Jebmh.

com Original Article

A STUDY ON INCIDENCE, CLINICAL PROFILE, AND MANAGEMENT OF OBSTRUCTIVE

JAUNDICE
Suramya Anand1, Charan Panda2, Aakala Trishul Senapati3, Manas Ranjan Behera4, Chittaranjan Thatei5

1Postgraduate Student, Department of General Surgery, M.K.C.G. Medical College, Berhampur, Odisha.
2Professor and HOD, Department of General Surgery, M.K.C.G. Medical College, Berhampur, Odisha.
3Postgraduate Student, Department of General Surgery, M.K.C.G. Medical College, Berhampur, Odisha.
4Assistant Professor, Department of General Surgery, M.K.C.G. Medical College, Berhampur, Odisha.
5Senior Resident, Department of General Surgery, M.K.C.G. Medical College, Berhampur, Odisha.

ABSTRACT

BACKGROUND
Jaundice is a frequent manifestation of biliary tract disorders and the evaluation and management of obstructive jaundice is a
common problem faced by the general surgeon. During the last decade significant advances have been made in our
understanding with regards to the pathogenesis, diagnosis, staging, and efficacy of surgical and nonsurgical management of
obstructive jaundice. To diagnose the cause, site of obstruction, and management of a case of surgical jaundice is indeed a
challenging task for the surgeon. Hence, a comprehensive study of the aetiology, clinical presentation, and management of
obstructive jaundice is of paramount importance in the appropriate management of these patients.

AIM
This study evaluates the age and sex distribution, clinical presentation, aetiology, and the different modalities of treatment of
obstructive jaundice.

MATERIALS AND METHODS

This prospective study was conducted in MKCG Medical College and Hospital, Berhampur, Odisha from September 2013-August
2015. Out of all surgical admissions from September 2013 to August 2015 in our hospital, 80 cases of surgical jaundice of
different age group were selected randomly. A detailed history and clinical examination was done and appropriate
investigations recorded. Patients were assessed preoperatively and later subjected to surgery or palliative procedure depending
on the need. Postoperatively, patients’ condition was assessed and complications were documented. Patients were followed
up for mean period of 6 months where patients underwent surgical intervention/ERCP, any tissue removed was subjected for
histopathological examination.

RESULTS
The occurrence of surgical jaundice was maximum in the 31-70 year age group. All patients presented with icterus and
ultrasonogram was the most common investigation of choice. Most common cause of obstruction was choledocholithiasis
followed by malignancy.

CONCLUSION
Commonest symptom of surgical jaundice in this study was pain abdomen and jaundice as per history. Commonest cause for
surgical jaundice was found to be choledocholithiasis. Open exploration of common bile duct under experienced hands was
found to be a good treatment modality in the management of obstructive jaundice.

KEYWORDS
Obstructive Jaundice, Choledocholithiasis, CBD exploration, T-tube drainage, Choledochoduodenostomy.

HOW TO CITE THIS ARTICLE: Anand S, Panda C, Senapati AT, et al. A study on incidence, clinical profile, and management
of obstructive jaundice. J. Evid. Based Med. Healthc. 2016; 3(59), 3139-3145. DOI: 10.18410/jebmh/2016/683
INTRODUCTION: Jaundice is a generic term for the yellow Jaundice is due to increase in the serum bilirubin level above
pigmentation of the skin, mucous membranes, or sclera. the normal range.
The biliary canaliculi empty into larger ducts, the
Financial or Other, Competing Interest: None. hepatic duct and common bile duct and then to duodenum
Submission 11-06-2016, Peer Review 24-06-2016, or to gall bladder through cystic duct.1 Obstructive jaundice
Acceptance 30-06-2016, Published 23-07-2016.
is strictly defined as due to a block in the pathway between
Corresponding Author:
Dr. Suramya Anand, the site of conjugation of bile in liver cells and the entry of
Room No. 118, P.G. Ladies Hostel, bile into the duodenum through the ampulla. An accurate
M.K.C.G. Medical College, Berhampur-760004, Odisha. diagnosis can usually be made with standard diagnostic
E-mail: [email protected]
DOI: 10.18410/jebmh/2016/683 techniques such as history, physical examination, and

