Back to Chronic Cholestasis

Introduction

Malignant obstruction of the bile ducts may give rise to extrahepatic chronic cholestasis and jaundice. Malignancies can be either biliary (e.g. cholangiocarcinoma) or non-biliary (e.g. pancreatic cancer).

History

Jaundice is usually a presenting symptom in chronic malignant cholestasis. Abdominal pain may or may not be present. Long-standing cholestasis may lead to deficiency of fat-soluble vitamins (A, D, E, K), and the associated signs and symptoms (e.g. night blindness, osteoporosis, easy bruising). Clay-colored stool may be present due to the lack of bilirubin. Weight loss and pruritus are also common. A long-standing alcohol history should raise suspicion for chronic pancreatitis and pancreatic cancer.

Physical examination

There are no specific findings. Patients may appear cachectic. The followings may be present:

• Scleral icterus
• Palpable abdominal mass
• Palpable gallbladder (highly suggestive of malignant biliary obstruction)
• Lymphadenopathy

Investigation

Since pancreatic cancer is the most common cause of malignant biliary obstruction in older patients, pancreatic-protocol CT scan or MRI should be among the initial studies. Serological markers are generally not useful in establishing the diagnosis. In certain cases, endoscopic ultrasound (EUS) and ERCP may be necessary for further evaluation and for obtaining tissue diagnosis.