01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Painless obstructive jaundice is a syndrome, not a tumour diagnosis. A pancreatic-head cancer may compress the distal common bile duct; distal cholangiocarcinoma arises within it; ampullary cancer obstructs at the papilla; perihilar cholangiocarcinoma separates right and left systems. Gallbladder cancer can invade the hilum or liver. Benign stones and strictures remain possible, but progressive painless cholestasis demands malignancy-focused investigation.
History should establish tempo, stool and urine colour, itch, weight and appetite, fever, previous pancreatitis or biliary surgery, inflammatory bowel disease, smoking, diabetes and medicine exposure. Examination includes hydration, scratch marks, hepatomegaly, abdominal mass, lymph nodes and signs of chronic liver disease. Courvoisier's sign changes probability but is neither sensitive nor diagnostic.
Sequence matters. Drainage can introduce infection, alter imaging appearances and complicate tissue decisions. In a stable patient with suspected pancreatic cancer, obtain pancreatic-protocol CT first. Once anatomy is known, the MDT decides whether tissue is required, whether disease is resectable and whether drainage offers a benefit. Cholangitis or organ dysfunction overrides an elective sequence because source control becomes urgent.
Key points
- In a person aged 40 or over, NICE recommends suspected pancreatic-cancer pathway referral for jaundice; do not wait for pain, a palpable gallbladder or profound bilirubin elevation.
- Confirm conjugated cholestasis and assess haemoglobin, renal function, coagulation, albumin and inflammatory markers while checking for immediate cholangitis.
- Ultrasound can show duct dilatation and gallstones, but it cannot reliably stage a pancreatic, ampullary or bile-duct cancer.
- For obstructive jaundice with suspected pancreatic cancer, NICE recommends pancreatic-protocol CT before draining the bile duct.
- NICE offers FDG-PET/CT and/or EUS with sampling if the diagnosis remains unclear after CT. Separately, offer FDG-PET/CT for staging when CT shows localised pancreatic disease and cancer treatment is planned; an urgent septic obstruction still requires source control.
- Resectable pancreatic cancer with obstructive jaundice usually proceeds to resection rather than routine preoperative drainage; cholangitis, severe symptoms, delay or neoadjuvant therapy may create a drainage indication.
- Agree biopsy route, drainage target and stent choice with the HPB MDT so an expedient procedure does not compromise staging, future liver remnant or definitive surgery.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Distal malignant blockade
Pancreatic-head, distal bile-duct and ampullary cancers narrow the terminal duct, producing upstream extrahepatic and intrahepatic dilatation and conjugated jaundice.
Proximal malignant blockade
Perihilar cholangiocarcinoma or invasive gallbladder cancer obstructs separated hepatic ducts, making segmental anatomy central to safe drainage and resection planning.
Benign mimics
Choledocholithiasis, chronic-pancreatitis stricture, IgG4-related disease and postoperative injury can create the same cholestatic presentation and sometimes require tissue-supported discrimination.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Bile-flow interruption
A fixed narrowing raises duct pressure, retains bile acids and conjugated bilirubin, and eventually impairs canalicular excretion and hepatocyte function.
- 2Systemic cholestasis
Water-soluble conjugated bilirubin enters urine, reduced pigment reaches stool, and retained pruritogens contribute to itch and sleep disturbance.
- 3Duct infection
Instrumentation or bacterial ascent into a pressurised obstructed system permits bacteraemia; decompression is therefore part of infection source control.
- 4Nutritional consequence
Prolonged loss of bile delivery impairs fat digestion and fat-soluble vitamin absorption, contributing to weight loss and procedural coagulation risk.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Both intrahepatic and extrahepatic ducts may dilate above a pancreatic-head, ampullary or distal bile-duct lesion; pancreatic duct dilatation may add a double-duct clue.
Intrahepatic ducts dilate while the distal common duct may remain normal; the separate right and left systems make drainage planning anatomically consequential.
Steadily deepening jaundice, persistent pruritus, pale stools and measured weight loss favour a fixed obstructing lesion over a transient migrating stone.
