It is the presence of a palpable RUQ mass, which represents a non-tender, enlarged gallbladder. It signifies obstruction, most often of the distal common bile duct, causing the biliary tree and the gallbladder to markedly distend, and is most commonly seen with malignancy (pancreatic, ampullary, or bile duct). Gallstone disease would result in RUQ pain and marked RUQ tenderness to palpation.

Painful jaundice implies an acute biliary obstruction, usually due to a gallstone, and is usually associated with inflammation/infection, such as acute cholangitis. Painless jaundice suggests a more insidious obstruction as seen with malignancy. The absence of pain also suggests an absence of infection. However, cancers can also be accompanied by mild, vague RUQ or epigastric pain as well.

Risk factors for pancreatic cancer include chronic pancreatitis (strongest risk factor), tobacco, high-fat diet, male gender, and family history. While recent onset of type 2 diabetes is also associated with pancreatic cancer, it is difficult to discern whether it is a risk factor or early symptom of disease. Patients with ulcerative colitis, especially with primary sclerosing cholangitis, are at increased risk for developing bile duct malignancy. Choledocholithiasis, particularly when associated with parasites, is considered a risk factor for bile duct cancer. Long-standing gallstone disease is associated with carcinomas of the gallbladder.

Examination of the skin should include the mucous membranes of the mouth (under the tongue), palms, soles, and sclerae. Areas that are not exposed to sunlight have more bilirubin due to lack of photodegradation. Rarely, excess consumption of carrots and other carotenoid-containing vegetables can cause yellowing of skin pigment, mimicking jaundice, without a change in the sclera or other mucous membranes.

Periumbilical mass (or nodule) signifying possible metastatic abdominal (or pelvic) malignancy. It is most often seen with GI malignancies (e.g., stomach, pancreatic).

A step-off felt during rectal exam suggesting metastatic disease to the pouch of Douglas. It is usually a site of metastasis of cancers of the lung, pancreas, and stomach.

Jaundice can be caused by excess serum bilirubin due to hemolysis or impaired metabolism/excretion from the liver into the intestines. Jaundice becomes apparent at approximately bilirubin >2.5 mg/dl.

Bilirubin is the product of heme degradation. Breakdown of red blood cells occurs in the spleen, liver, and intravascular space. Initially, bilirubin is unconjugated, not water soluble, and bound to albumin. Bilirubin is conjugated in the liver, becoming water soluble, and excreted into the intestine. Intestinal bacteria convert conjugated bilirubin into urobilinogen, which can be reabsorbed into the systemic circulation, converted to urobilin, and excreted in the urine. Urobilin gives urine its yellow color. The remaining intestinal urobilinogen is converted to stercobilin and excreted in the stool.

Stool derives its brown color from stercobilin, a final product of bilirubin metabolism in the intestine. Biliary obstruction decreases bilirubin in the intestines, decreasing stercobilin and resulting in the “clay-colored” stool.

Conjugated/direct bilirubin, and consequently total bilirubin, will be increased in all cases of obstructive jaundice. Direct bilirubin accumulates in the circulation and is excreted in the urine, which becomes much darker or “tea colored.” Urine urobilinogen is decreased. ALP levels will also be elevated indicating bile duct obstruction.

Hepatic causes of jaundice (such as hepatocellular injury from hepatitis) are usually nonsurgical problems, whereas posthepatic causes (such as biliary obstruction from acute cholangitis) are typically surgical. Distinguishing between the two is not always straightforward. Both will have some degree of elevation in total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), and ALP. AST and ALT are enzymes within the liver cells (though AST is also found in muscle and other cells). With hepatic cellular injury, these enzymes are released. As such with hepatic causes, the AST and ALT (transaminases) can sometimes reach into thousands and rise out of proportion to the ALP. Such a disproportionate rise in the transaminases is indicative of hepatocellular damage, as seen in acute viral hepatitis, ischemic liver injury, or toxic insult. ALP is present in the cells that line the bile ducts. A marked rise in ALP, out of proportion to the AST and ALT, is therefore more indicative of posthepatic (biliary obstruction) pathology such as choledocholithiasis or cholangitis. Since ALP levels increase with many other diseases (such as bone pathology), a concomitant and proportionate rise in GGT is helpful, as it is more specific to liver disease.