Diagnostic approach to patients with cholestatic jaundice

Table 1 Differential diagnosis of cholestasis and hyperbilirubinemia (cholestatic jaundice)

CBD dilated: Best approach is anatomically

Ampulla of Vater

Stones, carcinoma of pancreas, chronic pancreatitis, ampullary neoplasm, diverticulum, pancreatic cyst, abscess of pancreas, sphincter of Oddi dysfunction

Common bile duct

Benign traumatic stricture, stones, choledochal cyst, cholangiocarcinoma, parasites, hemobilia, extrahepatic atresia

Gallbladder

Carcinoma of gallbladder

Portal nodes

Cholangicarcinoma, lymphoma, metastatic carcinoma, cavernous portal vein

Table 2 (continued): Differential diagnosis of cholestatic jaundice

Normal CBD

Extrahepatic

Stone too early, stone too late, cholangiocarcinoma, and primary sclerosing cholangitis

Intrahepatic

Intrinsic diseases

Drugs, alcoholic hepatitis, viral hepatitis, AIDS, primary biliary cirrhosis, autoimmune cholangitis, primary sclerosing cholangitis, idiopathic adulthood ductopenia, Autoimmune hepatitis, decompensated liver cirrhosis

Infiltrative diseases

Granulomatous hepatitis (Tuberculosis, amyloidosis), sarcoidosis, Lymphoma, leukemia, fatty liver

Systemic diseases

Sepsis, total parenteral nutrition (TPN), benign recurrent intrahepatic cholestasis (BRIC), cholestasis of pregnancy, cystic fibrosis, disappearing intrahepatic ducts syndrome, allograft rejection, graft versus host disease (GVHD), sickle cell syndrome, mastocytosis, hypereosinophilic syndrome, Hyperthyroidism

Space occupying lesions

Blood-hematoma, peliosis; pus-bacterial, amebic; cyst-hydatid, polycystic Cancer-primary, secondary

Table 3 Common drugs known to cause cholestatic jaundice

Antimicrobial agents

Augmentin (amoxicillin-clavulanic acid), cloxacillin, erythromycin, ethambutol, dapsone, fluconazole, nitrofurantoin, griseofulvin, ketoconazole, terbinafine

Cardiovascular agents

Disopyramide beta-blockers, ACE inhibitors, propafenone, ticlopidine, warfarin, methyldopa

Endocrine agents

Sulfonylureas, clofibrate, estrogens, tamoxifen, androgens, niacin, oral contraceptives

Gastrointestinal agents

H2 blockers (e.g., ranitidine), penicillamine

Immunosuppressive agents

Azathioprine, cyclosporine, gold salts, NSAIDs (e.g. diclofenac, nimesulide, piroxicam)

Psychopharmacologic agents

Tricyclic antidepressants, benzodiazepines, phenothiazines, phenytoin, halothane

Table 4 Causes and syndromes of ductopenia in the adult patient

Syndromatic ductopenia (Alagille syndrome)

Non-syndromatic adult ductopenia

Ductal plate malformation (congenital hepatic fibrosis, biliary atresia

Primary biliary cirrhosis, autoimmune cholangitis

Primary sclerosing cholangitis

Chronic rejection

Graft-versus-host disease

Sarcoidosis

Cystic fibrosis

Byler disease (progressive familial intrahepatic cholestasis)

Histiocytosis X and

Different drugs (amoxicillin-clavulanic acid, carbamazepine)

Duct destruction after regional chemotherapy (e.g. floxuridine)

Idiopathic adulthood ductopenia