Question re obstructive jaundice

**Yixian** · 08-03-2010, 04:30 AM

Just a quick questions, I read a case history in which a woman was diagnosed as having obstructive jaundice secondary to a gallstone in the biliary tree, she also has dark urine but normal stools - my question is, if the gallstone is causing obstruction of the biliary tree, and her urine was dark, then why weren't her stools pale?

**cat_bach** · 10-03-2010, 03:56 AM

Could something else other than stercobilin (such as something she eats) colour her stools? Or maybe the change is more subtle than in the urine so while they actually are paler she hasnt noticed a change? Or (perhaps more likely) could she have not been eating because she feels shitty due to having a whacking big gallstone in her CBD so she hasnt actually passed a steratorrhea yet, but because urinating is more crucial and frequent than defaecation she is urinating so the dark urine is noticable?

I dont actually know, Im just wondering....

**Yixian** · 10-03-2010, 03:46 PM

I always thought that the "two" signs of obstructive jaundice were pale stools and dark urine, and that the former was blockage of stercobilin entering the intestines and the latter the absence of urobilinogen - I was wondering if it would be possible to obstruct urobilinogen, but not the bile.

But perhaps you're right, perhaps it just wasn't a noticeable change in this case, or something else is colouring her stools but I think that's probably less likely, stercobilin is def the mina pigment in faeces.

**cat_bach** · 11-03-2010, 01:31 AM

yeah, i was more thinking along the lines of that we pee way more than we poo (especially when we dont eat much bulky solids), so a change in pee would come apparent much quicker than a change in faeces. So she might well be producing some pale stools its just that they havent entered a toilet near you yet...especially if she`s acute (assuming she is).

again, second year speculation....not really what your after x

**melon** · 12-03-2010, 06:51 PM

Originally Posted by cat_bach

yeah, i was more thinking along the lines of that we pee way more than we poo (especially when we dont eat much bulky solids), so a change in pee would come apparent much quicker than a change in faeces. So she might well be producing some pale stools its just that they havent entered a toilet near you yet...especially if she`s acute (assuming she is).

again, second year speculation....not really what your after x

This is a possibility, there could be several days of lag time behind onset of obstructive jaundice and pale stools. Similar to why you continue to pass malaena several days after an OGD to band bleeding varices for example, it's just sat in the many feet of intestine. Especially if they take opiates or eat a low fibre diet.

She could just be a poor historian and hasn't actually looked what colour her stools are and so just says they are normal.

Or it could be an incomplete obstruction. The bilirubin is all conjugated, but restricted in the amount that passes into the bile. This explains her dark urine (often dark urine happens before the sclerae go yellow etc). However, if just enough bilirubin can enter the bile this would be sufficient to make the stools relatively normal in colour.

Basically, a tiny bit of bilirubin (or blood) can make the urine look very dark, especially against the white of a toilet pan. In contrast, to have pale stools you need a pretty substantial lack of stercobilin.

That was quite a garbled response but the gist is rarely do things present with the entire textbook list of symptoms.