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Jebmh.com Original Article
biochemical tests, and when appropriate cholangiography (SPSS, 2011. SPSS Inc: New York) to find out the descriptive
and liver biopsy and observation of the patient's course.2 parameters.
Transabdominal ultrasound is a sensitive, inexpensive,
reliable, and reproducible test to evaluate most of the biliary OBSERVATION AND RESULTS:
tree being able to separate patients with medical jaundice
from those with surgical jaundice. Therefore, this modality Male Female Total
Age in
is seen as the study of choice for the initial evaluation of (n=39) (n=41) (n=80)
Years
jaundice or symptoms of biliary disease.3 Treatment of No. % No. % No. %
malignant obstructive jaundice is especially challenging. <30 4 10.25 3 7.32 7 8.75
Surgical treatment ranges from definitive surgical 31-50 22 56.41 21 51.21 43 53.75
procedures to palliative procedures. Nonoperative 51-70 11 28.20 16 39.02 27 33.75
management includes endoscopic stenting and >70 2 5.12 1 2.44 3 3.75
interventional radiological procedure like PTBD. All these are Table 1: Sex and Age Distribution
especially challenging to the surgeon because of relative
inaccessibility of the extrahepatic biliary tree and pancreas. The above table shows analysis of age and sex
To diagnose the cause, site of obstruction, and management distribution. The peak age was between 31 to 70 years
of a case of surgical jaundice is indeed a challenging task for (87.50%). The age varied from 21 years to 75 years.
the surgeon. Hence, a comprehensive study of the aetiology, Number of male patients were 39(48.75%) and number of
clinical presentation, and management of obstructive female patients were 41(51.25%).
jaundice is of paramount importance in the appropriate
management of these patients and is the aim of my study.

MATERIALS AND METHODS: The prospective descriptive

study was done at Department of General Surgery, Maharaja
Krushna Chandra Gajapati Medical College, Berhampur. The
period of study is from September 2013-August 2015. This
is a prospective study. Study population has been selected
after applying the necessary exclusion criteria. The study
was approved by institutional ethics committee. Informed
consent was taken from all the patients. A random selection
of 80 patients from the patients admitted in surgical wards Fig. 1: Age Distribution
has been done.

Inclusion Criteria:
1. Age more than 15 years.
2. Patients proved to have obstructive jaundice by any
investigative modality.

Exclusion Criteria:
1. Less than 15 years.
2. Patients with medical jaundice.

Method of Collection of Data: After admission to the

hospital, data was collected from the patient’s records
regarding the clinical features and investigations and based
on the results they were diagnosed to have either surgical
jaundice or medical jaundice. Those patients diagnosed to
have surgical jaundice were assessed preoperatively and
later subjected to surgery or palliative procedure depending
on the need. Postoperatively, patients’ condition was
assessed and complication were documented. Patients’ were
followed up for mean period of 6 months where patients
underwent surgical intervention/ERCP. Any tissue removed
was subjected for histopathological examination. The
statistical operations were done through GraphPad InStat
(© 2013 GraphPad Software Inc.) and SPSS (Statistical
Presentation System Software) for Windows, version 20.00

