Original Article

MANAGEMENT OF OBSTRUCTIVE JAUNDICE:

EXPERIENCE IN A TERTIARY CARE SURGICAL UNIT

MUHAMMAD SADDIQUE, SYED ABDULLAH IQBAL

Department of Surgery (Unit IV), Dow Medical College & Civil Hospital, Karachi

ABSTRACT
Objective: To evaluate the presentation, clinical features and treatment of Obstructive Jaundice cases.
Design & Duration: Prospective observational study from Jan. 2003 to Dec. 2004.
Setting: Surgical Unit IV, Civil Hospital, Karachi.
Patients: All patients who were admitted and treated for Obstructive Jaundice.
Methodology: The patients were evaluated clinically and by investigations. After appropriate preparations surgery
was carried out; the procedure depending upon the nature of the lesion. Intra and post-operative complications, and
the outcome of the patient was noted and the whole data analyzed.
Results: This study comprises of 24 cases of Obstructive Jaundice. Their ages varied from 25-65 years (mean age
being 41.12 years); 10 were males and 12 females. Amongst these 13 (54.17%) patients had jaundice due to malig-
nancy, 9 (37.5%) had stones in the common bile duct (CBD) and the remaining 2 (8.33%) patients had amoebic liver
abscesses. In the malignant group five patients had Carcinoma Head of the Pancreas (two treated by pancreato-
duodenectomy and three by cholecystojejunostomy), three had Cholangiocarcinoma (treated by hepatojejunostomy),
three had Carcinoma Gall bladder (one treated by hepatojejunostomy, two inoperable) and two patients with malignant
nodes at the porta hepatis who refused surgery and were referred for endoprostheses. All patients with stones in the
CBD were treated by cholecystectomy and choledocholithotomy, whereas those with amoebic liver abscess underwent
drainage/aspiration.
Conclusion: Early diagnosis of the cause of obstruction is very important especially in malignant cases, as resection
is only possible at that stage.

KEY WORDS: Obstructive Jaundice, Choledocholithiasis, Carcinoma Pancreas, Cholangiocarcinoma, Liver Abscess

INTRODUCTION tic or endoscopic removal may be tried. In the cases of

Obstructive jaundice occurs when there is an obstruction
to the passage of conjugated bilirubin from liver cells
to intestine. As the patient with obstructive jaundice
has a high morbidity and mortality, the early diagnosis
is of great importance1-3. Malignancy and stones in the
CBD are common causes of obstruction. Stone disease
in fit patients is treated by surgical intervention but in
the elderly and unfit cases, other options like transhepa-
Correspondence:
Dr. Muhammad Saddique, Department of Surgery,
Surgical Unit IV, Dow Medical College &
Civil Hospital, Karachi.
Phones: 0300-9209027.
malignant obstruction, if an early diagnosis is made
then curative resection may be possible, otherwise only
palliative procedures are performed4,5; in inoperable
malignant cases endoprosthesis may be used to relieve
the obstruction.
PATIENTS & METHODS
Twenty four patients of Obstructive Jaundice were ad-
mitted in Surgical IV at Civil Hospital Karachi, between
January 2003 to December 2004. There were 10 male
and 14 female cases with ages varying from 25 to 65
years, mean age being 41.12 years. Their diagnosis
(Table I) was based on history, clinical examination and
investigations which included LFTs, Urea Creatinine
and Electrolytes, Prothrombin time, Ultrasonography,
PTC and MRCP.
Pre-operative preparations included maintaining good

