Subhepatic (mechanical) jaundice

The basis of subhepatic (mechanical) jaundice is a violation of the outflow of bile through the extrahepatic bile ducts due to the violation of their patency. Consequently, there is a violation of the release of bound (conjugated) bilirubin through the extrahepatic bile ducts and its regurgitation (reverse entry into the blood). Regurgitation of bile occurs initially at the level of the intrahepatic bile ducts due to increased pressure in the biliary tree, and then at the level of hepatocytes.

Causes of subhepatic jaundice:

• obstruction of the hepatic and common bile ducts (stones, tumors, parasites, inflammation of the duct mucosa with subsequent sclerosis);
• (pressure of the hepatic and common bile ducts from the outside (tumor of the head of the pancreas, gallbladder, enlarged lymph nodes, pancreatic cysts, sclerosing chronic pancreatitis);
• compression of the common bile duct by postoperative scars and adhesions;
• atresia (hypoplasia) of the biliary tract;
• obstruction of large intrahepatic bile ducts in liver echinococcosis, primary and metastatic liver cancer, congenital cysts.

The main features of subhepatic (mechanical) jaundice:

• most often occurs in people over 40 years of age, as a rule, most often it is jaundice of tumor origin (40%) and as a result of gallstone disease (30-40%);
• the development of jaundice is preceded by pain. In cholelithiasis, the pain is acute, paroxysmal, localized in the right hypochondrium, radiating to the area of the right half of the neck, shoulder, arm, shoulder blade. Often, pain of this nature is noted repeatedly, after which jaundice appears.

In jaundice of tumor genesis, pain occurs long before jaundice, is localized mainly in the epigastrium, in the hypochondrium, may be less intense, and quite often has a constant nature. In 20% of patients, pain may be absent;

• the presence of dyspeptic disorders is characteristic.

Dyspeptic disorders (nausea, vomiting) are short-term in benign jaundice, i.e. they occur shortly before the appearance of jaundice; in jaundice caused by a malignant tumor, they exist for a long time in the pre-icteric period.

Lack of appetite in benign mechanical jaundice appears shortly before jaundice, while in malignant jaundice, lack of appetite is long-term and appears long before jaundice;

• weight loss is more characteristic of malignant subhepatic jaundice and less characteristic of benign jaundice;
• body temperature is elevated; in benign jaundice due to infection of the bile ducts, in malignant jaundice - due to the tumor process itself;
• severe skin itching;
• there is pronounced jaundice of a greenish tint;
• with severe and prolonged cholestasis, a significant enlargement of the liver is observed;
• the spleen is not enlarged;
• subhepatic jaundice caused by a tumor of the pancreatoduodenal zone is accompanied by an enlargement of the gallbladder (Courvoisier's symptom), less often this symptom also occurs with benign jaundice (a stone in the ductus choledochus);
• hyperbilirubinemia is sharply expressed due to direct (conjugated) bilirubin;
• urobilin is absent in urine;
• stercobilin is absent in feces (acholia feces);
• bilirubin is detected in urine;
• cytolysis syndrome (increased blood levels of ALT, liver-specific enzymes, aldolase) may be absent at the onset of jaundice, but may later appear, but in a less pronounced form than with hepatic jaundice;
• laboratory signs of cholestasis are recorded: an increase in the blood levels of alkaline phosphatase, γ-GTP, cholesterol, bile acids, 5-nucleotidase, leucine aminopeptidase;
• Ultrasound reveals stones in the bile ducts or a tumor of the pancreatoduodenal zone. In cholestasis, signs of the echographic syndrome of biliary hypertension are revealed: expansion of the common bile duct (more than 8 mm) in extrahepatic cholestasis; expansion of the intrahepatic bile ducts in the form of star-shaped "bile lakes".

The main clinical manifestations of malignant tumors causing subhepatic jaundice

Cancer of the head of the pancreas

With cancer of this localization, jaundice is observed in 80-90% of cases. The characteristic clinical signs of cancer of the head of the pancreas are as follows:

