Causes, symptoms, diagnosis and treatment of obstructive jaundice
Content:
- What is obstructive jaundice?
- The causes of obstructive jaundice
- Obstructive jaundice symptoms
- Diagnosis of obstructive jaundice
- Obstructive jaundice treatment
What is obstructive jaundice?
Obstructive jaundice is a pathological syndrome consisting in a violation of the outflow of hepatic bile through the biliary tract into the duodenum due to mechanical obstacles.
Synonyms of the disease: obstructive jaundice, subhepatic jaundice, acholic jaundice, resorption jaundice, extrahepatic cholestasis.
Mechanical obstruction of the biliary tract develops as a complication of a large group of diseases of the pancreas and biliary system (the system of bile ducts and sphincters that regulate the flow of bile) and is accompanied by such general symptoms as icteric color of the skin, mucous membranes and sclera, dark urine, discoloration of feces, cutaneous itching, abdominal pain.
The consequence of progressive jaundice can be liver failure, renal failure, purulent cholangitis, sepsis, biliary cirrhosis or cholangitis liver abscess, in especially severe cases and in the absence of qualified medical care, death.
Among the most common causes of obstructive jaundice are cholelithiasis (29% of cases) and malignant tumors (67% of cases). At the age of 30, cholelithiasis prevails; in the age group of 30-40 years, tumors and gallstone disease as causes of jaundice occur equally often. In patients over 40, tumor neoplasms predominate.
In general, obstructive jaundice is more often diagnosed in women (82%). However, tumor obstruction of the biliary tract is more common in men (54%).
The causes of obstructive jaundice
To date, the causes of obstructive jaundice due to compression of the biliary tract are well studied.
Depending on the etiological factors, they are divided into 5 groups:
- Congenital malformations of the biliary system: hypoplasia and atresia of the biliary tract;
- Benign changes in the biliary system and pancreas caused by cholelithiasis: calculi (stones) in the bile ducts; a diverticulum (protrusion of the wall) of the duodenum and stenosis of the greater duodenal papilla (BDS), located inside the descending part of the duodenum; cicatricial structures of the ducts; cysts; chronic indurative pancreatitis; sclerosing cholangitis;
- Strictures of the main bile ducts as a consequence of surgery (formed as a result of accidental damage to the ducts or improper suture);
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Primary and secondary (metastatic) tumors of the organs of the pancreato-hepatobiliary system: cancer of the gallbladder, cancer of the pancreatic head and OBD, as well as the presence in the liver of metastases of tumors of various localization (common stomach cancer, lymphogranulomatosis);
- Damage to the liver and biliary tract by parasites (alveococcosis, echinococcal cyst, etc.).
The most common cause of obstructive jaundice is tumor neoplasms (liver, biliary tract, pancreatic head) and cholelithiasis. Congenital malformations of the biliary system and parasitic diseases are much less common. In old age, calculous (due to gallstones) and tumor obstruction occurs predominantly, at the age of less than 40 years, the cause is more often gallstone disease.
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Duodenal ulcer and acute appendicitis (in the case of the location of the appendix in the area of the liver gates) are very rare causes of this pathological syndrome.
Cholestasis (a decrease in the flow of bile into the duodenum) occurs most often due to the migration of calculi into the ducts from the gallbladder. The formation of calculi in the ducts themselves is observed much less frequently. They usually pass from the gallbladder to the common bile duct (common bile duct) during an attack of hepatic colic. Blockage of the duct occurs when a large stone cannot pass through it. Sometimes, due to prolonged spasm of the sphincter of Oddi (smooth muscle located in the OBD), even small stones get stuck in the terminal part of the common bile duct.
The presence of stones in the ducts is diagnosed in about 20% of patients with cholelithiasis. Jaundice with cholestasis caused by gallstone disease is transient in 65% of cases. Its symptoms are relieved by the passage of the stones into the intestines. The incidence of stenosis (narrowing) of OBD is 25%.
Tumors of the pancreato-hepatobiliary zone cause jaundice in 37% of cases. Cancer of the pancreatic head and BDS ranks first in frequency, and tumors of the main biliary tract and gallbladder rank second. Tumors of the liver and its ducts are rare.
Obstructive jaundice symptoms
Common symptoms of the disease include:
- Dull pains in the epigastric region and under the ribs on the right, which increase gradually;
- Dark urine and discolored, loose stools;
- Yellowness of the skin, mucous membranes and sclera of the eyes; the icteric color of the skin gradually takes on an earthy tint;
- Itchy skin;
- Nausea, occasionally vomiting;
- Decreased appetite, weight loss
- Increased body temperature;
- In some cases, yellowish cholesterol deposits on the eyelids in the form of well-defined formations protruding above the surface of the skin;
- Enlargement of the liver.
When the bile ducts are blocked by calculi, the pain is spasmodic, sharp, can be given to the chest area, to the right armpit and scapula. External signs of jaundice appear 1-2 days after the weakening of hepatic colic. Palpation of the liver area is painful. The gallbladder is not palpable. Pressing on the area to the right under the ribs causes an involuntary holding of the breath. Nausea and vomiting are possible.
With tumors of the pancreas, OBD, biliary tract, the pain is dull, localized in the epigastric region, and radiates to the back. Palpation reveals a distended gallbladder, pressing on which is painless. The liver is enlarged, has an elastic or dense consistency, in a malignant process it has a nodular structure. The spleen is rarely felt. Outward signs of jaundice are preceded by decreased appetite, itchy skin.
