Presence of white bile in malignant biliary obstruction is associated with poor prognosis: personal preliminary observations

OBJECTIVE: The chemical composition and clinical significance of white bile in patients with malignant obstructive jaundice were evaluated in a prospective study. MATERIALS AND 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. CONCLUSION: 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.