Presence of White Bile (Bilirubin-Free Bile) Is Associated with Cholangitis in Malignant Biliary Obstruction

Abstract

Background and Aims: White bile is colorless, translucent fluid found occasionally in obstructed bile duct. There has been no systemic study of the cause and effect of white bile. We undertake prospective study to determine the frequency and predictive value of white bile in malignant biliary obstruction Materials and Methods: Bile was aspirated during ERCP in consecutive patients with inoperable malignant biliary obstruction distal to CHD. Patients were divided into two groups: those whose bile bilirubin was < or = 1.5 mg/dL (white bile group) and > 1.5 mg/dL (yellow bile group). Two groups were compared for duration of jaundice, itching and cholangitis (bile WBC count >50/mm3 and positive bile culture), level of obstruction, decremental rate of bilirubin after insertion of 7 Fr endoscopic nasobiliary drainage until insertion of metal stent or 10 Fr plastic stent and survival. Results: Sixty patients (30 men; mean age 68.2 years) were included. Sixteen patients (26.7%) had white bile. Mean bile bilirubin was 0.4 mg/dL in white bile and 53.5 mg/dL in yellow bile. The causes of obstruction were 23 CBD cancer, 17 pancreas cancer, 10 CHD cancer, 5 GB cancer, 5 periampullary cancer. Cholangitis was more common in white than yellow bile (11/16 vs. 7/44, p = 0.000). WBC count in blood was higher in white than yellow bile (9,456/mm3 vs. 7,400/mm3, p = 0.029). Obstructed bile duct had communication with GB in 7/16 patients with white and 27/44 patients with yellow bile (p > 0.05). There were no differences in pre-drainage total bilirubin level and the decremental rate of bilirubin after endoscopic drainage in both groups. Mean survival time of the patients were 242 days in yellow and 227 days in white bile group(p > 0.05). Conclusions: White bile in malignant biliary obstruction was not rare and was associated with cholangitis. GB did not seem to have role in formation of white bile. There was no difference of mean survival time in both groups. Further study for the pathogenesis and prognosis of white bile in malignant biliary obstruction will be necessary.