Rigors, fever, hypotension or confusion converts a stable cancer investigation into an acute cholangitis pathway requiring antibiotics and decompression.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Liver panel, INR, FBC and renal profileFirst step - Why
- Confirm conjugated cholestasis, establish synthetic and renal consequence, and look for infection or anaemia before imaging and intervention.
- Interpretation and limitations
- ALP and bilirubin trends help quantify obstruction but do not stage cancer; elevated INR may reflect vitamin K malabsorption or hepatic dysfunction and needs procedural correction planning.
- 02
Transabdominal ultrasound - Why
- Confirm duct dilatation, identify gallstones and estimate whether obstruction is distal or proximal.
- Interpretation and limitations
- Ultrasound is a useful entry test but a negative or incomplete pancreatic view does not exclude malignancy and should not delay cancer-pathway cross-sectional imaging.
- 03
Pancreatic-protocol multiphasic CT - Why
- Identify a pancreatic or distal biliary mass and assess vascular, nodal, hepatic and peritoneal disease before elective drainage.
- Interpretation and limitations
- Resectability depends on more than size; record vessel contact and metastases for HPB MDT review. A subtle lesion can remain occult despite obvious obstruction.
- 04
MRI with MRCP - Why
- Map proximal duct extent and liver involvement, especially for perihilar obstruction or an indeterminate biliary stricture.
- Interpretation and limitations
- MRCP displays duct anatomy non-invasively and helps select drainage targets; it does not provide histology or decompress infected bile.
- 05
EUS with tissue sampling - Why
- Characterise and sample a pancreatic, ampullary or distal lesion after staging imaging when histological confirmation is needed.
- Interpretation and limitations
- EUS can detect small lesions and nodes. Decide the target and need for tissue with the MDT, particularly when immediate resection remains possible.
- 06
ERCP brush cytology - Why
- Obtain ductal cells when ERCP is already being performed to relieve obstruction without an established diagnosis.
- Interpretation and limitations
- A positive result is useful, but limited sensitivity means negative brushings do not exclude cholangiocarcinoma; correlate with imaging and further sampling strategy.
- 07
FDG-PET/CT for the separate pancreatic staging indication - Why
- Look for otherwise occult metastatic disease when pancreatic CT shows localised cancer and treatment is planned.
- Interpretation and limitations
- NICE NG85 distinguishes this staging offer from the use of FDG-PET/CT and/or EUS to resolve an unclear diagnosis. PET/CT complements the pancreatic-protocol CT; it does not justify delaying drainage of infected obstruction.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Common-duct stone
Pain may be absent, but prior episodic biliary pain and abrupt fluctuating biochemistry favour a mobile stone; MRCP or EUS can clarify.
Drug cholestasis
A compatible exposure can produce jaundice and pruritus without a dilated duct, although malignancy still requires exclusion when the clinical trajectory fits.
Autoimmune cholangiopathy
PBC, PSC and IgG4-related disease produce cholestatic tests with characteristic serology or duct patterns and may mimic malignant stricturing.
Hepatocellular jaundice
Viral, toxic, ischaemic or autoimmune hepatitis generally shows greater transaminase predominance, but mixed patterns require synthetic-function assessment and targeted testing.
Additional chapter-specific clues
Choledocholithiasis, pancreatitis-related stricture, IgG4-related disease and postoperative benign stricture can resemble cancer, so obtain tissue and multidisciplinary interpretation when diagnosis is uncertain.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Stable suspected pancreatic cancerImage before elective drainageFirst stepA stable afebrile adult has progressive painless jaundice, cholestatic liver tests and ultrasound duct dilatation.+
- 1Arrange urgent pancreatic-protocol CT before endoscopic or percutaneous drainage, while correcting dehydration and procedural coagulation risk.
- 2Refer CT images to the HPB MDT to assess resectability. When CT shows localised pancreatic disease and cancer treatment is planned, offer FDG-PET/CT for staging even when the primary diagnosis is already clear.
