CLINICAL APPROACH TO

A CASE OF OBSTRUCTIVE
JAUNDICE
BY Amr Badawy
Assistant Lecturer in HPB Surgery Unit, Alexandria university
Clinical Fellow, HPB Surgery and Liver Transplantation Department
Kyoto University, Japan
DEFINITION
 Yellowish discoloration of the body tissues and
fluids (except the brain, CSF, tears, saliva and
milk) which results from accumulation of
serum conjugated bilirubin.
 It becomes manifest when serum bilirubin
level exceeds 2 mg/dl
TYPES OF JAUNDICE
CLINICAL
EXAMINATION
HISTORY TAKING
 Age :

 Newborn  biliary atresia

 Young adult  stones
 Elderly  cancer

 Temporal pattern of Jaundice (Onset, Progression):

 Onset sudden (stones), gradual (malignancy)

 Course  Intermittent (stones), Progressive (malignancy)


 HISTORY TAKING
C. Associated Symptoms:

 Pain  colicky and intermittent pain (stones), constant

dull aching pain (cancer head of pancreas).
 Loss of appetite, weight loss (cancer)
 Itching
 Fever
 Melena and hematemesis
 Color of Urine and stools (Dark urine and pale stools)
 HISTORY
TAKING
 Risk Factors:

 Past Medical history (previous abdominal

surgeries like cholecystectomy , gall stones,
any liver diseases)
 Drug History (hepatotoxic drugs such as
acetaminophen)
 Family History (hemolytic diseases)
 Social History (IV drug abuse, alcohol
intake, travel history)
PHYSICAL
EXAMINATION
A. General Assessment 

 Build and nutrition (marked weight loss cachexia indicate

malignancy)
PHYSICAL
EXAMINATION
A. General Assessment 
 Jaundice:
 usually dark olive greenish yellow in obstructive
jaundice.
 It is checked in upper sclera (better seen against white
background in the sun light).
 It also can be checked in nailbed, ear lobule, nasal tip,
and on under surface of tongue.
 PHYSICAL EXAMINATION
A. General Assessment 
 Hypercarotinaemia mimics jaundice
which is due to increased yellow pigment
carotene.
 It is seen equally in face, palm, sole and
skin but not seen in sclera.
 It is common in vegetarians who eat
more raw carrot.
PHYSICAL
EXAMINATION
A. General Assessment 

 Vital Signs :
 Blood pressure 
hypotension (Reynolds’
pentad in acute cholangitis)
 Temperature  fever and
chills (Charcot’s triad of
acute cholangitis).
PHYSICAL
EXAMINATION
B. General Examination 

 Signs of chronic liver diseases

 Lower limb edema
 Palmer erythema
 Spider nevi

 Scratch marks
 Virchow’s Lymph nodes
(malignancy)
PHYSICAL
EXAMINATION
B. Local (Abdominal) Examination 

1. Inspection:

 Contour  distended (Ascites)

 Skin nodules around the umbilicus (Sister Mary Joseph’s
nodules)
 Skin  Scratch marks, dilated vein (PHT)
PHYSICAL EXAMINATION
B. Local (Abdominal) Examination 

2. Palpation:

Courvoisier's law  states that in the

presence of a palpably enlarged
gallbladder which is non-tender and
accompanied with mild painless jaundice,
the cause is unlikely to be gallstones.
 PHYSICAL EXAMINATION

B. Local (Abdominal) Examination 

2. Palpation:
Exceptions of Courvoisier’s law : 2) In malignant obstructive jaundice
1) In calcular obstructive jaundice
 Stones in both the CBD and GB causing  Cancer + chronic fibrotic GB
mucocele or empyema  Cancer of CHD above the insertion of the cystic
 Mirrizi syndrome with enlarged GB and duct
obstructive jaundice.
PHYSICAL
EXAMINATION
B. Local (Abdominal) Examination 

2. Palpation:
 Liver  usually enlarged in obstructive
state
 Gall bladder  felt in malignant
obstructive jaundice (98%)
(Courvoisier’s law)
 Spleen  enlarged in hemolytic
jaundice or cirrhosis
 Abdominal mass
PHYSICAL
EXAMINATION
B. Local (Abdominal)
Examination 

3. Percussion:

Presence of ascites indicates

either liver cirrhosis or
malignancy.
Malignant O.J. Calcular O.J.

Short (days or Long (months History

weeks) or years) DIFFERENCE
BETWEEN
Symptoms CALCULAR AND
Usually absent Fatty food • Dyspepsia MALIGNANT
intolerance
OBSTRUCTIVE
Absent Present •Pain & colics JAUNDICE
Present Absent •Anorexia
Present Absent •Weight Loss
 Malignant O.J. Calcular O.J.
Accidental discovery Following a heavy Onset of
(Painless Jaundice) meal and an attack jaundice
of biliary colic
(Painful Jaundice) DIFFERENCE
BETWEEN
CALCULAR AND
MALIGNANT
progressive Intermittent Course of OBSTRUCTIVE
jaundice
JAUNDICE
Never Yes Cholangitis
Never ± Previous
.attacks of O.J
USEFUL LINKS
 https://www.youtube.com/watch?v=0u3L2nIGciQ
 https://www.youtube.com/watch?v=DBif1jjAfKk
 https://www.youtube.com/watch?v=PYAnF6GJY2I
 https://www.youtube.com/watch?v=LpWqOYFb4DA