CAUSES OF MALIGNANT OBSTRUCTIVE JAUNDICE

Various types of malignancies, including pancreatic cancer, cholangiocarcinoma, hepatocellular carcinoma, gallbladder carcinoma and metastatic disease, can cause malignant obstruction of the biliary ducts. Cholangiocarcinomas represent approximately 3% of all gastrointestinal cancers (1). It was estimated that approximately 18,500 primary liver cancers would be diagnosed in the United States in 2006 (2) and of these, approximately 15% would be intrahepatic cholangiocarcinomas (3). An estimated 4,600 cases of extrahepatic cholangiocarcinoma were diagnosed in 2007 per estimates from the American Cancer Society. Risk factors include primary sclerosing cholangitis, ulcerative cholitis, choledochal cysts and biliary infections, such as in typhoid carriers. Chemical exposures to nitrosamines, dioxin, asbestos and polychlorinated biphenyls have also been linked to cholangiocarcinoma. Cholangiocarcinomas are usually adenocarcinomas (95% of the time) but rarely are found to be cystadenocarcinomas, hemangioendotheliomas or mucoepidermoid carcinomas. Patients commonly present with right upper quadrant pain, pruritis, anorexia, malaise and weight loss. Up to 30% of patients may present with cholangitis. Elevated liver enzymes, alkaline phosphate and bilirubin can also be seen. Cholangiocarcinomas are usually discovered on ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) or endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic cholangiography and laparoscopy can also be used for diagnosis. If the cholangiocarcinoma appears resectable, a Whipple resection or partial hepatectomy can be attempted; with complete resection, 5-year survival rates of up to 25% are seen. Palliative surgery with a biliary bypass can be done in the event that resection is not possible.