Global Journal of Medical Research: I

Surgeries and Cardiovascular System

Volume 15 Issue 4 Version 1.0 Year 2015
Type: Double Blind Peer Reviewed International Research Journal
Publisher: Global Journals Inc. (USA)
Online ISSN: 2249-4618 & Print ISSN: 0975-5888

Etiological Spectrum of Obstructive Jaundice in a Tertiary Care

Hospital
By Bimal Chandra Roy, Md. Abu Hanifa, Md. Shafiul Alam, Saimun Naher
& Prosannajid Sarkar PhD
Rangpur Medical College Hospital, Bangladesh
Abstract- Background: Jaundice due to biliary obstruction may be caused by a heterogeneous group of
diseases that include both benign and malignant conditions. As patients with obstructive jaundice have
high morbidity and mortality, early diagnosis of the cause of obstruction is very important especially in
malignant cases, as resection is only possible at that stage.
Objectives: To determine the etiological spectrum of obstructive jaundice in a tertiary care hospital.
Methods: Cross sectional observational study was done in this study. A detailed history and thorough
physical examination followed by investigations including liver function test, ultrasonography of whole
abdomen & in some selective cases CT scan was done. The data had collected in a pre designed data
collection sheet.
Keywords: obstructive jaundice, etiological spectrum, tertiary care hospital, morbidity and mortality.
GJMR-I Classification: NLMC Code: WI 703

EtiologicalSpectrumofObstructiveJaundiceinaTertiaryCareHospital

Strictly as per the compliance and regulations of:

2015. Bimal Chandra Roy, Md. Abu Hanifa, Md. Shafiul Alam, Saimun Naher & Prosannajid Sarkar PhD. This is a
research/review paper, distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License
http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited.
 Etiological Spectrum of Obstructive Jaundice in
a Tertiary Care Hospital
Bimal Chandra Roy , Md. Abu Hanifa , Md. Shafiul Alam , Saimun Naher & Prosannajid Sarkar PhD

Abstract- Background: Jaundice due to biliary obstruction may surgeons and contributes significantly to high morbidity
be caused by a heterogeneous group of diseases that include and mortality.2 The management of obstructive jaundice
both benign and malignant conditions. As patients with poses diagnostic and therapeutic challenges to general
obstructive jaundice have high morbidity and mortality, early
surgeons practicing specially in resource-limited area.2

2 015
diagnosis of the cause of obstruction is very important
There is huge discrepancy between the recognized
especially in malignant cases, as resection is only possible at
causes of obstructive jaundice at various centers and it

Year
that stage.
is mandatory to determine pre-operatively the existence,
Objectives: To determine the etiological spectrum of
the nature of obstruction because an ill-chosen
obstructive jaundice in a tertiary care hospital. 1
procedure can lead to high morbidity and mortality.3
Methods: Cross sectional observational study was done in this
Jaundice due to biliary obstruction may be

Global Journal of Medical Research ( ID ) Volume XV Issue IV Version I

study. A detailed history and thorough physical examination
followed by investigations including liver function test, caused by a heterogeneous group of diseases that
ultrasonography of whole abdomen & in some selective cases include both benign and malignant conditions.4 The
CT scan was done. The data had collected in a pre designed surgical jaundice can be caused by the obstruction of
data collection sheet. the bile duct due to some benign causes like as stone in
Results: 29 patients (58%) had malignant obstructive jaundice common bile duct, strictures and some malignancy,
and 21 patients (42%) had benign causes of obstructive such as cholangiocarcinoma, periampullary carcinoma,
jaundice. Amongst the malignancies, carcinoma head of the carcinoma gall bladder and carcinoma head of
pancreas was the commonest, 15 patients (30%) followed by pancreas.5
the carcinoma gall bladder 8 patients (16%). Regarding the The symptoms of obstructive jaundice include
benign causes choledocholithiasis was most common cause, jaundice with or without pain, dark urine, pruritis, pale
11 patients (22%) followed by 4 patients (8%) stricture of
stools, weight loss and anorexia.6
common bile duct. Amongst the common symptoms anorexia,
weight loss and clay colored stool were more frequent in Obstructive jaundice is characterized by the
patients with malignant disease and abdominal pain and fever raised levels of serum alkaline phosphatase rather than
were in benign conditions. asparate transaminase.7 There are various investigations
Conclusion: Obstructive jaundice in our setting is more which could be carried out for the diagnosis of
prevalent in females and the cause is mostly malignant. obstructive jaundice like ultrasonography,8 which can
Carcinoma head of pancreas is the commonest malignancy pick up stones, dilated intra-extra hepatic channels, any
while choledocholithiasis is the commonest benign cause. mass in the abdomen and presence of fluid in the
Keywords: obstructive jaundice, etiological spectrum, peritoneal cavity, but the gold standard is Endoscopic
tertiary care hospital, morbidity and mortality. Retrograde Cholangiopancreatography (ERCP).9 ERCP
can pick up choledocholithiasis, strictures of CBD, any
I. Introduction
obstruction of the CBD as well as helps in taking the

