause jaundice by obstruction of intrahepatic bile ducts.

I’m praying that this patient has a common bile duct stone and obstruction that can be cured with removal of the stone and cholecystectomy, but know that it is likely that the stones are not the problem.

Other causes of jaundice include the many types of cellular inflammation of the liver called hepatitis, overly rapid breakdown of red blood cells called hemolysis that can overload the liver with hemoglobin that is metabolized into bilirubin and can lead to jaundice, bile duct disorders like the autoimmune disorder called primary sclerosing cholangitis, and other causes of bile duct obstruction.  Still common things being common I am anxiously awaiting word from my gastroenterology consultant on the results of the ERCP (endoscopic retrograde cholangiopancreatography- a test where a scope passed through the stomach into the duodenum is used to inject dye into the bile and pancreatic ducts) to see what is causing my patient’s jaundice symptoms.

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