An enlarged liver is a common symptom of prolonged obstructive jaundice. The liver enlarges due to its overflow with stagnant bile and inflammation of the biliary tract.
An enlarged gallbladder is characteristic of tumors of the OBD, the head of the pancreas and the terminal part of the common bile duct. An enlarged liver occurs in 75% of patients, an enlargement of the gallbladder - in 65%, but with laparoscopy it is diagnosed in almost 100% of patients.
Itchy skin often begins to bother even before signs of jaundice appear, especially in the case of tumor genesis of the disease. It is strong, debilitating, and cannot be removed by therapeutic agents. Scratches appear on the skin, small hematomas form. Weight loss is usually seen with cancer-related jaundice.
An increase in temperature is mainly associated with infection of the biliary tract, more rarely - with the collapse of the tumor. A prolonged rise in temperature is a differential sign that distinguishes subhepatic jaundice from viral hepatitis, in which, during the period when signs of jaundice appear, the temperature drops to normal limits.
Obstructive jaundice prognosis
The duration of the disease varies in a wide range: from several days with a short-term blockage of common biliary tract stones to several months with tumor processes. The prognosis of obstructive jaundice is determined by the course of the underlying disease.
Diagnosis of obstructive jaundice
The preliminary diagnosis is not difficult in the presence of an advanced tumor that is easily palpable. But with the initial manifestations of cholestasis, the diagnosis causes certain difficulties, since the patient's complaints and general clinical symptoms can be signs of many diseases. Laboratory methods are of little use for early diagnosis of obstructive jaundice. An increase in cholesterol, bilirubin, and alkaline phosphatase activity is characteristic of both intrahepatic cholestasis and viral hepatitis.
Therefore, the decisive role belongs to instrumental research methods, of which the following are applied:
- Ultrasound diagnostics. Reveals the expansion of the bile ducts, the presence of calculi and focal liver damage. With localization of stones in the gallbladder, the probability of their detection is 90%, with localization in the terminal part of the common bile duct - 25-30%. A rare mistake is the identification of a tumor of the gallbladder as an accumulation of calculi.
- Relaxation duodenography. The method is an X-ray of the duodenum in conditions of its artificial hypotension. It is used to diagnose Frostberg's symptom (deformation of the inner surface of the descending part of the duodenum, as a result of which its contour resembles the letter "E") and the duodenal diverticulum. Frostberg's symptom is a sign of indurative pancreatitis or pancreatic cancer with metastases to the duodenum.
- Endoscopic retrograde cholangiopancreatography (ERCP). It is used in case of insufficient ultrasound results, when OBD blockade is suspected. In this method, a contrast agent is injected into the duct using a cannula (special tube), and then a series of X-rays are taken. RCPH allows diagnosing small tumors, conducting cytological and histological analysis of the epithelium and duct contents. This is a highly informative method, but because it is invasive, it can be accompanied by serious complications.
- Percutaneous transhepatic cholangiography. It is indicated for blockade of the biliary tract at the gate of the liver. In this case, under local anesthesia under the control of ultrasound, a thin needle with a contrast agent is inserted through the skin and liver tissue into one of the hepatic ducts. The number of complications with this method is greater than with RCPH (internal bleeding, bile leakage, peritonitis).
- Radioisotope liver scan. It is used to diagnose tumors and with parasitic lesions of the liver (alveococcosis), when it is difficult to identify a mechanical obstruction in the biliary tract in another way.
- Laparoscopy. This is the most invasive method, and it is used when other methods have proved ineffective in terms of accurate diagnosis. The use of laparoscopy is advisable when detecting metastases, to determine the degree of liver damage in alveococcosis, etc.
Obstructive jaundice treatment
Treatment of this disease is mainly surgical.
Conservative therapy
Includes adherence to a diet with an emphasis on vegetables, fruits, dairy products. Meals should be fractional, dishes should be boiled and mashed. It is recommended to drink as much liquid as possible (juices, water).
Intravenous administration of glucose, B vitamins, Essentiale, methionine or lipocaine (to stimulate blood circulation in the liver), Vikasol (to prevent bleeding), Trental, glutamic acid is carried out. If necessary, antibiotics, plasmapheresis (blood purification), enterosorption (detoxification procedure) are prescribed.
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Operative treatment
Depends on the primary disease causing obstructive jaundice. Depending on this, the following can be carried out:
- External drainage of the bile ducts - restoration of the outflow of bile in case of blockage of the biliary system. It is a minimally invasive method that can be applied routinely.
- Endoscopic cholecystectomy - removal of the gallbladder through endoscopic openings in the abdominal wall.
- Endoscopic papillosphincterotomy - removal of stones from the gallbladder.
- Choledocholithotomy - carried out in conjunction with the removal of the gallbladder and consists in removing stones from the common bile duct, for which its anterior wall is opened.
- Partial hepatectomy - removal of areas of liver tissue affected by the pathological process.
The author of the article: Gorshenina Elena Ivanovna | Gastroenterologist
Education: Diploma in the specialty "General Medicine" received at the Russian State Medical University named after N. I. Pirogova (2005). Postgraduate studies in the specialty "Gastroenterology" - educational and scientific medical center.
