Sabina Delin

Degree project in Medicine

Sahlgrenska Academy

An inquiry of Obstructive Jaundice at Tribhuvan University Teaching hospital, Kathmandu, Nepal

An inquiry of Obstructive Jaundice

at Tribhuvan University Teaching hospital,

Kathmandu, Nepal

Degree project thesis in Medicine

Sabina Delin

Supervisors:

Göran Kurlberg, MD, Sahlgrenska Academy, University of Gothenburg, Sweden

Yogendra P. Singh, Prof. Chief Surgeon at the department of surgery at Tribhuvan University

Teaching Hospital, Kathmandu, Nepal

Programme in medicine

Sahlgrenska Academy

University of Gothenburg, Sweden, 2018

Table of Contents

1. Introduction .............................................................................................................................................. 1

1.1 Country background .......................................................................................................................... 1

1.2 Health care system ............................................................................................................................. 1

1.3 The hospital ........................................................................................................................................ 2

1.4 Obstructive jaundice as a disease ..................................................................................................... 2

1.5 Obstructive jaundice research .......................................................................................................... 4

2. Aim ............................................................................................................................................................. 4

3. Objective ................................................................................................................................................... 4

4. Material and methods .............................................................................................................................. 5

4.1Retrospective part ............................................................................................................................... 5

4.2 Prospective cross-sectional part ....................................................................................................... 7

4.3 Statistical methods ............................................................................................................................. 8

5. Ethics ......................................................................................................................................................... 9

6. Results ...................................................................................................................................................... 10

6.1 Retrospective data ............................................................................................................................ 10

6.2 Prospective cross-sectional data .................................................................................................... 14

7. Discussion ............................................................................................................................................... 17

7.1 Retrospective data ............................................................................................................................ 17

7.2 Prospective cross-sectional data .................................................................................................... 21

7.3 Methodological considerations ...................................................................................................... 23

8.Conclusion ................................................................................................................................................ 26

9. Populärvetenskaplig sammanfattning på svenska ............................................................................. 27

10. Acknowledgment ................................................................................................................................. 28

11. References ............................................................................................................................................. 29

12. Appendices ............................................................................................................................................ 31

12.1 Attachment A: Patient form ......................................................................................................... 31

12.2 Attachment B: Informed consent................................................................................................ 32

12.3 Attachment C: Collection form for both retrospective and prospective cross-sectional part ............................................................................................................................................................ 33

12.4 Attachment D: Flow-chart for the retrospective and the prospective part........................... 35

12.5 Attachment E: Ethical approval .................................................................................................. 36

file:///C:/Users/Admin/Desktop/Projektarbete%202.docx%23_Toc507591866

Abstract

This degree project in medicine, “An inquiry of Obstructive Jaundice at Tribhuvan University

Teaching hospital, Kathmandu, Nepal” written by Sabina Delin, medical student at the

University of Gothenburg, Sweden, 2018.

Introduction: No previous studies have been made in Nepal concerning the causes and

symptoms of obstructive jaundice. This study explores correlations between the disease and sex,

age, underlying causes and symptoms.

Method: The study consisted of two parts. The first was a retrospective study where one-

hundred-and-ten patients were included. Their medical records were used as a basis. The other

was a prospective cross-sectional study where eighteen patients were included, of the one-

hundred-and-ten patients from the retrospective part. A patient form and their medical records

were used to collect data.

Results: Retrospective data: 110 patients were included. There were 61 (55.5 %) females and

49 (44.5 %) males. About half of the patients had a malignant cause to the disease and half had a

benign cause. The mean age of the patients with malign cause was 61 years compared to the

mean age of 47 years for those with benign cause. There was a difference of 14 - years in mean

difference. The most common cause was distal cholangiocarcinoma (15.5%) followed by

pancreatitis (13.6%). The most common presentation of obstructive jaundice (presented as

percentage of how many patients had each symptom) was jaundice (79.1%), other symptoms

(58.2%), RUQ - pain (40.9%), itching (38.2%), anorexia/loss of appetite/loss of weight (38.2%)

and epigastric pain (37.3%. Prospective cross-sectional data: 18 patients were included, of

these were 11 (61.1%) women and 7 (38.9%) men. There were 10 (55.6%) malign cases, 6

(33.3%) benign cases and 2 (11.1%) patients with unknown cause. The mean age of the patients

with malign cause was 62 years compared to the mean age of 34 years for those with benign

cause. There was a difference of 28 years in mean difference. Hilar cholangiocarcinoma was the

most common cause of all followed by bile duct injury. The presenting symptoms noted in the

medical journals were jaundice 58.8 %, itching 41.2%, anorexia/weight loss/loss of appetite

35.3%, RUQ - pain 35.3%, fever without chills 35.3%, clay-coloured stool 29.4%, other

symptoms 29.4%, dark urine 17.6%, epigastric pain 17.6 % and fever with chills 5.9%. The

symptoms found in the patient forms were jaundice 83.3%, itching 77.8%, RUQ - pain 55.6%,

fever with chills and rigor 33.3%, clay-coloured stool 38.9% and dark urine 61.1%.

Conclusions: It is more common for older people to have a malignant cause of obstructive

jaundice. This study indicates other proportions of the malign spectrum, compared to

comparative studies, with distal cholangiocarcinoma as the leading cause. It seems like

cholangiocarcinoma is more common in Nepal compared to what studies have shown in

neighbouring countries. This indicates a different pattern of care-seeking due to i.e. economic

factors or that cholangiocarcinoma as a cause to obstructive jaundice is more common in Nepal

and possibly has a hinger incidence in the Nepalese population.

Keywords: Obstructive Jaundice, Aetiology, Symptoms

1

1. Introduction

This Degree Project, initiated by Prof. Singh, Chief surgeon at the Department of Surgery at

T.U.T.H. is an attempt to elucidate this area of medicine from a Nepali perspective.

1.1 Country background

Nepal is situated in south Asia bordering to China in the north and to India in all other

directions. Nepal has a diverse landscape with lowlands with its forests and forested watersheds

to the Himalayas with mountains, alpine pastures and temperate forests and the inner Himalayan

valle