Obstructive Jaundice (Cholangiocarcinoma)

usually due to stones or tumor

ROS: Painless jaundice suggests malignancy whereas choledocholithiasis often p/w colicky abdominal pain

PE: jaundice, abd ttp. Courvoisier's sign is the presence of a palpable GB due to malignancy as tumor causes biliary obstruction and progressive dilatation of the intrahepatic bile ducts. Choledocholithiasis has an acute presentation so GB does not distend

Labs: choledocholithiasis rarely causes t bili>15; tbili>20 suggestive of malignancy. Alk phos may rise before t bili and fall before t bili(after obstruction resolved). AST/ALT may be 4-10 x nl in acute obstruction

Management: Most patients who present with cholangiocarcinoma are not candidates for curative surgical therapy but require palliation for biliary obstruction with decompression using endoscopic, percutaneous, or surgical approaches
Gemcitabine has shown some promise
Other treatment modalities include radiation, phototherapy, transplant (when localized) but prognosis remains poor unless disease caught early and excised.

(Ellen Eaton MD, 9/28/10)