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Jebmh.com Original Article

Benign Malignant Total

Symptoms Significance (p value)
n=56 (%) n= 24 (%) n = 80 (%)
Pain abdomen 40(71.42) 20(83.33) 60(85) 0.398
Jaundice as per history 30(53.57) 22(91.66) 52(65) 0.0017
Itching 22(39.28) 12(50) 34(42.5) 0.461
High-coloured urine 22(39.28) 18(75) 40(50) 0.0066
Clay-coloured stools 18(32.14) 16(66.66) 34(42.5) 0.0063
Nausea/vomiting 20(35.71) 10(41.66) 30(37.5) 0.801
Fever 6(10.71) - 6(7.5) 0.17
Loss of appetite 18(32.14) 20(83.33) 38(47.5) 0.00027
Loss of weight 18(32.14) 22(91.67) 40(50) 0.0001
Melaena - 2(8.33) 2(2.5) 0.08
Pallor 18(32.14) 18(75) 36(45) 0.0005
Icterus 56(100) 24(100) 80(100) -
Palpable Gallbladder 9(16.07) 10(41.67) 19(23.75) 0.021
Abdominal tenderness 22(39.28) 10(41.67) 32(40) -
Table 2: Association of Symptoms and Signs with Diagnosis

Fig. 3: Bar Chart Showing Percentage Distribution of Presenting

Symptoms and Signs of Benign and Malignant Condition

p value of 0.0017. High-coloured urine and clay-coloured

1. Pain abdomen. stools also were present significantly in malignant
2. Jaundice. conditions. Loss of appetite was present in 38 patients. In
3. Itching. benign condition, it was 32.14%, and in malignant condition,
4. High-coloured urine.
it was 83.33% showing significant p value of 0.003. Loss of
5. Clay-coloured stools.
6. Nausea/vomiting. weight was present in 40 patients. In benign condition, it
7. Fever. was 32.14%, and in malignant condition, it was 91.67%
8. Loss of appetite. showing significant p value of 0.001. Melena was present in
9. Loss of weight. 2 patients in malignant condition. Pallor was present in 36
10. Melaena. (45%), patients with benign condition (32.14%), and in
11. Pallor.
malignant condition, it was 75% with significant p value of
12. Icterus.
0.005. Icterus was present in all patients who were
13. Palpable gallbladder.
14. Abdominal tenderness. diagnosed as surgical jaundice. Gallbladder was palpable in
19 patients (23.75%), in patients with benign condition
16.07%, and malignant condition 41.67% prevalence with a
The above analysis shows the incidence of presenting 3.7 times increased risk for malignancy with a p value <0.05,
symptoms and signs. Jaundice as per history in benign which was statistically significant for a malignant aetiology.
condition was in 30 patients (53.6%) and in malignant
condition 22 patients (91.67%) with significant difference of

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Benign (n=56) Malignant (n= 24) Total (n=80)

Lab Parameters P value
Mean ±SD Mean ±SD Mean ±SD
Haemoglobin (gm %) 10.8±2.06 10.45±2.59 10.70±2.22 0.511
Total bilirubin (mg/dL) 10.15±2.93 12.48±2.69 10.9±3.04 0.001
Direct bilirubin (mg/dL) 6.42±2.35 7.71±1.87 6.81±2.29 0.019
Alkaline phosphatase IU 606.57±120.33 990.37±114.63 721.71±212.68 <0.001
Albumin (mg/dL) 3.47±0.83 2.72±0.93 3.25±0.93 0.0005
Prothrombin time
16.2±2.56 18.23±2.89 16.81±2.81 0.002
(seconds)
Blood urea (mg/dL) 30.56±5.73 31.04±6.3 31±5.91 0.742
Serum creatinine (mg/dL) 1.09±0.42 1.13±0.55 1.1±0.46 0.749
Table 3: Laboratory Investigations in Comparison of Benign and Malignant Conditions

There were significantly higher values of total bilirubin, direct bilirubin, and alkaline phosphatase in malignant conditions.
Also, significant decrease in value of albumin and alteration in coagulation profile was found in malignancy.

