Jaundice in the elderly: A retrospective study of causes and prognosis

Ajaj A, Saeed S, Brind A
The Medical and Gastroenterology Department City general hospital, Stoke-on-Trent, UK

Correspondence:
Dr A S Ajaj MBBCh MSc (Keele) FRCP (Lond)
Consultant Physician
Pinderfield General Hospital
Aberford Road
Wakefield
WF1 4DG
E-mail: ajaj@doctors.org.uk

INTRODUCTION

Jaundice is an important symptom apparent to both the patient and doctor. The underlying diseases range from totally benign conditions to diseases with very poor prognosis^[1,2].

Diseases affecting the gallbladder and bile ducts occur commonly in the elderly. By age 70 cholelithiasis is the most common disorder affecting these organ systems and its sequelae, choledocholithiasis, are found in 33% of the population in the United States^[3].

In the elderly ERCP is a well-tolerated procedure and often the most appropriate treatment of choledocholithiasis with relief of jaundice in 98% of patients obviating the need for emergency biliary tract surgery in the elderly who may have other conditions that may contribute to significant morbidity and mortality.

The aim of our study was determining the causes and prognosis of jaundice in patients over 65 years of age.

METHODS

The biochemistry computer database was used to identify all patients with a bilirubin concentration of > 70 umol/l. The case notes of 93 patients who were admitted to our district general hospital from August 98 to January 1999 were reviewed. Our hospital has 1200 beds with a catchment area of 300.000.

Within the number of 93 patients there were 45 women (48%) and 48 men (52%) of an age ranging from 65 to 96. The mean age was 74.9 (SD ±6.76). All patients had bilirubin level > 70 umol/l.

Further diagnostic procedures included ultrasound, ERCP, CT scans and biopsy of organs.
Cancer diagnosis was confirmed by post-mortem examination in a few cases.

RESULTS

Table 1: presents the final diagnosis based on clinical examination, investigations, the mean LOS, serum albumin and serum bilirubin at presentation for each diagnosis.

* LOS: Length of stay

Presentation:
In addition to jaundice, other frequent symptoms were: abdominal aches (36), nausea (24), vomiting (21), itching of the skin (20) and periodic increase in the coloration of urine and lighter colour stool (32 patients).
Twenty-eight patients (30%) noted more than 10% decrease in body weight.

Investigations:
Investigations performed included abdominal ultrasound (all patients), Abdominal CT 30 patients), ERCP (41) and liver biopsy liver biopsy (12 patients).
The mean serum bilirubin and albumin are shown in table 1.

Management and outcome:
The causes of jaundice is tabulated (see table 1) ERCP was needed in 19 patients of the cholithiasis group (86%) and was successful in all of them except one. The procedure was uneventful except for self-limiting pancreatitis that occurred in 2 patients. Ascending cholangitis occurred in 3 patients and was treated with parenteral antibiotics. Two of the latter patients died with severe septicaemia.

The primary tumour in the metastatic group of patients was identified in 7 patients (70%). The sources include adenocarcinoma of the stomach and colon (3 patients each), and one patient with breast cancer. Seven patients died within one month of presentation with jaundice, and 3 died within 3 months. Three patients required palliative biliary stenting.

Patients in the alcoholic liver disease group were chronic heavy drinkers and presented with recurrent alcoholic hepatitis. Within six months of follow up 6 (70%) recovered completely, but 2 patients were readmitted with alcoholic hepatitis after starting to drink. Three patients (30%) died during their acute presentation. The causes of death include staphylococcal septicaemia and severe oesophageal variceal bleeding.

Three patients with carcinoma of the head of pancreas had successful palliative stenting via ERCP. One patient needed a combined procedure for relieving the obstruction (ERCP and percutaneous transhepatic chalangiography). Two patients had successful Wipple's procedure and were alive 6 months later. Three patients were too ill and were treated conservatively. Five of the 9 patients with this diagnosis died within 6 months (55%).

Six patients in the CCF group were treated with intensive heart failure therapy and were still alive 6 months after the initial presentation with jaundice. Three patients died within a month of presentation.

Cholangiocarcinoma patients presented with abdominal pain and severe obstructive jaundice. All 6 patients had successful biliary stenting via ERCP except one patient who needed both external and internal drainage procedures. Four patients (66%) died within 4 months of presentation.

DISCUSSION

The most frequent individual cause of jaundice in our study, that included patients with moderately severe jaundice was choledocolithiasis (24%).