• the disease is more common in men over 40 years of age;
• Before the onset of jaundice, patients are bothered by a decrease in appetite, pain in the upper abdomen (it gradually becomes permanent), weight loss, and itchy skin;
• in 10% of patients, jaundice appears without any other preceding subjective or objective symptoms;
• jaundice is intense, has all the signs characteristic of subhepatic jaundice; once it appears, it quickly increases and acquires a greenish-gray or dark olive color;
• In 30-40% of patients, the Courvoisier symptom is positive - a large and painless gallbladder is palpated, which is caused by the complete closure of the common bile duct and the accumulation of bile in the bladder;
• an enlargement of the liver is determined due to bile stasis; when the tumor metastasizes to the liver, the latter becomes lumpy;
• in advanced cases, a tumor can be felt in the epigastric region;
• characterized by anemia, leukocytosis, increased ESR, and increased body temperature;
• during a multi-position X-ray examination of the stomach and duodenum, displacements, indentations and deformations of these organs, expansion of the loop of the duodenum, infiltration and ulceration of the wall are revealed;
• duodenography under conditions of artificial hypotension (filling the duodenum through a duodenal tube after preliminary intravenous administration of 2 ml of a 0.1% solution of atropine sulfate) reveals an indentation on the inner wall of the duodenum (due to an increase in the head of the pancreas), a double-contour medial wall;
• Ultrasound, computed tomography and magnetic resonance imaging reveal a tumor in the area of the head of the pancreas;
• scanning of the pancreas with radioactive 75S-methionine reveals a focal defect in the accumulation of the isotope in the head region;
• Retrograde cholangiopancreatography is a relatively accurate method for diagnosing pancreatic cancer. Using a flexible duodenofibroscope, a contrast agent is injected into the main pancreatic duct and its branches through a special catheter, then X-rays are taken, which reveal "breaks" (non-filling) of the ducts and foci of tumor infiltration, destruction of the main passages of the main pancreatic duct.

Cancer of the ampulla of Vater

The following features are characteristic of cancer of the large duodenal (Vater's) ampulla:

• the disease is more common in men aged 50-69 years;
• the appearance of jaundice is preceded by weight loss in patients;
• Jaundice develops gradually, without pain and without a sharp deterioration in the general condition. With further progression of the disease, pain appears in the upper half of the abdomen;
• jaundice has all the features of post-hepatic (mechanical), however, in the initial period it may be incomplete and urobilin is determined in the urine along with bilirubin;
• Jaundice is often characterized by a recurrent (wave-like) course, periods of increased jaundice are followed by periods of its decrease. A decrease in the intensity of jaundice is explained by a decrease in swelling and inflammation in the tumor area or its disintegration;
• the liver enlarges;
• Courvoisier's symptom appears;
• an ulcerated tumor may be complicated by intestinal bleeding;
• X-ray examination of the duodenum reveals changes characteristic of a tumor of the ampulla of Vater: a filling defect or persistent, gross deformation of the wall of the duodenum;
• Carcinoma of the major duodenal papilla is detected by duodenoscopy. During endoscopy, a biopsy of the mucous membrane is performed to clarify the diagnosis.

Ultrasound, computed tomography and magnetic resonance imaging can be used to make a diagnosis.

Gallbladder cancer

Gallbladder cancer leads to the development of subhepatic jaundice when the tumor process spreads to the liver and bile ducts (common hepatic duct, common bile duct). As a rule, gallbladder cancer occurs against the background of previous chronic calculous or non-calculous cholecystitis. In most patients, the disease is asymptomatic in the early stages. In some patients, early signs may include pain in the gallbladder, bitter belching, and a feeling of bitterness in the mouth. These symptoms are difficult to distinguish from the banal manifestations of calculous cholecystitis. Anorexia, weight loss, subhepatic (obstructive) jaundice, a palpable dense tumor in the gallbladder are signs of an advanced tumor process.

Ultrasound, computed tomography and magnetic resonance imaging play an important role in diagnosing gallbladder cancer.

Primary liver cancer

Primary liver cancer is characterized by the following clinical and laboratory-instrumental symptoms:

• the disease most often develops in men, mainly at the age of 40-50 years;
• the development of cancer is usually preceded by cirrhosis of the liver;
• patients are concerned about increasing general weakness, weight loss, loss of appetite, constant pain in the right hypochondrium; high body temperature with chills;
• persistent intense jaundice develops; it is most often of a subhepatic (mechanical) nature due to compression of the intrahepatic bile ducts, accompanied by skin itching;
• hepatomegaly is clearly expressed, the liver increases in size very quickly, its surface is lumpy, the consistency is very dense (“stony liver”);
• persistent ascites, refractory to therapy, in many patients it develops simultaneously with the appearance of jaundice;
• episodes of spontaneous hypoglycemia are possible, it often recurs repeatedly, can be severe, and hypoglycemic coma may develop;
• laboratory data: anemia (however, erythrocytosis is also possible due to the fact that the tumor can produce erythropoietin), leukocytosis, increased ESR; hyperbilirubinemia with a predominant increase in the content of conjugated bilirubin in the blood; normo- or hypoglycemia; increased content of alanine aminotransferase, alkaline phosphatase, bile acids in the blood, the detection of alpha-fetoprotein in the blood is typical;
• Ultrasound, computed tomography, magnetic resonance imaging, and radioisotope scanning of the liver reveal focal liver damage.

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