title: Presence of white bile in malignant biliary obstruction is associated with poor prognosis: personal preliminary observations.
abstract: OBJECTIVE
  The chemical composition and clinical significance of white bile in patients with malignant obstructive jaundice were evaluated in a prospective study.
  
  
  METHODS
  115 consecutive patients with inoperable malignant biliary obstruction underwent endoscopic placement of 10 Fr straight, plastic biliary stents, Amsterdam-type. Bile was aspirated during the endoscopic procedure and a blood sample was taken. Patients were divided into two groups: those with white bile and those with yellow bile. The groups were compared for decremental fall in bilirubin, cholangitis after stent insertion, and survival.
  
  
  RESULTS
  Thirty-five patients (15 men, 20 women; mean age 54 years) underwent endoscopic drainage for malignant obstruction (29 hilar, 6 distal bile duct). Eighteen patients had white bile. Refractory jaundice (p > -0.025) was seen in nine (50%) patients with white bile compared with three (17.6%) patients with yellow bile; mean difference -42.2 (95% CI [-62.4, -22.0]) and -45.7 (95% CI [-72.0, -19.4]), respectively. The bilirubin (0.49 mg/L) and bile acid (14.6 mmol/L) concentrations in white bile were significantly less than bilirubin (41.9 mg/L) and bile acid (62.2 mmol/L) concentrations in yellow/black bile. Cholangitis developed in 66.6% of patients with white bile compared with 35% of those with yellow/black bile (OR 3.67: 95% CI [0.74, 19.25]). Kaplan-Meier curves showed that median survival was shorter in patients with white bile (36 [23-60] vs 75 [35-220] days) (p = 0.004, log rank test), which was significant even after adjusting for potential confounders with Cox proportional hazards regression.
  
  
  CONCLUSIONS
  White bile is largely devoid of bilirubin and bile acids. The presence of white bile was associated with significantly worse survival in patients with malignant biliary obstruction.
authors.affiliation: Faculty of Medicine and Surgery, Section of General and Thoracic Surgery, University of Palermo, Via Liborio Giuffre' N. 5, 90100 Palermo, Italy. girgera@tin.it
authors.forename: Girolamo
authors.initials: G
authors.lastname: Geraci
authors.forename: Carmelo
authors.initials: C
authors.lastname: Sciumè
authors.forename: Franco
authors.initials: F
authors.lastname: Pisello
authors.forename: Francesco
authors.initials: F
authors.lastname: Li Volsi
authors.forename: Tiziana
authors.initials: T
authors.lastname: Facella
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Modica
mesh_terms: D000368:Aged; D000469:Alkaline Phosphatase / Q000097:blood; D001646:Bile / Q000737:chemistry; D001647:Bile Acids and Salts / Q000032:analysis; D001661:Biliary Tract Neoplasms / Q000378:metabolism / Q000401:mortality*; D001663:Bilirubin / Q000032:analysis; D002779:Cholestasis / Q000378:metabolism / Q000401:mortality*; D003116:Color; D005260:Female; D005706:Gallbladder Neoplasms / Q000378:metabolism / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000378:metabolism / Q000401:mortality; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D015607:Stents
chemical_list: D001647:Bile Acids and Salts; D000469:Alkaline Phosphatase; D001663:Bilirubin