Subsequent causes were variable types of accompanying cancer including metastatic liver cancer (11%), carcinoma of the head of pancreas (10%), and cholangiocarcinoma (6%). The commonest benign causes were alcoholic liver disease (10%) and congestive cardiac failure (10%). Previous literature has shown that the most common cause of jaundice was choledocholithiasis^[4,5].

Our study has shown that the proportion of patients with gall stones and those with malignancy is higher than in a similar study from London and Stockholm^[6]. The latter study showed jaundice in 144 cases among 120,000 observed persons and its causes were as follows: gall stone disease (20.1%), cholangiocarcinoma (1.4%), hepatoma (0.6%), malignant obstruction and metastasis (6.9%), and pancreatic carcinoma (7.6%). This study included patients younger and older than 65 and we studied patients with all grades of severity.

Choledocholithiasis is a significant problem in the elderly especially in those patients who present with gall bladder disease and such a condition should be considered before planning or embarking on surgical treatment. In the general population 5% of patients presenting with cholecystitis have coexisting bile duct stones. In the elderly however this figure rises to 10-20%^[7].

In addition in elderly patients who have undergone an emergency cholecystectomy the incidence of bile duct stones approaches 50 %. ERCP is a diagnostic and therapeutic procedure that is well tolerated in the elderly and operative intervention such as cholecystectomy is not required.

The length of stay in hospital is limited to 2-3 days and in the published results the overall complication rate was 3 %^[8]. The mortality rate incurred among the elderly in surgical series is 4-10% for elective procedures but this figure rises to 20% in emergency operations^[9]. ERCP was performed with success in removing the stones in 20 (91%) of our patients with complete recovery. Two patients presented with ascending cholangitis and septicaemia and died.

Metastatic liver disease:
This group of patients presented with painless obstructive jaundice, weight loss and low serum albumin. All patients died within three months of presentation. This concurs with a previous study which showed that the prognosis of such patients is dismal especially when they present with obstructive picture and hepatic insufficiency^[10]. Malignant disease of the pancreas usually accounts for a significant proportion of cases with jaundice as the presenting symptom. In a study by Madden et al, of 140 patients with obstructive jaundice 28% were due to malignant disease and 16% were caused by carcinoma of the pancreas including periampullary carcinoma^[11].

Among patients who were diagnosed as carcinoma of the pancreas in our study, 50% were still alive and well 6 months following ERCP and palliative biliary drainage procedures.

Congestive cardiac failure:
This is a common treatable cause of jaundice in the elderly. With improved treatment of severe heart failure now available, the development of fibrosis and ultimately cirrhosis now occur very rarely^[12]. Among patients who presented with jaundice due to CCF, 70% responded very well to intensive management were discharged home and were alive 6 months later. Thirty percent of patients who had severe (NYHA 4) CCF died within 2 months of presentation with jaundice.

Alcohol:
Between 1 and 6% of older individuals are heavy drinkers and the alcoholism rate is higher for elderly men than women (1:5)^[13]. A recent study from the United States national hospital data revealed that among patients aged 65 and over, alcohol-related hospitalisations occurred as frequentlt as those for myocardial infarction^[14]. Abstinence from alcohol is more common in the elderly, and the prognosis for patients with late-onset alcoholism is usually better than for those with early-onset^[15,16].

Alcoholism is a chronic relapsing condition. Elderly patients are not different, they will also have slips and return to drinking. This may bring guilt and lead to avoiding follow-up. Therefore physicians have to give them a non-judgemental invitation to return for treatment and to provide education on the adverse effects of alcohol.

Our finding is consistent with previous studies. Eight patients (70%) recovered completely after abstaining from alcohol. Three patients with severe alcoholic hepatitis died despite supportive management. The average LOS in this group was high at 23 days with a mortality of 30%. The causes of death were variceal bleeding and staphylococcal septicaemia.

Cholangiocarcinoma:
Bile duct cancer occurs in the elderly. 25% of patients are over 65 years of age. The clinical features are similar to hepatocellular carcinoma except that jaundice is more frequent with hilar tumours. Cholangiocarcinoma is difficult to diagnose with both ultrasound and CT scans that show the obstruction^[17,18]. The survival can be prolonged if the tumour is diagnosed early. The mean length of stay in our patients was 14.6 days and all patients had successful biliary stenting via ERCP.

