Yellowing of the skin and whites of the eyes, light-coloured stools and dark urine could be signs of obstructive jaundice – a condition where normal drainage of bile from the liver to the small intestines is blocked.
Obstructive jaundice is not a disease in itself but a symptom of an underlying condition involving the liver, the gallbladder or the pancreas. It will usually require surgical intervention, and is also known as surgical jaundice.
Gallstones, which can easily be removed by surgery, are the most common cause of obstructive jaundice.
The liver produces bile to digest food and deliver waste products to the intestines for elimination. When bile drainage is obstructed, bilirubin – a byproduct of red cell recycling – builds up in the liver and spills over to the bloodstream, causing the skin and whites of eyes to turn yellowish.
It is important to distinguish between the possible causes of obstructive jaundice. While the common causes are related to gallstone disease, the more sinister causes are related to cancer (pancreatic cancer, bile duct cancer, or less commonly liver cancer).
One of the main distinguishing symptoms between benign and malignant causes is pain. Painful obstructive jaundice is usually related to gallstones, while painless obstructive jaundice tends to be related to tumours. The reason for this difference is that stones tend to harbour bacteria and cause bile duct infection, resulting in pain and fever.
Interestingly, as pain is not a key feature for malignant causes, patients with tumours tend to seek expert help later. Such patients may also have worrisome symptoms of weight loss and loss of appetite.
Two types of jaundice (surgical and medical jaundice)
Obstructive jaundice is one of two types of jaundice (surgical or medical jaundice). Patients with medical jaundice will have yellowing of the skin, without dark urine or lightcoloured stools. Medical jaundice can be related to:
• Hepatocellular jaundice, caused by a liver condition such as hepatitis and liver cirrhosis; and
• Haemolytic jaundice (blood disorder), a result of sudden rapid increase in the breakdown of red blood cells due to thalassaemia, autoimmune disease or malaria.
All these types of jaundice lead to an abnormal increase of bilirubin, causing the yellowing of the skin.
As mentioned above, there are both benign and malignant causes of obstructive jaundice.
• Benign causes: Gallstones or cysts in the bile ducts (choledochal cyst), narrowing of the bile ducts (bile duct strictures), pancreatitis (inflammation of the pancreas).
• Malignant causes: Cancerous tumours in the pancreas, bile duct, gallbladder and liver.
Malignancy can result in complete blockage of bile drainage with significant itching due to accumulation of bilirubin and malnutrition as bile is part of the digestive system.
Watch out for a yellowing of the skin and the whites of the eyes, which may be followed by a skin itch. As the condition worsens, other symptoms may appear:
• Severe abdominal pain
• Vomiting and nausea
If your liver disease Depending on the underlying cause, the doctor may initially prescribe pain medications and antibiotics to treat infections, especially if the cause is related to gallstone disease. Diagnostic imaging and blood tests will usually be able to distinguish the various causes of jaundice. Definitive treatment will depend on the cause of the jaundice.
If gallstones are diagnosed, laparoscopic cholecystectomy or keyhole surgery is recommended for the removal of gallstones. Endoscopic removal of stones obstructing the bile duct is sometimes necessary prior to laparoscopic surgery to fully clear all the stones. Endoscopic stenting is also sometimes necessary as a temporary measure to relieve the bile duct obstruction and clear any bacterial infection before definitive surgery.
If the root cause of obstructive jaundice is a malignant tumour, the long-term outcome of such patients is best served if the tumour can be surgically removed.
Such surgery is a major undertaking and patients are best served when managed by hepatobiliary pancreatic surgeons (surgeons specialising in liver, pancreas and biliary problems). The outcomes of major pancreatic, biliary and liver surgeries are much improved when performed in a highvolume dedicated surgical centre.
Unfortunately, the majority of patients with malignant tumours may not be suitable for surgery, hence, chemotherapy and/or radiotherapy will be the next best option. For such patients, obstructive jaundice can be relieved by inserting a stent by endoscopic guidance or radiologic guidance, once the diagnosis of cancer is established.
If obstructive jaundice is left untreated, there is a high risk of infection when bilirubin overflows into the bloodstream. In addition, it is vital to distinguish the various causes of obstructive jaundice. Painful jaundice is usually associated with gallstone disease. Painless jaundice associated with tumours can lead to delayed treatment as patients generally feel okay.
To prevent jaundice resulting from gallstone disease, eat a healthy, balanced diet and reduce your intake of fatty foods and alcohol.