History

Patients commonly complain of yellow skin and eyes, pale stools, dark urine, jaundice, and pruritus.

The following considerations are important:

Patients' ages and associated conditions
The presence or absence of pain
The location and characteristics of the pain
The acuteness of the symptoms
The course of the jaundice (ie, progressive, intermittent, fluctuating)
The presence of systemic symptoms (eg, fever, anorexia, weight loss)
Symptoms of gastric outlet obstruction or stasis (eg, early satiety, vomiting, belching)
History of anemia
Previous malignancy
Known gallstone disease
Gastrointestinal bleeding
Hepatitis
Previous biliary surgery
Diabetes or diarrhea of recent onset
Abdominal pain may be misleading; some patients with common bile duct calculi have painless jaundice, whereas some patients with hepatitis have distressing pain in the right upper quadrant. Malignancy is more commonly associated with the absence of pain and tenderness during the physical examination.

Also, explore the use of alcohol, drugs, and medications.

Physical Examination

Upon physical examination, the patient may display signs of jaundice (skin and icterus). Look for signs of dissemination of cancer (eg, left supraclavicular lymph node, umbilical nodule, pelvic deposits on per rectal [P/R] or per vaginal [P/V] examination).

When the abdomen is examined, the gallbladder may be palpable (Courvoisier sign). This may be associated with underlying pancreatic malignancy. Also, look for signs of weight loss, adenopathies, and occult blood in the stool, suggesting a neoplastic lesion. In addition, note the presence or absence of splenomegaly, ascites, and collateral circulation associated with cirrhosis. Nodular enlarged liver suggests metastases in malignant biliary obstruction.

A high fever and chills suggest a coexisting cholangitis. Early recognition of primary sclerosing cholangitis is essential as fulminant sepsis may develop.^[5]

Xanthomata are associated with primary biliary cirrhosis (PBC).

Excoriations suggest prolonged cholestasis or high-grade biliary obstruction.

