Jaundice: Surgical considerations

Abstract

It was pointed out that in so-called surgical (obstructive) jaundice, a history of biliary colic is usually obtained and is the main factor pointing to a surgical condition. A history of chills and fever and light-colored stools may also be obtained. Tenderness and rigidity of the right upper abdominal wall may or may not be present. However, no hard and fast rule, based on either history or physical examination can be made to select those cases in which operation is indicated. Because of this difficulty laboratory tests based on disturbances of normal functions of the liver are often indicated and helpful in making a diagnosis. These tests of function fall into several main groups: (1) Secretion of bile: bile and urobilinogen in urine, icteric index of blood, Van den Bergh tests of blood; (2) storage of carbohydrate: glucose or galactose tolerance tests; (3) excretion or secretion of enzymes: phosphatase in blood; (4) detoxifying: formation of hippuric acid from sodium benzoate; (5) abnormal globulin formation: cephalin-cholesterol test; (6) dye excretion: bromsulfalein retention; and (7) storage of vitamin K and protbrombin formation: prothrombin level of the blood. Even in the most probable acute surgical cases, a preliminary period of four to six hours for parenteral administration of salt, water and glucose is necessary. Glucose replenishes the glycogen reserves of the liver and protects its cells. Vitamin κ is also given to control the bleeding tendency in jaundice. Moderate amounts of protein in the form of plasma or amino acids help liver regeneration. In those patients whose clinical picture is less acute, conservative management with salt, water, glucose, vitamin κ and protein may result in the clearing up of jaundice which was due to industrial or other poisons or cirrhosis. Laboratory tests may not be able to differentiate obstruction, cirrhosis, stone in the common duct, liver abscess, metastases to the liver, or carcinoma of the common duct or head of the pancreas. Therefore, persistent signs of obstruction such as jaundice, light-colored stools, bile in the urine and a positive direct Van den Bergh test will require eventual surgical exploration. Even when the decision to operate is difficult to make, preliminary therapy as outlined above builds up the general condition of the patient, while at the same time a few key laboratory tests can be carried out. It is emphasized that obstruction of the biliary tract often co-exists with damage to the liver cells so that laboratory tests may not be clear-cut. It is in these cases that judgment and experience decide the course to be taken.