Obstructive Jaundice

Question 1

What is cholestasis?

Answer 1

Obstruction to bile outflow from the liver –> jaundice

Question 2

How can cholestatic jaundice be classified?

Answer 2

Location of the obstruction

• Intrahepatic
• Extrahepatic

Question 3

What are the causes of intrahepatic obstruction?

Answer 3

Obstruction of hepatic bile canniliculi

• Hepatitis
• Cirrhosis
• Neoplasm
• Drugs
• Pregnancy

Question 4

What are the causes of extrahepatic obstruction?

Answer 4

Obstruction of hepatic ducts/biliary tree

• w/i lumen (gallstones)
• w/i wall (cholangiocarcinoma, primary sclerosing cholangitis, congenital atresia of common bile duct)
• external (pancreatitis, tumour of pancreatic head)

Question 5

What are the classical clinical features of obstructive jaundice?

Answer 5

Pale stools

Dark urine

Question 6

What is the underlying pathology of the classical features of obstructive jaundice?

Answer 6

Low bile in gut –> stercobilinogen low –> pale stools
No hepatic recycling –> low urinobilogen
Urinary bilirubin –> dark urine

Question 7

What investigations are appropriate in a patient with suspected obstructive jaundice?

Answer 7

FBC
Reticulocytes
LFTs (HIGH ALP)
U&Es
Clotting
Glucose
Bilirubin
Urinary urobilinogen/bilirubin
USS
MRCP
CT/MRI

Question 8

What is Cholelithiasis?

Answer 8

Formation of stones in gallbladder

Question 9

How prevalent are gallstones?

Answer 9

10% of women in 40s

Increases w/ age

Question 10

What are the two types of gallstone disease?

Answer 10

Cholesterol gallstones

Bile pigment stones

Question 11

What causes cholesterol gallstones?

Answer 11

Cholesterol crystallisation w/i gall bladder

Question 12

What are the risk factors for cholesterol gallstones?

Answer 12

Age
Obesity, high fat diet
Rapid wt loss
Female, multiparity, pregnancy, OCP
DM
Ileal disease
Liver cirrhosis

Question 13

What causes bile pigment stones?

Answer 13

Black pigment gallstones - haemolytic conditions

Brown pigment gallstones - biliary stasis/infection

Question 14

What are the potential consequences of cholelithiasis?

Answer 14

Often asymptomatic
Recurrent symptoms
-pain
-ascending cholangitis
-acute pancreatitis
-obstructive jaundice
-bowel obstruction

Question 15

What are the risk factors for pancreatic adenocarcinoma?

Answer 15

>60
Smoking
Alcohol
Diabetes
Chronic pancreatitis
Genetics

Question 16

What affects the presentation of pancreatic adenocarcinoma?

Answer 16

Location of tumour

Question 17

How do carcinomas of the pancreatic head present?

Answer 17

Present earlier w/ painless jaundice

Signs related to obstructive jaundice

Question 18

How do carcinomas of the body/tail of the pancreas present?

Answer 18

Present later w/ dull abdominal pain radiating to back (relieved by sitting forwards)
Non specific sx common

Question 19

What are the common pancreatic neoplasms?

Answer 19

Ductal adenocarcinomas

• 60% in head
• 25% in body
• 15% in tail

Question 20

Describe islet cell tumours

Answer 20

<2% pancreatic neoplasms

Sx. relate to secreted hormone

Question 21

What are the five types of islet cell tumour?

Answer 21

Insulinoma
Glucagonoma
Gastrinoma
Somatostatinoma
VIPoma

Question 22

What is the prognosis of pancreatic carcinomas?

Answer 22

Mean survival <6/12
5 yr survival <2%
-rises to 5-15% following Whippet’s

Question 23

What pancreatic carcinomas have a better prognosis?

Answer 23

Ampullary/islet cell tumours (present early)