Differential Diagnoses

Center SA. Diseases of the gallbladder and biliary tree. Vet Clin North Am Small Anim Pract. 2009 May. 39(3):543-98. [QxMD MEDLINE Link].
Marrelli D, Caruso S, Pedrazzani C, et al. CA19-9 serum levels in obstructive jaundice: clinical value in benign and malignant conditions. Am J Surg. 2009 Sep. 198(3):333-9. [QxMD MEDLINE Link].
Bektas M, Dokmeci A, Cinar K, et al. Endoscopic management of biliary parasitic diseases. Dig Dis Sci. 2010 May. 55(5):1472-8. [QxMD MEDLINE Link].
Zhu AX, Hong TS, Hezel AF, Kooby DA. Current management of gallbladder carcinoma. Oncologist. 2010. 15(2):168-81. [QxMD MEDLINE Link]. [Full Text].
O'Connell W, Shah J, Mitchell J, et al. Obstruction of the biliary and urinary system. Tech Vasc Interv Radiol. 2017 Dec. 20(4):288-93. [QxMD MEDLINE Link].
Lee JG. Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol. 2009 Sep. 6(9):533-41. [QxMD MEDLINE Link].
Chu YC, Yang CC, Yeh YH, Chen CH, Yueh SK. Double-balloon enteroscopy application in biliary tract disease-its therapeutic and diagnostic functions. Gastrointest Endosc. 2008 Sep. 68(3):585-91. [QxMD MEDLINE Link].
Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy. 2007 Dec. 39(12):1068-71. [QxMD MEDLINE Link].
Nanashima A, Abo T, Sakamoto I, et al. Three-dimensional cholangiography applying C-arm computed tomography in bile duct carcinoma: a new radiological technique. Hepatogastroenterology. 2009 May-Jun. 56(91-92):615-8. [QxMD MEDLINE Link].
Niu H, Gao W, Cheng J, et al. Improvement of percutaneous transhepatic biliary internal-external drainage and its initial experience in patients with malignant obstruction of the upper biliary tree. Hepatogastroenterology. 2012 Jul-Aug. 59(117):1368-73. [QxMD MEDLINE Link].
Hanada K, Iiboshi T, Ishii Y. Endoscopic ultrasound-guided choledochoduodenostomy for palliative biliary drainage in cases with inoperable pancreas head carcinoma. Dig Endosc. 2009 Jul. 21 suppl 1:S75-8. [QxMD MEDLINE Link].
Maranki J, Hernandez AJ, Arslan B, et al. Interventional endoscopic ultrasound-guided cholangiography: long-term experience of an emerging alternative to percutaneous transhepatic cholangiography. Endoscopy. 2009 Jun. 41(6):532-8. [QxMD MEDLINE Link].
Dhir V, Itoi T, Khashab MA, et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc. 2015 Apr. 81(4):913-23. [QxMD MEDLINE Link].
Mutignani M, Iacopini F, Perri V, et al. Endoscopic gallbladder drainage for acute cholecystitis: technical and clinical results. Endoscopy. 2009 Jun. 41(6):539-46. [QxMD MEDLINE Link].
Lin H, Li S, Liu X. The safety and efficacy of nasobiliary drainage versus biliary stenting in malignant biliary obstruction: A systematic review and meta-analysis. Medicine (Baltimore). 2016 Nov. 95(46):e5253. [QxMD MEDLINE Link].
Jaganmohan S, Lee JH. Self-expandable metal stents in malignant biliary obstruction. Expert Rev Gastroenterol Hepatol. 2012 Jan. 6(1):105-14. [QxMD MEDLINE Link].
Gwon DI, Ko GY, Sung KB, et al. A novel double stent system for palliative treatment of malignant extrahepatic biliary obstructions: a pilot study. AJR Am J Roentgenol. 2011 Nov. 197(5):W942-7. [QxMD MEDLINE Link].
Fukasawa M, Takano S, Shindo H, Takahashi E, Sato T, Enomoto N. Endoscopic biliary stenting for unresectable malignant hilar obstruction. Clin J Gastroenterol. 2017 Dec. 10(6):485-90. [QxMD MEDLINE Link].
Chang G, Xia FF, Li HF, Niu S, Xu YS. Unilateral versus bilateral stent insertion for malignant hilar biliary obstruction. Abdom Radiol (NY). 2017 Nov. 42(11):2745-51. [QxMD MEDLINE Link].
Acu B, Kurtulus Ozturk E. Feasibility and safety of percutaneous transhepatic endobiliary radiofrequency ablation as an adjunct to biliary stenting in malignant biliary obstruction. Diagn Interv Imaging. 2018 Apr. 99(4):237-45. [QxMD MEDLINE Link].
Kogure H, Ryozawa S, Maetani I, et al. A prospective multicenter study of a fully covered metal stent in patients with distal malignant biliary obstruction: WATCH-2 Study. Dig Dis Sci. 2018 Sep. 63(9):2466-73. [QxMD MEDLINE Link].
