CAUSES OF OBSTRUCTIVE JAUNDICE

Original
Article
CAUSES OF OBSTRUCTIVE JAUNDICE
JAVERIA IQBAL, ZAHOOR KHAN, FARYAL GUL AFRIDI, ABDUL WAHAB JAMSHED ALAM,
MOHAMMAD ALAM, MOHAMMAD ZARIN, MOHAMMAD AZIZ WAZIR
Department of Surgery, Surgical ‘D’ Ward, Khyber Teaching Hospital, Peshawar
ABSTRACT
Objective: To evaluate the causes of obstructive jaundice in our set-up.
Design & Duration: Prospective, cross sectional study from July 2005 to December 2006.
Setting: Surgical ‘D’ Ward, Khyber Teaching Hospital, Peshawar.
Patients: A total of 50 cases of obstructive jaundice were included in the study. Patients who were lost to follow-up
were excluded.
Methodology: All cases were thoroughly investigated and their cause established. Different procedures were performed
and the patients discharged home after their condition stabilized. They were followed-up and assesed for short and
long term complications.
Results: Out of the total 50 patients half (25) were males and the rest females. Their age of the patients ranged from
46 to 93 years. All patients had jaundice, while abdominal pain, pruritis and abdominal mass were other presenting
complaints. The causes of obstructive jaundice included gall stones in 20 (40%) patients, mass head of pancreas in
16 (32%), and biliary strictures in 4 (8%) cases while hepatic abscesses, pseudopancreatic cyst, cholangiocarcinoma,
choledochal cyst and periampullary carcinoma each accounted for two cases.
Conclusion: Obstructive Jaundice is commonly caused by gall stones, pancreatic tumours, biliary strictures and
malignancies in our set-up.
KEY WORDS: Obstructive Jaundice, Gall Stones, Pancreatic Carcinoma, Biliary Strictures
INTRODUCTION
Obstructive jaundice results from biliary obstruction,
which is blockage of any duct that carries bile from
liver to gall bladder and then to small intestine. 1 Therefore
the causes of obstructive jaundice can be intrahepatic
or extrahepatic. Hepatitis, cirrhosis and hepatocellular
carcinoma are the commonest intrahepatic
causes. 2 Extrahepatic causes are subdivided into intraductal
and extrahepatic aetiologies. Neoplasms, choledocholithiasis,
biliary strictures, parasites and primary
sclerosing cholangitis leads to intraductal obstruction.
External compression of biliary channels by neoplasms
pancreatitis, and cystic duct stones with subsequent gall
bladder distension leads to extraductal obstruction. 3-6
Correspondence:
Dr. M. Zarin, Senior Reg., Surgical ‘D’ Ward,
Khyber Teaching Hospital, Peshawar.
Phones: 091-9216340, 0333-9414477.
E-mail: drmzareen@yahoo.co.uk
Obstructive jaundice, caused by stones, is a common
disorder. 7,8 Stones in the common bile duct occurs in
10-15% of patients with gall stones. These stones account
for more than 80% of common bile duct stones; they
migrate from the gall bladder and are similar in appearance
and chemical composition to the stones found elsewhere
in the biliary tree. Primary bile duct stones may
develop infrequently within the common bile duct many
years after a cholecystectomy and starts as accumulation
of biliary sludge consequent upon dysfunction of
the sphincter of Oddi. In far East countries, CBD stones
are thought to follow bacterial infection secondary to
parasitic infestation with Clonorchis sinensis, Ascaris
lumbricoides or Fasciola hepatica. 9
In investigating obstructive jaundice, ultrasonography
is the gold standard examination. 2 It gives clues for further
investigations including CT scan, Magnetic Resonance
Cholangio-pancreaticography (MRCP), Endoscopic
Retrograde Cholangiopancreaticography (ERCP),
and Percutaneous Cholangiography (PTC). Much work
is on going in the management of obstructive jaundice,
and its treatment modalities have changed from open
cholecystectomy and exploration of the common bile
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Causes of Obstructive Jaundice
Obstructive jaundice is equally prevalent among males
and females. Its main causes are gall stones and maligduct
(CBD) to ERCP and laparoscopic procedures. 10-12
PATIENTS & METHODS
This study was carried out on obstructive jaundice patiadmitted
to the Surgical ‘D’ ward of Khyber Teaching
Hospital, Peshawar. A proforma was designed which
included information about the demography of patients,
symptoms and signs, confirmatory investigations, diagnosis,
treatment, follow-up and the outcome.
