Subhepatic (mechanical) jaundice

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

Causes of subhepatic jaundice:

• Obturation of the hepatic and common bile ducts (stones, swelling, parasites, inflammation of the mucous duct with subsequent sclerosing);
• (pressure of the hepatic and common bile ducts from the outside (tumor of the head of the pancreas, gall bladder, enlarged lymph nodes, pancreatic cysts sclerosing chronic pancreatitis);
• compression of the common bile duct with postoperative scars, spikes;
• atresia (hypoplasia) of the bile ducts;
• obturation of large intrahepatic bile ducts with liver echinococcosis, primary and metastatic liver cancer, congenital cysts.

The main features of subhepatic (mechanical) jaundice:

• most often occurs in people older than 40 years, as a rule, most often jaundice of tumor origin (40%) and due to cholelithiasis (30-40%);
• the development of jaundice is preceded by pain. With cholelithiasis, the pain is acute, paroxysmal, localized in the right hypochondrium, radiating into the region of the right side of the neck, shoulder, arms, scapula. Often pain of a similar nature is noted repeatedly, after which jaundice appears.

With jaundice of tumor origin, pain occurs long before jaundice, is localized mainly in epigastrium, in hypochondria, may be less intense, quite often has a permanent character. In 20% of patients, pain may be absent;

• characterized by the presence of dyspeptic disorders.

Dyspeptic disorders (nausea, vomiting) have a short-term character in benign jaundice, i.e. Occur shortly before the appearance of jaundice; with jaundice caused by a malignant tumor they last for a long time in the pre-jaundiced period.

Lack of appetite with benign mechanical jaundice appears shortly before jaundice, with malignant - lack of appetite long, arises long before jaundice;

• a decrease in body weight is more typical for malignant subhepatic jaundice and little characteristic of benign;
• body temperature increased; with benign jaundice due to infection of the biliary tract, with malignant - due to the very tumor process;
• pronounced skin itching;
• there is a pronounced jaundice of a greenish hue;
• with significant and prolonged cholestasis, there is a significant increase in the liver;
• the spleen is not enlarged;
• subhepatic jaundice caused by a tumor of the pancreatoduodenal zone is accompanied by an increase in the gallbladder (a symptom of Courvoisier), less often this symptom occurs with benign jaundice (a stone in the ductus choledochus);
• Hyperbilirubinemia is strongly pronounced due to direct (conjugated) bilirubin;
• urobilin in the urine is absent;
• stercobilin in the feces is absent (achalia of feces);
• bilirubin is determined in urine;
• cytolysis syndrome (an increase in blood ALT, hepatic specific enzymes, aldolase) at the beginning of jaundice may be absent, but then it may appear, but in a less pronounced form than with hepatic jaundice;
• laboratory signs of cholestasis are registered: an increase in the blood of alkaline phosphatase, y-GTP, cholesterol, bile acids, 5-nucleotidase, leucine aminopeptidase;
• Ultrasound reveals stones in the biliary tract or tumor of the pancreatoduodenal zone. With cholestasis, signs of echographic syndrome of biliary hypertension are revealed, an expansion of the common bile duct (more than 8 mm) with extrahepatic cholestasis; enlargement of intrahepatic bile ducts in the form of stellate "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 pancreatic head cancer are as follows:

