Obstructive Jaundice (Cholestatic Jaundice)

What is Obstructive Jaundice?

Obstructive jaundice, or cholestatic jaundice, is the yellowish discoloration of the skin, sclera and deeper tissue as a result of high plasma levels of bilirubin due to obstruction of bile flow

In obstructive jaundice, the liver cells absorb free bilirubin and it is conjugated within the cell. However, it cannot leave the liver  or sometimes even the liver cell due to a back flow and congestion of bile as a result of an obstruction. Conjugated bilirubin then empties into the bloodstream thereby resulting in jaundice.

Signs and Symptoms of Obstructive Jaundice

The first signs and symptoms include :

• Pale stools
• Dark urine
• Fever, if due to infectious cholangitis
• Sudden abdominal pain, if due to gallstones

This is then followed by :

• Pruritis (itchy skin)

Eventually, jaundice (yellowish skin and eye discoloration) becomes evident.

If left untreated, it will lead to malabsorption, particularly of vitamins A, D, E and K. The effects of these vitamin deficiencies will also be evident. Some of these effects include :

• Steatorrhea (‘fatty stools’)
• Unintentional weight loss
• Softening of the bones (osteomalacia)
• Bleeding disorders
• Muscle pain and weakness
• Abnormal sensations like numbness and tingling

Other late features of obstructive jaundice include xanthomas, which are small nodules of fat on the skin. Eventually, destruction of liver cells (hepatocytes) and biliary cirrhosis may occur, which further complicates the condition.

Other signs and symptoms that may be present are more  likely to be related to the cause. The most common cause of obstructive jaundice is a gallstone causing an obstruction of the common bile duct.

• Abdominal Pain
  • Gallstones – stones are in the common bile duct
  • Choledochal cysts (congenital anomalies of the bile duct)
  • Pancreatitis

• Fever with Abdominal Pain
  • Gallstones
  • Choledochal cyst
  • Stricture

• Abdominal Mass
  • Pancreatitis
  • Choledochal cyst
  • Liver cancer

• Hepatomegaly(Enlarged Liver)
  • Liver cancer
  • Pancreatic cancer is more likely to result in a palpable gallbladder

• Other Causes
• May not present with any additional symptoms except changes in color of the stool and urine and pruritis.
  • Primary sclerosing cholangitis
  • Primary biliary cirrhosis

Causes of Cholestatic Jaundice (Obstructive)

• Gallstones
  • Stones lodged in the common bile duct (choledocholithiasis) prevents the flow of bile.

• Cancer
  • Carcinoma of the bile duct, ampullary, pancreas and liver metastases may result in obstructive jaundice.

• Alcohol and Drugs
  • Leads to hepatitis (liver inflammation) and cirrhosis (fibrosis of liver tissue).
  • Certain drugs may affect the conjugation of bilirubin by disturbing the enzyme glucoronyl transferase.
  • Cholesterol-lowering drugs may increase the chance of gallstone formation.
  • Some of he drugs that may be responsible include :
    • Alpha-methyldopa
    • Antibiotics like isoniazid which is used for TB (tuberculosis)
    • Benzodiazepines like diazepam
    • Methotrexate

• Infections
  • Severe and prolonged bacterial and viral infections accounts for intra-hepatic obstructive jaundice.
  • Parasitic infections like liver flukes usually result in extra-hepatic obstructive jaundice as a result of obstruction in the ducts.

• Primary biliary cirrhosis
  • Destruction of medium-sized bile ducts as a result of inflammation followed by fibrosis.
  • It usually affects the smallest bile ducts within the liver as well as the surrounding liver cells.
  • The exact cause is unknown but it may be linked to autoimmune causes.

• Primary sclerosing cholangitis
  • Chronic inflammation of the bile ducts, leading to hardening of the duct and scar tissue formation.
  • Eventually leads to liver failure.
  • The exact cause is unknown but it may be linked to genetic factors, autoimmune and infectious causes. This condition is more likely to occur in a person with inflammatory bowel disease.

• Biliary stricture
  • Narrowing of the bile duct as a result of the some of the causes mentioned (gallstones, pancreatitis, primary biliary cirrhosis) or trauma (surgery, injury).

• Other causes
  • Amyloidosis
  • Pregnancy
  • Chronic right heart failure
  • Chronic pancreatitis
  • Cystic fibrosis
  • Summerskill-Walshe-Tygstrup syndrome (rare)