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Painless Jaundice: Causes and Diagnosis

Jaundice or icteric is a medical condition characterized by skin, eye sclera, and mucosa, which appears yellowish due to increased bilirubin levels. Bilirubin is the result of a catabolic process that breaks down heme from hemoglobin excreted in bile. Increased bilirubin can be caused by increased production or decreased excretion. Painless jaundice is the jaundice of the body without accompanying abdominal pain, body aches, or fever.

Painless Jaundice: Causes and Diagnosis
Jaundice


Based on the location of the disorder, jaundice can be divided into intrahepatic and extrahepatic:

a. intrahepatic is a disorder of the liver parenchyma, for example, in patients with hepatitis due to viruses, alcohol, fatty liver, autoimmune, or drugs.
b. extrahepatic is divided into two, namely pre-hepatic and post-hepatic
- prehepatic: hemolytic anemia in malaria patients, hemoglobin disorders such as thalassemia, and hereditary conjugate disorders like Gilbert's syndrome.
- posthepatic, commonly known as obstructive jaundice: due to cholelithiasis, chronic pancreatitis, gallbladder carcinoma, or pancreatic carcinoma.


Differential Diagnosis of Painless Jaundice

Adult patients present with jaundice without abdominal pain or fever must be evaluated early whether the mass is palpable or not in the liver area. A positive Courvoisier-Terrier sign on abdominal physical examination is the palpable gallbladder enlargement. An abdominal ultrasound examination can ascertain tactile.

a. Palpable Gallbladder Enlargement

A positive Courvoisier-Terrier sign leads to a diagnosis of pancreatic carcinoma. Jaundice's character in Pancreatic carcinoma is progressive, can be without or with pain. Other clinical signs are choluria, fecal acholia, itching throughout the body, weight loss dramatically, and fatigue. Investigations to make a definitive diagnosis are imaging and biopsy examinations. In Laboratory tests,  a 1.5-2-fold increase in liver function, bile enzymes in urine, putty-colored stools, and an increase in tumor markers can be found.

b. Impalpable Enlargement of Gallbladder

Extrahepatic bile duct obstruction is a common cause of painless jaundice in adult patients. One of obstruction cause is malignancy, such as:
  • pancreatic or duodenal periampullary malignancy, 
  • gallbladder carcinoma, 
  • ampullary carcinoma, 
  • lymphoma, 
  • or extrinsic compression from other gastrointestinal malignancies.

Other causes of painless jaundice include:

  • stricture of the bile duct due to pancreatic pseudocysts or chronic pancreatitis, 
  • external compression by gallstones in the neck gallbladder area (Mirizzi's syndrome), 
  • or due to intraductal parasites such as clonorchiasis.


Pancreatic Carcinoma
The most common cause of painless obstructive jaundice is cholelithiasis or carcinoma of the pancreas head. This condition can manifest as painless jaundice caused by the bile duct obstruction. Weight loss, weakness, and other constitutional symptoms accompany the symptoms of cholestasis. On investigations, the bile duct is often found dilated to the pancreas head area and accompanied by a mass.


Mirizzi's Syndrome
Mirizzi's syndrome is a syndrome characterized by gallstone impaction in the cystic duct or the gallbladder neck resulting in mechanical obstruction in the hepatic ducts. It produces inflammatory stricture in the bile ducts, causing continuous obstructive jaundice. Mirizzi's syndrome is a rare complication that can cause cholecystobilliary fistula.

This syndrome is divided into several types, namely: type 1 gives an overview of external compression without the appearance of fistulas, and type II-IV with the level of progression of the fistula. POther complaints experienced by patients besides jaundice are upper right abdominal pain and fever. Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic modality choice, although its accuracy is still limited.


Intraductal parasites
Several parasitic infections, such as Strongyloides, Ascariasis spp, Opisthorchis Sinensis, and Fasciola hepatica, also can cause Extrahepatic biliary obstruction.


Investigations on Painless Jaundice

A definitive diagnosis of a painless jaundice condition requires a complete history, physical and supporting examinations.

Supporting examinations that need to be performed are:

a. Laboratory Tests
Laboratory tests that need to be carried out are:
  • measurements of bilirubin (total, unconjugated, conjugated), 
  • liver function enzymes (SGOT, SGPT, alkaline phosphatase), 
  • albumin, protein, 
  • Blood clotting (prothrombin time / PT, activated partial thromboplastin time / APTT). 
  • If suspicious malignancy, the examination of tumor markers such as alpha-fetoprotein (AFP), CA 19-9, and CEA can be performed.


b. Imaging Evaluation
Abdominal ultrasound can also be useful in determining the etiology of painless jaundice. Other examination techniques include CT scan and magnetic resonance cholangiopancreatography (MRCP). MRCP examination helps describe the anatomy of the gallbladder. MRCP and ERCP have comparable sensitivity, specificity, and accuracy in diagnosis to distinguish malignancy and stricture of benign bile ducts.

The stricture characteristics seen on examination can estimate etiology. Most strictures in the bile ducts are caused by benign etiology. Characteristics of long strictures with irregular edges or shelf signs lead to malignancy. In contrast, the appearance of a short stricture with regular and smooth edges reflects a benign stricture. In Mirizzi's syndrome, the stricture usually appears long and regular. And in the autoimmune process, it is often multifocal.

Endoscopic techniques or ERCP can be performed not only as a diagnostic tool but also in therapy. As part of the treatment, the surgical procedure is not fully implemented in patients with painless jaundice, especially patients with malignancy.

Stenting is associated with lower morbidity than surgery, so it is indicated in patients with jaundice due to malignancy before implementing chemotherapy.


Conclusion
Painless jaundice is the jaundice of the body without abdominal pain, body aches, or fever. The initial painless jaundice examination is to look for a Courvoisier-Terrier sign, a palpable gallbladder enlargement that can be ascertained by an ultrasound examination of the abdomen. If palpable, the diagnosis leads to pancreatic carcinoma. In contrast, if it is not palpable, it can be caused by disorders of the pre-hepatic, hepatic, or post-hepatic processes such as Mirizzi's syndrome caused by obstruction of the stones in the cystic duct tract.

Supporting examinations that need to be done are imaging and laboratory, consisting of examining the liver function and measuring bilirubin concentration.



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