O
bstructive jaundice is a common surgical brushing cytology. Another important non-invasive
problem that occurs when there is an procedure is Magnetic Resonance Cholangiopancreato-
obstruction to the passage of conjugated graphy (MRCP). Computerized Tomography (CT),
bilirubin from liver cells to intestine.1 It is among the Endoscopic ultrasound and Percutaneous Transhepatic
most challenging conditions managed by general Cholangiopancreatography (PTC) can also be used
Author : Associate Professor, Department of Surgery, Rangpur Medical
when required.10 Invasive tests may cause cholangitis
College Hospital, Rangpur, Bangladesh. and imaging techniques like computed tomography
e-mail: drbimalroy@gmail.com (CT) scan, PTC, ERCP and MRCP are expensive and
Author : Registrar, Department of Surgery, Rangpur Medical College are not readily available in most centers.11
Hospital, Rangpur, Bangladesh. e-mail: drpavel135@gmail.com
Author : Assistant Professor, Department of Medicine, Rangpur
Surgery in jaundiced patients is associated with
Medical College Hospital, Rangpur, Bangladesh. a higher risk of postoperative complications compared
e-mail: shafiulssmc23@gmail.com with surgery in non jaundiced patients.12 These
Author : Registrar, Department of Surgery Rangpur Medical College complications primarily consist of septic complications
Hospital, Rangpur, Bangladesh. e-mail: saimunssmc26@gmail.com
(cholangitis, abscesses and leakage), hemorrhage,
Author : Researcher, Dr. Wazed Research Institute Begum Rokeya
University, Rangpur. Rangpur-5400, Bangladesh. impaired wound healing and renal disorders.12
e-mail: drpsarkarbrur@yahoo.com Understanding factors responsible for increased

2015 Global Journals Inc. (US)

 Etiological Spectrum of Obstructive Jaundice in a Tertiary Care Hospital

morbidity and mortality in these patients will better guide not be ascertained by sonographicaly then CT scan was
appropriate management.13 done with all possible means a pre-operative diagnosis
was made. The final diagnosis was based on per-
II. Objective of the Study operative findings and histopathological findings of the
The main objective of this study was to resected specimen.
determine the etiological spectrum of obstructive Data was collected by pre design data
jaundice in a tertiary care hospital. collection sheet. Appropriate statistical analysis of the
data was done using computer based SPSS (Statistical
III. Materials and Methods Program for Social Science) version-16.0. For
comparison of data Chi-square probability test was
A Cross sectional observational study was done
performed. For each analytical test level of significance
in the Department of Surgery, Rangpur Medical College
was 0.05 and p< 0.05 was considered significant. The
Hospital, Rangpur, during July-2012 to June-2014.
study was done with existing facilities in Rangpur
2 015

Patients of obstructive jaundice admitted in different

Medical College Hospital.
surgical wards of Rangpur Medical College Hospital,
Year

