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Jaundice results from excessive deposition of bilirubin in tissues, appearing as a yellowish discoloration of skin, sclerae, and mucous membranes that . Jaundice usually develops when serum bilirubin levels rise above
Clinical Evaluation
Evaluation of jaundice requires evaluation of the mucous membranes of the mouth, the palms, the soles, and the sclerae. These areas are protected from the sun; therefore, photodegradation of bile is minimized; thus, the yellowish discoloration of elastic tissues may be more easily detected. Consumption of large quantities of food containing carotene or drugs such as rifampin or quinacrine may occasionally cause a yellowish pigmentation of the skin jondice, jandice
DIRECT VERSUS INDIRECT HYPERBILIRUBINEMIA
Once the presence of jaundice has been confirmed, further clinical assessment determines whether the hyperbilirubinemia is predominantly direct or indirect. This distinction is based on the division of bilirubin into conjugated and unconjugated fractions, which are also known, respectively, as direct and
Cholestatic Syndrome
The term cholestasis refers to decreased delivery of bilirubin into the intestine (and subsequent accumulation in the hepatocytes and in blood), irrespective of the underlying cause. When cholestasis is mild, it may not be
Imaging
Once the history has been obtained and bedside and laboratory assessments have been completed, the next step is imaging, the goals of which are (1) to confirm the presence of an extrahepatic
Of the many imaging methods available today, the gold standard for defining the level of a biliary obstruction before operation in a jaundiced patient remains direct cholangiography, which can be performed either via endoscopic retrograde
cholangiopancreatography (ERCP) or via percutaneous transhepatic cholangiography (PTC). Unlike other imaging modalities,
SUSPECTED CHOLANGITIS
If a jaundiced patient exhibits a clinical picture compatible with acute suppurative cholangitis (Charcot’s triad or Raynaud’s pentad), the most likely diagnosis is choledocholithiasis. After appropriate resuscitation, correction of
SUSPECTED CHOLEDOCHOLITHIASIS WITHOUT CHOLANGITIS
Choledocholithiasis is the most common cause of biliary obstruction13,14 and should be strongly suspected if the jaundice is episodic or painful or if ultrasonography has demonstrated the presence of gallstones or bile duct stones.
Patients with suspected choledocholithiasis should be referred for laparoscopic cholecystectomy with
SUSPECTED LESION OTHER THAN CHOLEDOCHOLITHIASIS
If no gallstones are identified, if the clinical presentation is less acute (e.g., constant abdominal or back pain), or if there are
Nonoperative Management: Drainage and Cholangiography
In the majority of patients with malignant obstructions, treatment is palliative rather than curative. It is therefore especially important to recognize and minimize the iatrogenic risks related to the manipulation of an obstructed biliary system.
Cholangiography and decompression of obstructed
Operative Management at Specific Sites: Bypass and Resection
Surgical treatment of tumors causing biliary obstruction is determined primarily by the level of the biliary obstruction. There is
a growing body of evidence indicating that modern surgical approaches are resulting in lower postoperative morbidity and, possibly,
improved five-year survival54; however, the prognosis is still