Hamada T, Nakai Y, Lau JY, et al. International study of endoscopic management of distal malignant biliary obstruction combined with duodenal obstruction. Scand J Gastroenterol. 2018 Jan. 53(1):46-55. [QxMD MEDLINE Link].
Nakai Y, Isayama H, Yamamoto N, et al. Indications for endoscopic ultrasonography (EUS)-guided biliary intervention: Does EUS always come after failed endoscopic retrograde cholangiopancreatography?. Dig Endosc. 2017 Mar. 29(2):218-25. [QxMD MEDLINE Link].
Adamek HE, Albert J, Weitz M. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut. 1998 Nov. 43(5):680-3. [QxMD MEDLINE Link].
Ahmed A, Cheung RC, Keeffe EB. Management of gallstones and their complications. Am Fam Physician. 2000 Mar 15. 61(6):1673-80, 1687-8. [QxMD MEDLINE Link].
American Society of Gastrointestinal Endoscopy. Technology status evaluation: magnetic resonance pancreatography. American Society of Gastrointestinal Endoscopy Clinical Guidelines. Oak Brook, Ill: ASGE; 1998.
Bass NM. Sclerosing cholangitis and recurrent pyogenic cholangitis. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998. 1006-18.
Beers MH, Berkow R. Hepatic and biliary disorders. Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck & Co; 1999. chap 46.
Bilhartz MH, Horton JD. Gallstone disease and its complications. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998. 948-72.
Cancado EL, Leitao RM, Carrilho FJ, Laudanna AA. Unexpected clinical remission of cholestasis after rifampicin therapy in patients with normal or slightly increased levels of gamma-glutamyl transpeptidase. Am J Gastroenterol. 1998 Sep. 93(9):1510-7. [QxMD MEDLINE Link].
Cotran RS, Kumar V, Robbins SL. The biliary system. Schoen FJ, ed. Robbins Pathologic Basis of Disease. 5th ed. Philadelphia: WB Saunders; 1994. 883-96.
Erickson RA, Garza AA. EUS with EUS-guided fine-needle aspiration as the first endoscopic test for the evaluation of obstructive jaundice. Gastrointest Endosc. 2001 Apr. 53(4):475-84. [QxMD MEDLINE Link].
Friedman LS. The liver, biliary tract, and pancreas. Tiernery LM, McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment. 39th ed. New York: McGraw-Hill; 2000. 656-97.
Fukuda Y, Tsuyuguchi T, Sakai Y. Diagnostic utility of peroral cholangioscopy for various bile-duct lesions. Gastrointest Endosc. 2005 Sep. 62(3):374-82.
Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am. 2000 Sep. 14(3):521-46. [QxMD MEDLINE Link].
Kaplan LM, Isselbacher KJ. Jaundice. Fauci AS, Longo DL, Kasper DL, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998. 249-55.
Kasiske BL, Keane WF. Laboratory assessment of renal disease: clearance, urinalysis, and renal biopsy. Brenner BM, ed. Brenner and Rector's The Kidney. 6th ed. WB Saunders; 2000. 1143.
Kok KY, Yapp SK. Tuberculosis of the bile duct: a rare cause of obstructive jaundice. J Clin Gastroenterol. 1999 Sep. 29(2):161-4. [QxMD MEDLINE Link].
Lewis JH. Drug-induced liver disease. Med Clin North Am. 2000 Sep. 84(5):1275-311, x. [QxMD MEDLINE Link].
Lindnor KD. Primary biliary cirrhosis. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998. 1279.
Lopera JE, Soto JA, Munera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions. Radiology. 2001 Jul. 220(1):90-6. [QxMD MEDLINE Link].
Luketic VA, Shiffman ML. Benign recurrent intrahepatic cholestasis. Clin Liver Dis. 1999 Aug. 3(3):509-28, viii. [QxMD MEDLINE Link].
Mallery S, Van Dam J. Advances in diagnostic and therapeutic endoscopy. Med Clin North Am. 2000 Sep. 84(5):1059-83. [QxMD MEDLINE Link].
Maze M, Bass N. Anesthesia and the hepatobiliary system. Miller R, ed. Anesthesia. 5th ed. New York: Churchill Livingstone; 2000. 1968-9.
Nissen D. Rifampin (002188). In: Mosby's Drug Consult 2002. Orlando, Fla: Harcourt Health Sciences; 2002.
Ostroff JW, LaBerge JM. Endoscopic and radiologic treatment of biliary disease. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998. 1043.
Paumgartner G. Nonsurgical management of gallstone disease. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia: WB Saunders; 1998. 984-92.
Ravel R. Liver and biliary tract tests. Ravel R, ed. Clinical Laboratory Medicine. 6th ed. St. Louis, Mo: Mosby-Year Book; 1995. 309-29.
