Painless Jaundice: A Happy Ending

Abstract

Significantly elevated serum bilirubin can predict malignancy. The following case discusses a patient with a very high bilirubin and our search for its cause. A 58-year-old female presented with painless jaundice. There were no new medications, supplements or weight loss. Physical exam revealed jaundice and scleral icterus. Laboratory analysis showed a total bilirubin 40.1 mg/dL, AST 110 U/L, ALT 134 U/L and alkaline phosphatase 1665 U/L. Computed tomography revealed intra and extra-hepatic biliary ductal dilatation, tapering of the common bile duct (CBD) within the pancreatic head, and no pancreatic head mass. ERCP showed two stones in the CBD, the largest being 13.4 mm in diameter (Fig. 1, Fig. 2). Three biliary stents were placed to bypass the obstructing stones and liver tests subsequently normalized. Follow-up ERCP with cholangioscopy and electrohydraulic lithotripsy successfully removed the obstructing stones (Fig. 3) and the patient underwent cholecystectomy. Choledocholithiasis commonly presents with abdominal pain and elevated liver tests. These are often modestly elevated in a cholestatic pattern, but dramatic elevations of total bilirubin (>10 mg/dL) have been described1. Elevations of this magnitude are concerning for primary liver disease or malignancy, often leading to delays in diagnosis and extensive testing. Levels of bilirubin elevation in obstructive jaundice correlate with underlying pathology, and significant elevation (>11 mg/dL) may predict malignancy2. Painless choledocholithiasis occurs in about 24% of patients. It is more likely in patients >65 years old with diabetes mellitus, hypertension, atherosclerosis, coronary artery disease and/or cerebrovascular disease. It is associated with higher morbidity and mortality3. Multiple small (< 8mm) stones are more often found with painless presentation, whereas few (< 4) large stones (>8mm) may produce typical pain. Our patient's presentation was concerning for underlying neoplasm. Thankfully, her painless jaundice had a happy ending.Figure: ERCP showing an obstruction in the common bile duct.Figure: ERCP showing a large common bile duct stone (approximately 13.4 mm in diameter).Figure: ERCP showing free flowing contrast in the common bile duct after placement of three plastic biliary stents.