Rangpur were included in this study. The sample size IV. Results
was 50. Purposive sampling method was used as per
2 The mean age was 50.40 (29-70years),
inclusion and exclusion criteria. All patients were given
an explanation of the study and informed written SD10.92. Majority of benign cases was seen in 31-40
Global Journal of Medical Research ( ID ) Volume XV Issue IV Version I

consent was taken. None of the names were used in the years of age, while the malignant cases were more
data bases. common above 50 years old. Female are more
After proper counseling a detailed history was prevalent both in benign and malignant. The male to
taken and a thorough physical examination was done to female ratio for benign jaundice was 1:1.33, while it was
detect the causes of obstructive jaundice. Routine 1:1.23 for the malignant obstructive Jaundice. 37 (74%)
investigations including ultrasonography of whole number of the patients in this study belong low socio-
abdomen specially hepatobiliary system & pancreas to economical conditions. Among them malignant patients
detect the cause & level of biliary obstruction and liver are more (42%).
function test. When cause of biliary obstruction could
Among distribution of various causes with nature (n=50)
Nature Causes No. of patients Percentage (%) Total (n=50)
Choledocolithiasis 11 22
Post cholecystectomy biliary stricture 4 8
Post cholecystectomy CBD stone 2 4
21
Worm in CBD 2 4
Benign 42%
Choledochal cyst 2 4
Carcinoma head of the Pancrease 15 30
Carcinoma GB 8 16 29
Cholangiocarcinoma 3 6 58%
Malignant
Periampullary carcinoma 3 6
n=number of patient
Benign in 21 (42%) cases, whereas 29 (58%) case of benign diseases and it was statistically
patients had malignant cause. Choledocholithiasis was significant. Anorexia was present in 29 patients (58%). In
the commonest benign cause whereas carcinoma head benign condition it was 5 patients (23.80%) and in
of the pancreas was commonest in malignant group. malignant condition it was 24 patients (82.75%) and
Among distribution of association of symptoms statistically significant in case of malignant.
and signs with diagnosis, itching was present in 32 Weight loss was present in 30 patients (60%). In
patients (64%). In benign-66.66% and 62.02% in benign condition it was 4 patients (19.04%) and in
malignant condition which is statistically not significant. malignant condition it was 26 patients (89.65%) and
Clay coloured stools was present in 35 patients (70%). statistically significant for a malignant etiology. Fever
In benign condition, it was 11patients (52.38%) and in was present in a total of 27 patients (54%) with benign
malignant condition 24 patients (82.75%) and condition 17 patients (80.95%) and malignant condition
statistically significant. Pain abdomen was present in 27 10 patients (34.48%) which was statistically significant
patients (54%). 19 patients (90.47%) with benign and 8 for benign disease. Gall bladder was palpable in 14
patients (27.58%) with malignant etiology presenting patients (28%). In patients with benign condition 1
with this symptom. Pain is predominantly present in patients (4.76%) and malignant condition 13 patients

2015 Global Journals Inc. (US)

 Etiological Spectrum of Obstructive Jaundice in a Tertiary Care Hospital

(44.82%) which was statistically significant for a Carcinoma head of pancreas was the commonest, 15
malignant etiology. patients (30%) followed by the carcinoma gall bladder 8
In evaluation of imaging techniques for patients (16%), cholangiocarcinoma 4 patients (8%) and
diagnosis, all patients underwent USG, 41 patients periampullary carcinoma 2 patients (4%). Similar
(82%) revealed cause of obstruction but in case of 9 incidence of various malignancies in patients of
patients (18%) exact cause of obstruction could not be obstructive jaundice has been seen in various
ascertained and 12 patients underwent CT scan, most studies.14,20,21 These observations reflect differences in
of them were malignant cases and detect accurate etiological spectrum from one centre to another. Among
cause of obstruction in 11 patients (91%). Sensivity of the symptoms, pruritis was present in 32 patients (64%)
ultrasonogram was 82% but CT scan 91%. Almost all which was near to equally in both the benign 14 patients
benign cases diagnosed were made correctly pre- (66.66%) and 18 patients (62.02%) in malignant cases.
operatively but in malignant, some cases confirmed Clay coloured stools was present in 35 patients (70%).
diagnosis made after histopathology. In benign condition, it was 11 patients (52.38%) and

