One-page cheat sheet
Obstructive jaundice
Painless jaundice is cancer until proven otherwise
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Key facts
- Visible jaundice when bilirubin is above about 40–50 µmol/L
- Obstruction: pale stools, dark urine, itching (conjugated bilirubin reaches the urine, none reaches the gut)
- Pre-hepatic (haemolysis) and hepatic causes have different patterns: use the LFTs
Surgical causes
- CBD stones (often painful, fluctuating)
- Pancreatic head, distal bile duct and ampullary cancer (painless, progressive, weight loss)
- Hilar cholangiocarcinoma, metastatic nodes at the porta
- Benign stricture (after surgery), chronic pancreatitis, PSC, Mirizzi syndrome
Investigations
- LFTs: ALP and GGT rise more than ALT; R-factor 2 or less = cholestatic
- INR: often prolonged (no vitamin K absorption): give IV vitamin K
- Ultrasound: dilated ducts? stones?
- Suspected cancer: pancreas-protocol CT before any stent
- MRCP for stones and strictures; EUS ± biopsy; ERCP to treat
Before any procedure
- Correct the INR (vitamin K; FFP or PCC if bleeding)
- Keep well hydrated and watch urine output: risk of acute kidney injury
- Antibiotics for ERCP or surgery when there is cholangitis
- Relieve itching (colestyramine), nutrition support
Treat the cause
- Stones: ERCP clearance, then cholecystectomy
- Resectable pancreatic head cancer: Whipple’s, usually without a stent first unless there is cholangitis or a delay
- Unresectable: metal stent by ERCP, palliative care
Don’t miss
- Cholangitis: fever with jaundice needs urgent drainage
- Courvoisier’s law: palpable non-tender gallbladder suggests malignancy
- Troisier’s sign (Virchow’s node) and Sister Mary Joseph nodule: spread
Exam pearls
- CBD normally up to about 6 mm, wider with age and after cholecystectomy
- Pruritus comes from bile salts, not bilirubin
- Ask about stools, urine, weight loss, itching, alcohol, travel and drugs