The proformas were filled by doctors. Patients who
could not be followed-up were excluded from the study.
All the data collected was compiled and then systematically
analyzed.
RESULTS
A total of 54 patients were seen during the study period
with obstructive jaundice. Out of these four were lost
to follow-up and were excluded. Of the remaining 50
patients, half were males and half females. Their ages
ranged from 46-93 years, the mean age being 62 years
(Table I). All patients presented with jaundice; 34 had
abdominal pain, 23 pruritis and eight abdominal mass
also. The causes of obstructive jaundice included gall
stones in 20(40%) patients, mass head of pancreas in
16(32%) and CBD strictures in 4(8%) patients as shown
in Table II.
DISCUSSION
In our study we discovered that the incidence of obstructive
jaundice was more common amongst middle
aged patients. Gall stones were the aetiological cause
in 20 (40%) patients and malignant tumours in 16 (36%).
cases. Khurram et al also noted gall stones as the commonest
cause of biliary obstruction 1 in their study.
Stone disease was more common among females in this
Table I. Age Incidence
J. Iqbal, Z. Khan, F. G. Afridi, A. W. J. Alam et al
study, while neoplasia was mostly seen in males; a finding
similar to that of other workers. 2 Vargus and Astete
also reported that choledocholithiasis and neoplasia of
the common bile duct ranked as first and third common
diagnosis respectively amongst male patients undergoing
ERCP. 3
Tumours causing biliary channel obstruction are generally
ampullary carcinomas, gall bladder carcinomas
extending into the CBD, metastatic tumours (usually
from the gastrointestinal tract or the breast), secondary
lymphadenopathies at the porta hepatis and cholangiocarcinomas.
4 In our study neoplastic obstructions were
mainly caused by pancreatic tumours; the remaining
being cholangiocarcinomas and the lymphadenopathies
causing extrinsic pressure on the CBD. Biliary related
malignancies occur equally in both sexes. 5
Choledochal cysts were seen in 4% of our cases. They
are congenital cystic dilatations of extra and intra-hepatic
biliary tree, or both. Cholechodal cysts are prevalent
more in Asia, especially Japan, and are 3-4 times more
common in females. 1,6
Retained biliary stones and strictures caused post-cholecystectomy
jaundice in five of our patients. Other authors
also found CBD ligation and traumatic strictures
as the commonest cause of obstructive jaundice after
cholecystectomy. 7,8 Benign non-traumatic inflammatory
stricture of the common bile duct (CBD) may result
in obstructive jaundice which can be misdiagnosed as
a neoplastic lesion 9 ; however malignant strictures of
the biliary tree are not that common. 12
CONCLUSION
Table II. Causes of Obstructive Jaundice
Cause
No.
%
Age Group
40-50 years
50-60 years
60-70 years
70-80 years
80-90 years
> 90 years
No.
6
16
20
4
2
2
%
12
32
40
8
4
4
Gall Stones
Ca. Head Pancreas
Biliary Strictures
Liver Abscess
Pseudopancreatic Cyst
Cholangiocarcinoma
Peri-ampullary Ca.
Choledochal Cyst
20
16
4
2
2
2
2
2
40
32
8
4
4
4
4
4
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Causes of Obstructive Jaundice
nancies. Choledocholithiasis is more common among
females and neoplastic lesions among males.
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