2 015
Regarding treatment, all choledocholithiasis more commonly by patients with the malignant jaundice

Year
patients were treated by choledocholithotomy and 24 patients (82.75%).
insertion of T-tube. After laparotomy 4 cases of The pain in the abdomen was present in 27
carcinoma gall bladder were found such an advanced patients (54%) and it was more frequently seen amongst 3
stage that only biopsy specimen were taken, other 4 the benign causes 19 patients (90.47%) and almost

Global Journal of Medical Research ( ID ) Volume XV Issue IV Version I

cases of carcinoma gallbladder were treated with always present in every case of choledocholithiasis.
extended cholecystectomy, other than this all malignant While 8 patients (27.58%) with malignancy also had
cases were treated as palliative surgery like double or abdominal pain on presentation possibly due to
triple bypass. Maximum palliative surgery done by advanced disease.16
double bypass procedure in the form of Anorexia was present in 29 patients (58%) and
hepaticojejunostomy and jejunojejunostomy. was more frequently seen amongst the patients of
malignant jaundice, 24 patients (82.75%) and it was
V. Discussions statistically significant. In benign condition it was 5
patients (23.80%). Weight loss was present in 30
The mean age of the patients with the benign or
patients (60%). In benign condition it was 4 patients
malignant etiology of obstructive jaundice was 50.40
(19.04%) and in malignant condition it was 26 patients
(29-70years), SD10.92. Most of the patients with the
(89.65%). Fever was present in a total of 27 patients
benign jaundice were between 3140 years of age while
(54%) with benign condition 17 patients (80.95%) and
malignant causes were more common in the older
malignant condition 10 patients (34.48%) which
patients and were maximally seen >50 years of age.
statistically significant for benign etiology. Gall bladder
The increased incidence of malignant obstructive
was palpable in 14 patients (28%). The palpable gall
jaundice with the increasing age has also been reported
bladder was appreciated in 13 patients (44.82%) with
by various study.6, 14, 15
malignancy thus supporting the Courvoisiers law 16,22,
In this study, both the benign and malignant
and only 1 patients (4.76%) gall bladder palpable in
obstructive jaundice are found more commonly
cases benign condition.
amongst the females than males. The male to female
Amongst the radiological investigations
ratio for benign jaundice was 1:1.33, while it was 1:1.23
ultrasonogram was the initial imaging investigation for all
for the malignant obstructive Jaundice. The increased
cases of obstructive jaundice to diagnose the cause of
incidence of obstructive jaundice amongst the females
obstruction. Forty one patients (82%) USG revealed
is due to the fact that gall stones are frequently found in
cause of obstruction but in case of 9 patients (18%)
them.16,17 Some study support this findings.14,16 In case
exact cause of obstruction could not be ascertained. CT
of nature, malignant obstructive jaundice was more
scan has several advantages over USG. CT scan was
common than benign, 58% Vs 42% which is in
done in patients mostly suspecting of malignancy in
agreement with other studies reported elsewhere.1,16,18-20
USG. Tumor size, its local, regional and distant spread
but in contrast to Bekele et al 5 in Ethiopia who reported
can more accurately be determined by CT scan. CT
benign obstructive jaundice as the most common cause
scan done in 12 patients and detect accurate cause of
of obstructive jaundice. Regarding the benign causes
obstruction in 11 patients (91%). ERCP cannot
choledocholithiasis was most common cause, 11
performed as because this facility was not available in
patients (22%) followed by 4 patients (8%) stricture of our hospital. Though ERCP has been defined as a Gold
common bile duct, 2 patients (4%) post Standard for the diagnosis of obstructive jaundice.23
cholecystectomy CBD stone, 2 patients (4%) worm in The final diagnosis was then made based upon the
CBD, 2 patients (4%) choledochal cyst. Choledocho- results of histopathology and then results were drawn.
lithiasis was also found to be the commonest benign Justification of treatment modalities in the biliary
cause in others study.14,18-21 Amongst the malignancies, obstruction depend on the site and nature of
2015 Global Journals Inc. (US)
 Etiological Spectrum of Obstructive Jaundice in a Tertiary Care Hospital

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