Presence of white bile in malignant biliary obstruction is associated with poor prognosis: personal preliminary observations

Abstract

The chemical composition and clinical significance of white bile in patients with malignant obstructive jaundice were evaluated in a prospective study. 115 consecutive patients with inoperable malignant biliary obstruction underwent endoscopic placement of 10 Fr straight, plastic biliary stents, Amsterdam-type. Bile was aspirated during the endoscopic procedure and a blood sample was taken. Patients were divided into two groups: those with white bile and those with yellow bile. The groups were compared for decremental fall in bilirubin, cholangitis after stent insertion, and survival. Thirty-five patients (15 men, 20 women; mean age 54 years) underwent endoscopic drainage for malignant obstruction (29 hilar, 6 distal bile duct). Eighteen patients had white bile. Refractory jaundice (p > -0.025) was seen in nine (50%) patients with white bile compared with three (17.6%) patients with yellow bile; mean difference -42.2 (95% CI [-62.4, -22.0]) and -45.7 (95% CI [-72.0, -19.4]), respectively. The bilirubin (0.49 mg/L) and bile acid (14.6 mmol/L) concentrations in white bile were significantly less than bilirubin (41.9 mg/L) and bile acid (62.2 mmol/L) concentrations in yellow/black bile. Cholangitis developed in 66.6% of patients with white bile compared with 35% of those with yellow/black bile (OR 3.67: 95% CI [0.74, 19.25]). Kaplan-Meier curves showed that median survival was shorter in patients with white bile (36 [23-60] vs 75 [35-220] days) (p = 0.004, log rank test), which was significant even after adjusting for potential confounders with Cox proportional hazards regression. White bile is largely devoid of bilirubin and bile acids. The presence of white bile was associated with significantly worse survival in patients with malignant biliary obstruction.