- 3If the primary diagnosis remains unclear after CT, the separate diagnostic branch uses FDG-PET/CT and/or EUS with tissue sampling. Agree whether tissue is needed for the chosen treatment; neither branch replaces urgent drainage when cholangitis or organ dysfunction develops.
- 4Proceed directly to resection when pancreatic cancer is resectable and no drainage indication exists; document any reason for preoperative decompression.
02Infected obstructionResuscitate and drainThe jaundiced patient develops fever, rigors and hypotension before the planned cancer clinic assessment.+
- 1Recognise suspected cholangitis, obtain cultures and organ-function tests, and begin sepsis resuscitation and an appropriate intravenous biliary antimicrobial regimen.
- 2Use available imaging to identify the obstruction level without delaying urgent source control in a deteriorating patient.
- 3Coordinate ERCP, percutaneous or specialist EUS-guided drainage according to anatomy and local expertise.
- 4After decompression, verify haemodynamic improvement, inflammatory-marker response, bile flow and a revised cancer-staging plan.
03Proximal obstructionProtect future liver drainageImaging shows a perihilar stricture separating the right and left biliary systems.+
- 1Send CT and MRI/MRCP to the HPB centre before endotherapy so longitudinal and vascular extent can be reviewed.
- 2Define the intended future liver remnant and which segments are infected or undrained before choosing a duct.
- 3Avoid indiscriminate contrast filling or bilateral stenting that creates infected, non-drained segments.
- 4Record the drainage map and ensure pathology, resectability and palliation decisions remain linked to the MDT plan.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Acute cholangitis
Obstructed infected bile can cause septic shock and kidney injury; antibiotics must be paired with timely duct decompression.
Procedural harm
ERCP and drainage can cause pancreatitis, bleeding, perforation, migration, occlusion or infection of contrast-filled but undrained ducts.
Progressive malnutrition
Anorexia, cancer catabolism, steatorrhoea and pruritus-related sleep loss reduce functional reserve for surgery or systemic treatment.
Delayed curative treatment
Uncoordinated biopsy or drainage can postpone definitive resection, introduce sepsis or make later anatomical interpretation more difficult.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Trend bilirubin, ALP, renal function, INR and symptoms while staging proceeds; worsening fever, pain or physiology requires immediate reassessment for cholangitis.
- After any stent, give the patient a clear contact route and review recurrent jaundice, fever, rigors or pain promptly for blockage or migration.
- Record nutritional intake, weight, fat-soluble consequences and pruritus because obstruction affects fitness for surgery and systemic therapy.
- Ensure every investigation has named MDT follow-up: negative cytology cannot silently end evaluation of a radiologically suspicious stricture.
- For resectable disease, reassess performance status and interval imaging if treatment or drainage causes delay before definitive surgery.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Painless does not mean stable
A fixed malignant blockage may initially lack pain yet later become infected; observations and inflammatory symptoms determine acute urgency.
CT precedes the tube
Pancreatic-protocol CT before drainage preserves staging information and is an explicit NICE recommendation for suspected pancreatic cancer with obstructive jaundice.
Location shapes procedure
A distal obstruction is often accessible by ERCP, whereas perihilar disease requires segment-specific planning and may need percutaneous expertise.
Cytology has limited exclusion power
Negative brushings do not cancel convincing malignant imaging; diagnostic certainty emerges from combined pathology, imaging and specialist review.
Drainage is an intervention
It can relieve itch, infection and treatment delay, but it also brings pancreatitis, bleeding, migration and cholangitis risks.
11Common pitfallsFrequent interpretation and management errors.
- 01
Waiting for abdominal pain before urgent cancer referral misses the classic painless obstructive presentation.
- 02
Placing a stent before staging-quality CT in a stable patient can obscure anatomy and commits the patient to device complications.
- 03
Assuming all duct dilatation is pancreatic cancer overlooks distal cholangiocarcinoma, ampullary tumours and benign strictures.
- 04
Treating a negative brush cytology as proof of benign disease ignores the test's limited sensitivity.
- 05
Draining whichever hilar duct is easiest without an MDT map can infect undrained segments or compromise the intended future liver remnant.