Rossi RL, Traverso LW, Pimentel F. Malignant obstructive jaundice. Evaluation and management. Surg Clin North Am. 1996 Feb. 76(1):63-70. [QxMD MEDLINE Link].
Scheiman JM, Carlos RC, Barnett JL, et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol. 2001 Oct. 96(10):2900-4. [QxMD MEDLINE Link].
Shaker R, Dua KS, Koch TR. Gastroenterologic disorders. Duthie EH, ed. Practice of Geriatrics. 3rd ed. Philadelphia: WB Saunders; 1998. 514-5.
Shim CS, Cheon YK, Cha SW. Prospective study of the effectiveness of percutaneous transhepatic photodynamic therapy for advanced bile duct cancer and the role of intraductal ultrasonography in response assessment. Endoscopy. 2005 May. 37(5):425-33.
Vlahcevic ZR, Heuman DM. Diseases of the gallbladder and bile ducts. Goldman G, ed. Cecil Textbook of Medicine. 21 ed. Philadelphia: WB Saunders; 2000. 821-33.
Yeh TS, Chen NH, Jan YY, et al. Obstructive jaundice caused by biliary tuberculosis: spectrum of the diagnosis and management. Gastrointest Endosc. 1999 Jul. 50(1):105-8. [QxMD MEDLINE Link].
Yeh TS, Jan YY, Tseng JH. Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings. Am J Gastroenterol. 2000 Feb. 95(2):432-40.
Tang Z, Igbinomwanhia E, Elhanafi S, Othman MO. Endoscopic ultrasound guided rendezvous drainage of biliary obstruction using a new flexible 19-gauge fine needle aspiration needle. Diagn Ther Endosc. 2016. 2016:3125962. [QxMD MEDLINE Link].
Kitamura K, Yamamiya A, Ishii Y, Mitsui Y, Nomoto T, Yoshida H. Side-by-side partially covered self-expandable metal stent placement for malignant hilar biliary obstruction. Endosc Int Open. 2017 Dec. 5(12):E1211-E1217. [QxMD MEDLINE Link].
Nakai Y, Yamamoto R, Matsuyama M, et al. Multicenter study of endoscopic preoperative biliary drainage for malignant hilar biliary obstruction: E-POD hilar study. J Gastroenterol Hepatol. 2018 May. 33(5):1146-53. [QxMD MEDLINE Link].
Zhu Y, Wang S, Zhao S, Qi L, Li Z, Bai Y. Obstructive jaundice due to a blood clot after ERCP: a case report and review of the literature. BMC Gastroenterol. 2018 Nov 3. 18(1):163. [QxMD MEDLINE Link]. [Full Text].
Jo JH, Cho CM, Jun JH, et al, for the EUS Study Group of the Korean Society of Gastrointestinal Endoscopy. Same-session endoscopic ultrasound-guided fine needle aspiration and endoscopic retrograde cholangiopancreatography-based tissue sampling in suspected malignant biliary obstruction: A multicenter experience. J Gastroenterol Hepatol. 2019 Apr. 34(4):799-805. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Jennifer Lynn Bonheur, MD Attending Gastroenterologist

Jennifer Lynn Bonheur, MD is a member of the following medical societies: American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, New York Academy of Sciences, New York Society for Gastrointestinal Endoscopy, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Coauthor(s)

Peter F Ells, MD Associate Professor, Division of Gastroenterology-Hepatology, Albany Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Chief Editor

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS Professor of HPB Surgery, Mahatma Gandhi Medical College and Hospital (MGMCH), Jaipur, India

Vinay K Kapoor, MBBS, MS, FRCSEd, FICS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Pfizer Sanofi.

Additional Contributors

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS Professor of Medicine, Director of Digestive Diseases, Medical Director of Nutrition Support, Medical Director of Gastrointestinal Endoscopy, Internal Medicine Department, University of Mississippi Medical Center; Clinical Professor, University of Mississippi School of Pharmacy

Anil Minocha, MD, FACP, FACG, AGAF, CPNSS is a member of the following medical societies: American Academy of Clinical Toxicology, American Society for Gastrointestinal Endoscopy, American Federation for Clinical Research, American Association for the Study of Liver Diseases, American College of Forensic Examiners Institute, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous coauthor Flavio R Kamenetz, MD, PhD, to the development and writing of this article.

Biliary Obstruction Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?