Ultrasound Final diagnosis

Cause of Obstruction Sensitivity
Number % of total USG Number % of total diagnosis
CBD stones 51 66.23 54 67.5 94.4
CBD benign strictures 1 1.29 1 1.25 100
Malignancy 24 31.16 24 30 100
Mirizzi’s syndrome 1 1.3 1 1.25 100
Total 77 80 96.25
Table 4: Comparison of Ultrasonography and Final Diagnosis

In the radiological studies, the role of ultrasound to Operative Procedures/Non- Number

%
know the cause of obstruction, which was used as the main operative Procedures (n=56)
diagnostic procedure. In this study, 66.23% of patients had Open cholecystectomy with CBD
23 41.07
common bile duct calculi, 31.16% of patients were exploration and T-tube drainage
diagnosed as malignant, 1.29% of patients with common Open cholecystectomy with CBD
bile duct benign stricture, and 1.23% of patients with exploration and 26+1*+1Ɨ 50
Mirizzi’s syndrome. In the final diagnosis, CBD calculi was Choledochoduodenostomy
present in 67.50% patients, benign stricture in 1.25%, Open cholecystectomy with
malignancy in 30%, and Mirizzi’s syndrome in 1.25% of 3 5.36
choledochojejunostomy
patients with USG showing no significant difference to the Open cholecystectomy with CBD
final diagnosis. The other investigations done was ERCP, 2 3.57
stenting
which was done in 2 patients to confirm diagnosis of USG. Table 5: Operative Procedures for CBD
Calculi/Mirizzi’s Syndrome/Benign Stricture

* Mirizzi’s syndrome Ɨ Benign stricture

Fig. 4: Operative Procedures for Benign Conditions

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23 patients underwent cholecystectomy and CBD underwent cholecystectomy with CBD exploration and
exploration with T-tube drainage for CBD calculi. One patient choledochoduodenostomy for CBD calculi.
with Mirizzi’s Syndrome underwent cholecystectomy with Cholecystectomy with CBD stenting was carried out in 2
CBD exploration and choledochoduodenostomy. One patient patients for CBD calculi cholecystectomy with CBD
with CBD benign stricture underwent cholecystectomy with exploration and choledochojejunostomy was carried out in 3
CBD exploration and choledochoduodenostomy. 26 patients patients for CBD calculi.

Operative procedures/Nonoperative procedures Number (n=24) %

Whipple’s procedure 2 8.33
Palliative cholecystojejunostomy + jejunojejunostomy + gastrojejunostomy 4 25
Palliative choledochojejunostomy + jejunojejunostomy + gastrojejunostomy 16 58.33
Roux-en-Y hepaticojejunostomy 2 8.33
Table 6: Operative (Curative/Palliative) Procedures for Malignancy

Malignant cause for obstruction was seen in 24 patients (30%). Whipple’s procedure was done for 2 patients. Palliative
cholecystojejunostomy with jejunojejunostomy with gastrojejunostomy was done for 25% of patients. Palliative
choledochojejunostomy and jejunojejunostomy and gastrojejunostomy was done for most (58.33%) of malignant cases. Roux-
en-Y hepaticojejunostomy was done in 2 (8.33%) of patients.

Types of Malignancy No. of Cases Percent of Malignant Cases

Carcinoma Head of Pancreas 17 70.83
Carcinoma ampulla of Vater 1 4.17
Carcinoma Lower CBD 6 25
Carcinoma Duodenum 2nd Part - -
Table 7: Causes of Malignant Obstruction on HP Study

Malignant cause for obstruction was seen in 24 patients (30%). Carcinoma head of pancreas was seen in 17 patients, distal
cholangiocarcinoma in 6 patients, and carcinoma of ampulla of Vater in 1 patient on histopathological examination of the
resected specimen.

Operative procedures No. of Percentage of no.

Complications
(No. Performed) complications performed
Peritubal leak with
Cholecystectomy with CBD exploration and cholangitis (2)
5 21.7
T-tube drainage (23) Retained stones (2)
Wound dehiscence (1)
Cholecystectomy with CBD exploration and Cholangitis (1)
2 7.1
choledochoduodenostomy (28) Wound dehiscence (1)
Palliative cholecystojejunostomy (4) Death 1 25
Whipple’s procedure (2) Death 1 50
Pleural effusion (1)
Palliative choledochojejunostomy (16) 2 12.5
Wound dehiscence(1)
Roux-en-Y hepaticojejunostomy (2) Cholangitis 1 50
Table 8: Postoperative Complications with Various Procedures