• the disease is more common in men over the age of 40;
• before the appearance of jaundice patients are concerned about a decrease in appetite, pain in the upper half of the abdomen (they gradually acquire a permanent character), weight loss, itching of the skin;
• in 10% of patients, jaundice appears without any other prior subjective and objective symptomatology;
• jaundice intense, has all the signs characteristic of subhepatic jaundice; when it appears, it rapidly grows and acquires a greenish-gray or dark olive color;
• in 30-40% of patients positive symptom Courvoisier - a large and painless gallbladder is palpated, which is due to the complete closure of the common bile duct and the accumulation of bile in the bladder;
• the increase in the liver due to congestion of bile; when the tumor metastasizes to the liver, the latter becomes tuberous;
• in far-reaching cases, a tumor is sensed in the epigastric region;
• characteristic anemia, leukocytosis, increased ESR, increased body temperature;
• when polycystonic X-ray examination of the stomach and duodenum, displacement, deformation and deformation of these organs, widening of the duodenum loop, infiltration and ulceration of the wall are detected;
• duodenography in conditions of artificial hypotension (filling of duodenum through duodenal probe after preliminary intravenous injection of 2 ml of 0.1% solution of atropine sulfate) reveals an impression on the inner wall of the duodenum (due to an increase in the head of the pancreas), a two-contour of the medial wall;
• Ultrasound, computer and magnetic resonance tomography reveal a tumor in the head of the pancreas;
• scanning of the pancreas with radioactive 75S-methionine reveals a focal defect of isotope accumulation in the head region;
• Retrograde pancreatocholangiography is a relatively accurate method for diagnosing pancreatic cancer. With the help of a flexible duodenofibroscope, a contrast agent is introduced into the main pancreatic duct and its branches through a special catheter, then X-rays are taken, which reveal "cuts" (incompleteness) of the ducts and tumor infiltration sites, destruction of the main passages of the main pancreatic duct.

Fat pectoral cancer

For cancer of the large duodenal (faterovaya) nipple, the following features are characteristic:

• the disease is more common in men aged 50-69 years;
• the appearance of jaundice is preceded by the weight loss of patients;
• the development of jaundice occurs gradually, without pain and without a sharp violation of the general condition. With further progression of the disease, pains appear in the upper half of the abdomen;
• jaundice has all the features of posthepatic (mechanical), but in the initial period it may be incomplete and urine along with bilirubin is determined by urobilin;
• often jaundice is characterized by a recurrent (undular) course, periods of increased jaundice are replaced by periods of its decrease. The decrease in the intensity of jaundice is explained by the reduction of edema and inflammation in the tumor region or its decay;
• the liver is enlarged;
• a symptom of Courvoisier;
• ulcerated swelling can be complicated by intestinal bleeding;
• fluoroscopy of the duodenum reveals the changes characteristic of the tumor of the fat nipple: defect filling or persistent, rough deformation of the wall of the duodenum;
• the carcinoma of the large duodenal nipple is revealed during duodenoscopy. During endoscopy, a biopsy of mucosal areas is performed to clarify the diagnosis.

For the diagnosis, ultrasound, computer and magnetic resonance imaging can be used.

Cancer of the gallbladder

Cancer of the gallbladder leads to the development of subhepatic jaundice when the tumor process spreads to the liver and biliary tract (common hepatic duct, holedoch). As a rule, the cancer of the gallbladder arises against the background of the previous chronic calculous or noncalculous cholecystitis. In most patients in the early stages of the disease is mildly symptomatic. Some patients with early signs may have pain in the area of the gallbladder, belching bitter, 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, palpable dense tumor in the gallbladder area are signs of a far-reaching tumor process.

To diagnose gallbladder cancer, ultrasound, computer and magnetic resonance tomography play an important role.

Primary liver cancer

The following clinical and laboratory-instrumental symptoms are characteristic of primary liver cancer:

• the disease often develops in men, mostly at the age of 40-50;
• The development of cancer is usually preceded by cirrhosis;
• patients are worried about the growing general weakness, weight loss, lack of appetite, pain in the right hypochondrium of a permanent character; high body temperature with chills;
• develop persistent intense jaundice; it often has a subhepatic (mechanical) character due to compression of the intrahepatic biliary tract, accompanied by pruritus;
• hepatomegaly is pronounced, the liver grows very quickly, its surface is tuberous, 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, often it recurs repeatedly, it washes heavily, hypoglycemic coma may develop;
• laboratory data: anemia (however, erythrocytosis is possible due to the fact that the tumor can produce erythropoietin), leukocytosis, increased ESR; Hyperbilirubinemia with a predominant increase in blood levels of conjugated bilirubin; normo- or hypoglycemia; an increase in the blood levels of alanine aminotransferase, alkaline phosphatase, bile acids, is characteristic of the detection of a-fetoprotein in the blood;
• Ultrasound, computer and magnetic resonance tomography, radioisotope scanning of the liver reveal focal liver damage.

[1], [2], [3], [4], [5], [6]