Drugs:
Abnormal liver tests caused by drugs is common in the elderly and may be responsible for up to 40% of cases^[19]. Although adverse drug reactions are said to be commoner in the elderly, it is possible that this is caused by increased prescribing in the elderly and the fact that elderly patients have more intercurrent illness with impaired cardiac or renal function which may directly or indirectly potentate the effects of some drugs on the liver^[20].
In our patients, the drug induced hepatitis and jaundice were caused by amiodarone, cyproterone acetate, azathioprime, haloperidol and co-amoxiclav. All recovered after cessation of the drug except thise who were on cyproterone acetate and haloperidol.

CONCLUSSIONS

Our study has shown that obstructive jaundice is a common problem in the elderly. Our findings of the cause of jaundice in this age group of patients presenting to a district general hospital is different from other studies, probably because we have chosen to study moderately severe jaundice with a moderately high serum bilirubin. The mortality of the age group studied was high at 50% indicating that jaundice is a serious problem in the elderly who may have coexisting medical problems. We have also concluded that patients who presented with high serum bilirubin and low albumin had high mortality.

1. Schenker S, Ralint J, Schiff L. Amer J Dig Dis 1962; 7: 449-63.
2. Stern R. B, Knill-Jones RP, Williams R. Brit Med J 1975; 2: 659-62.
3. Mc Sherry CK, Fersten berg H, Calboun WF et al. The natural history of
   diagnosed gall stone disease in symptomatic and asymptomatic patients. Ann Surg
   1985; 202:59.
4. Malchow-Moller A et al: A decision tree for differentiation between obstructive and non-obstructive jaundice. Scand J Gasroenterol 1988; (4): 391.
5. Beimart C, Efremidis S, Cohen B, Mitty HA: Obstruction without dilation,
   importance in evaluation of jaundice. Jama 1981; 245(5): 352.
6. Lindburg G, Björkman A, Knill-Johnes R: Computer aided diagnosis of jaundice,
   acomparison of two data bases. Scand J of Gastroenterology 1987; 128:180.
7. Beeton HL. Surgical cosideration. In: Gelb A, (ed). Clinical Gastroenterology in
   the elderly. New York; Marcel Dekker, 1996; 271-282.
8. Pigott JP, Williams GB, Cholicystectomy in the elderly. Am J Surg 1988; 155:408.
9. Harness JK, Strodel WE, Talsma SE. Symptomatic biliary disease in the elderly
   patient .Am Surgeon 1986; 52:442.
10. Lau W, Leung K, Leung TW, Liew CT, Chan et al: A logical approach to
    hepatocellular carcinoma presenting with jaundice. Annals of surgery
    1997; 225 (3): 281-5.
11. Madden JL, Gruez JA, Tan PY. Obstructive (surgical) jaundice: Analysis of 140
    consecutive cases and a consideration of cholidochodudenostomy in treatment
    AM j Surg 1965:109:89.
12. Clain DJ, Liver disease in the elderly. In: Gelb AM (ed). Clinical
    gastroenterology in the elderly. Dekker; New-York 1996: pp 167-83.
13. Butcholz KK, Sheline YI& Helzer JE. The epidmiology of alcohol use problems and dependence in elders. A review. In T Beressford & Gomberg (eds) Alcohol and Ageing 1995, pp 19-41; Oxford University Press, New York)
    
14. Adams WL, Yuan Z, Barbariak JJ et al. Alcohol-related hospitalizations. JAMA
    1993; 270:1222-5).
15. Zimberg S. Diagnosis and treatment of elderly alcoholic. Alcoholism, Clin Exp. Res 1978;2:27-9
16. Moos RH, Brennan PL, Moos BS. Short-term processes of remission and
    nonremission among late-life problem drinkers. Alcohol Clin Exp Res 1991;
    05:948-55.
17. Choi PI, Lee JH, Han MC, Kim SH, Yi JG, Kim CW. Hilar cholangiocarcinoma:
    comparative study with sonography and CT scan. Radiology 1989; 172:689-692.
18. Di Lelio A, Cestari C, Lomazzi A, Beretta L. Cirrhosis: diagnosis with
    sonography study of the liver surface Radiology 1989; 172:389-92.
19. Benhamous JP: Drug induced hepatitis: clinical aspects. In: Fillaster JP(ed):
    Hepatotoxicity of drugs. University of Rouen, France 1986: 23-30.
20. James OFW. The liver. In: Tallis RC, Fillit HM, Brocklehurst JC. Text book of
    geriatric medicine and gerontology, fifth edition. Chrchill-livingstone; London