Patients were followed up during the post-operative exploration, postoperative cholangiogram showed retained
period for 6 months. One patient who underwent Whipple’s stone in CBD and they had to undergo CBD exploration
procedure for Carcinoma head of Pancreas, died on the again.
14thpost operative day due to pancreatic leak and sepsis. Three patients had wound dehiscence, which was
One patient with palliative cholecystojejunostomy with closed with secondary suturing. Other patients did well
jejunojejunostomy again for carcinoma head of pancreas without any complications during the follow up period.
died on the 5th postoperative day due to sepsis. One case
that underwent Whipple’s procedure for Carcinoma ampulla
of Vater was asymptomatic during his follow up. One patient
with hepaticojejunostomy had episodes of cholangitis, which
was treated with antibiotics. In two patients with CBD

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DISCUSSION: Several studies have been done on this study, the peak incidence of surgical jaundice was seen
obstructive jaundice worldwide, till date. This study was in age group of 31 to 70 years with male: female ratio of M:
done in south Odisha. Many significant findings were F: 48.75: 51.25%.
observed in our study. Present study was compared with
those of other authors. It has been summarised below: In

Sharma MP
Name of Study Siddique K et al5 Talpur et al6 Lawal D et al7 Present Study
et al4
Mean age of patients 62.5 49.5 47.15 42 47
Table 9: Mean Age of Patients in Various Studies

In Sharma MP et al4 mean age was 62.5. In this study, the mean age of patients was 47±12.3, which corresponds to
studies like Siddique et al5 and Talpur et al6 with mean age of 49.5 and 47.15. In Lawal D et al7, mean age was 42.

Total Male Female M:F

Lawal D et al7 50 28 22 1:0.78
Sharma et al4 429 229 200 1:0.87
Talpur et al6 83 25 58 1:2.32
Siddique K
60 40 20 1:0.5
et al5
Present Study 80 39 41 1:1.05
Table 10: Sex Ratio in Various Studies of Obstructive Jaundice

In this study of 80 cases of obstructive jaundice, there was a slight female preponderance at 1:1.05, which intermediate
between studies like Talpur et al6 at 1:2.32 and studies with slight male preponderance like Lawal D et al7 at 1:0.78 and Sharma
et al4 at 1:1.05.

Aetiological Distribution:

Talpur Sharma
Nadkarni Kar Siddique K PhillipoChalya Present
et al6 et al4
et al8 (%) et al9 (%) et al 5(%) et al10 (%) study (%)
(%) (%)
CBD stones 37.5 24.8 25.3 12.4 35 25.8 67.5
CBD benign stricture 41.67 31 14.46 10.8 5 10.3 1.25
Mirizzi’s syndrome - - - 1.25
CBD injuries 25.3
Carcinoma head of
12.05 26.5 30 37.9 21.25
pancreas
Periampullary 58.3 72.09
9.8 1.66 5.1 1.25
carcinoma
Cholangiocarcinoma 10.8 11.6 7.5
Others 22.89 28.7 6.8
Table 11: Comparison of Aetiological Distribution

In this study, common bile duct stone was the main aetiology for jaundice when compared to Nadkarni et al8 Kar et al9 and
Phillipo Chalya et al10 in which malignancies were more common. This study is comparable with Talpur et al 6 and Siddique et
al5 where benign causes of obstruction were more common. In this study, malignancy was 30% with other categories being
benign stricture and Mirizzi’s syndrome.

Agarwal et al11 Nadkarni et al8 Phillipo Chalya et al10 Present study

Jaundice 100 100 58.6 100
Pain abdomen 79.1 53.8 17.2 85
Itching 50 73.1 43.1 42.5
Fever 12.5 53.8 7.5
Nausea/Vomiting 70.9 88.5 37.5
Loss of weight 66.7 19.2 56.9 50
Clay-coloured stools 41.7 92.3 42.5
Table 12: Comparison of Symptoms and Signs

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