23 Volume 23, Issue 1, 2007

 Management of Obstructive Jaundice Muhammad Saddique, Syed

while two were found inoperable at laparotomy; both

Cause Male Female Total
Malignancy 7 6 13
Stone in CBD 2 7 9 endoprosthesis.
Liver Abscess 1 1 2 Nine cases of Obstructive Jaundice were due to stones
Total 10 14 24
Table I. Aetiology of Obstructive Jaundice
hydration and administration of antibiotics, intravenous
dextrose (10%) solution and Vit. K injections6. In anae-
mic patients blood transfusion was also carried out. Du-
ring surgery intravenous Mannitol was used in all the
patients. The nature of surgical procedure carried out
depended upon the cause and the findings at the time
of surgery.
RESULTS
All the 24 cases with Obstructive Jaundice presented
with pain, while weight loss and pruritis was seen in
14 (58.33%) patients. Ultrasound abdomen, performed
in all the patients, revealed extrahepatic biliary obs-
truction amongst 17 patients (70.83%), though the cause
was correctly diagnosed in 12 (50%) cases only.
Out of the 13 patients of Obstructive Jaundice due to
malignancy, five had Carcinoma Head of the Pancreas;
two were treated by pancreatoduodenectomy and three
by cholecystojejunostomy (Table II). All the three cases
of cholangiocarcinoma were treated by hepatojejunos-
tomy; one deteriorated postoperatively and died in the
ward after 10 days. Three patients had Carcinoma of
the Gall bladder, one was treated by hepatojejunostomy
Table II. Surgery and Outcome in cases of Obstructive Jaundice
the later cases died in the immediate post-operative
period. Two patients had suspected malignant nodes at
the porta hepatis; they refused surgery and were advised
in the common bile duct. They all underwent cholecys-
tectomy and choledocholithotomy. No complications
were noticed in them except bile leakage from around
the T-tube in one patient, which was treated conserva-
tively. Two patients had amoebic liver abscesses; one
underwent open drainage and the other ultrasonogra-
phic guided aspiration. Both made uneventful recovery.
DISCUSSION
Obstructive Jaundice is a common surgical problem.
Its commonest cause was malignancy (54.17%) in our
study followed by choledocholithiasis (37.5%) and am-
oebic liver abscess (8.33%). Sharma et al reported a
higher incidence (75.3%) of malignant cases in a series
of 429 patients3.
Tompkins et al, and other authors described pain as a
symptom in less than one third of their patients1,7; but
pain in the right hypochondrium was present in all of
our cases. Weight loss and pruritis was seen in 50% of
the patients elsewhere7; in our series the incidence of
these symptoms was 58.33%.
Ultrasonography detected extrahepatic biliary obstruc-
tion reliably in 70.83% of our cases, but the cause was
correctly reported only in 50% of the cases. Other stu-
dies established the site of obstruction in 94% cases
with a specificity of 96%3,8.

Cause Surgical Procedure Cured Palliation Not improved Mortality

Ca. Head Pancreas Pancreatodudenectomy (2) 2 - - -

Cholangiocarcinoma
Ca. Gall Bladder
Malignant nodes at porta
Choledocholithiasis
Amoebic LiverAbscess
Cholecystojejunostomy (3) - 3 - -
Hepatojejunostomy (3) - 3 1 1
Hepatojejunostomy (1) - 1 - -
Laparotomy/inoperable (2) - - 2 2
Refused surgery (2) - - - -
Choledocholithotomy+ (9) 9 - - -
Cholecystectomy
Drainage of abscess (2) 2 - - -

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 Management of Obstructive Jaundice
In our study 13 (54.17%) patients had jaundice due to
malignancy; out of these in nine (37.5%) patients curative
surgery was not possible. Seven (29.17%) patients, how
ever, underwent palliative bypass surgery; three with
Ca. Head of Pancreas had cholecystojejunostomy, while
three with cholangiocarcinoma and one with Ca. Gall
bladder had hepaticojejunostomy. Two with nodes in
the porta hepatis refused surgery and were advise endo-
prosthesis. Fortner9 in his study on 52 patients with
obstructive jaundice reported palliative procedures in
38 (73.1%) cases including endoprosthesis placement
in 22 (42.31%) and bypass surgery in 16 (30.8%) cases.
Other authors have also quoted similar figures10-14.
In the study nine patients had jaundice due to stones in
the common bile duct; they underwent choledocholitho-
tomy and T-tube insertion. No complication was noted
except bile leakage from around the T-tube in one case.
Pappas et al15 reported choledocholithotomy and T-tube
insertion in 93 out of 95 patients; five (5.26%) cases
had retained stones.
CONCLUSION
Early diagnosis of the cause of obstruction is very im-
portant especially in malignant cases. For this there
should be trained staff at primary care health centers
all over the country. Cholecystectomy & exploration
of CBD remains the first line of therapy for stone disease
of gall bladder and bile ducts. In malignant jaundice,
resection is only possible when the diagnosis is made
early, otherwise palliation is only alternative.
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