Is Obstructive Jaundice Always Cancer?

What obstructive jaundice is

It is jaundice that develops when bile cannot drain from the liver into the bowel because of a physical blockage. Bilirubin builds up in the blood, which makes the eyes and skin turn yellow, the urine dark and the stool pale, and itching may appear. The blockage can be a stone in the bile duct, a benign narrowing of the duct or a tumor of the head of the pancreas, the bile ducts or the major duodenal papilla.

How jaundice develops with tumors and how bile drainage is restored is described on the page on obstructive jaundice.

Is obstructive jaundice always cancer?

No. Its cause is often a stone in the bile duct. Pain in the upper right abdomen, nausea and fever more often come with a stone, while painless jaundice that builds up gradually more often raises concern about a tumor. But symptoms alone cannot reliably tell the cause: pain can occur with a tumor, and painless jaundice can occur with stones, so the cause is found through tests.

How the cause is found

The first steps are blood tests for liver function and an abdominal ultrasound. Together they show how likely a stone in the duct is. If suspicion remains but no stone is seen on ultrasound, endoscopic ultrasound or MRI of the bile ducts (MRCP) is done^[1].

If a tumor is suspected, contrast-enhanced CT and/or MRI showing the bile ducts is needed. It is best done before a stent is placed: a stent distorts the images and makes it harder to judge how far the tumor has spread. That is why I ask, whenever possible, to show the scans to a surgeon before drainage. The exception is cholangitis and other emergencies: then bile drainage is restored at once, without waiting for CT. An uncovered metal stent should not be placed in a duct outside the liver hilum while the cause of the narrowing is still unknown^[2].

If the cause is a stone

Stones in the common bile duct should be removed in everyone fit enough for the procedure, even if they cause no symptoms^[1]. This is usually done endoscopically, during ERCP.

If a stone has caused cholangitis, bile drainage is restored mainly endoscopically, and the timing depends on severity. In severe cholangitis it is done as soon as possible, and within 12 hours in septic shock; in moderate cholangitis within 48–72 hours, and in mild cholangitis electively^[1]. After the stones are cleared from the duct, laparoscopic removal of the gallbladder is also advised, preferably within two weeks of ERCP, to lower the risk of repeat attacks^[1]. For more on gallstone disease, see the page on gallstones.

If the cause is a tumor: drainage or straight to surgery

It seems logical to relieve the jaundice first and operate afterwards. But research has shown that this should not be done for everyone. A randomized trial in patients with cancer of the head of the pancreas and obstructive jaundice compared 4–6 weeks of duct drainage before surgery with surgery within a week of diagnosis. Serious complications within 120 days occurred in 74% of patients with drainage and in 39% of those who had surgery straight away. Mortality and length of hospital stay did not differ significantly between the groups. Importantly, the trial included patients with bilirubin of 40–250 µmol/L, that is, without very severe jaundice^[3].

That is why the European guideline does not recommend routine duct drainage before surgery for tumors outside the liver hilum. A drain is placed when there is cholangitis, severe jaundice symptoms such as unbearable itching, when surgery has to be delayed, or before chemotherapy planned ahead of surgery^[2]. If drainage is needed, endoscopic placement of a 10 mm self-expandable metal stent is recommended^[2]. Which stent to use and when is decided together with the surgeon who is planning the operation.

Tumors at the liver hilum, such as a Klatskin tumor, are a separate story. Routine drainage is not recommended here either, but it is used for cholangitis or when the part of the liver that will remain after surgery is small, and then that part is drained. The decision is made by the team planning the operation^[2]. Whether radical surgery is possible and what to do if the tumor cannot be removed is described on the page on obstructive jaundice.

What to do if you have jaundice

1. Do not delay testsJaundice always needs its cause to be found. Start with blood tests and an ultrasound.
2. Know the warning signsJaundice with a fever: go to a hospital within 1–2 hours; with pain in the upper right abdomen: see a doctor the same day. Confusion, dizziness, sudden severe weakness: call 103.
3. If a tumor is suspectedIt is best if CT is done before a stent is placed, except in cholangitis. Ask whether you really need a drain and why.
4. Show your results to a surgeonSend your blood tests, CT or MRI: the online consultation is free. We discuss a treatment plan after a full work-up and a multidisciplinary team review.

Sources

1. Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019;51(5):472–491. PMID 30943551
2. Dumonceau JM, Tringali A, Papanikolaou IS, et al. Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline — Updated October 2017. Endoscopy. 2018;50(9):910–930. PMID 30086596
3. van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med. 2010;362(2):129–137. PMID 20071702

This article is for general information and does not replace a consultation: the cause of jaundice is determined from your test results and scans.