# Situation: A 55-year-old woman has jaundice, itching, dark urine, and pale stools from a common bile duct stone that could not be removed endoscopically. She is scheduled for open cholecystectomy with common bile duct exploration. Which substance, deposited in the skin, causes her itching?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630491  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 55-year-old woman has jaundice, itching, dark urine, and pale stools from a common bile duct stone that could not be removed endoscopically. She is scheduled for open cholecystectomy with common bile duct exploration.

Which substance, deposited in the skin, causes her itching?

## 보기

1. Conjugated bilirubin
2. Bile salts **✔ 정답**
3. Urea crystals
4. Ammonia

**정답: 2**

## 해설

In obstructive jaundice, bile salts that cannot reach the intestine accumulate in the blood and skin and cause pruritus. Bilirubin produces the yellow color of jaundice but is not the cause of the itching. Care includes cool baths, emollients, short nails, and cholestyramine as ordered.

## 심화 해설

Bile salts cause the itching
In obstructive jaundice, a stone in the common bile duct prevents bile from reaching the duodenum. Bile contains bile salts (bile acids), conjugated bilirubin, cholesterol, and other substances. When flow is blocked, these components back up into the liver and then into the bloodstream. Retained bile salts deposited in the skin cause the pruritus of obstructive jaundice. The itching can be intense, is often worse at night, and leads to scratching, broken skin, and poor sleep.

What bilirubin does and does not do
Conjugated bilirubin that spills into the blood gives the skin and sclerae their yellow color and, because it is water-soluble, is excreted in urine, making it dark. Lack of bilirubin reaching the gut leaves the stools pale or clay-colored. Bilirubin is therefore responsible for the color changes of jaundice, but it is not the cause of the itching. This distinction is a classic exam point: her four presenting features, jaundice, itching, dark urine, and pale stools, each have a specific mechanism.

| Finding | Cause |
| --- | --- |
| Yellow skin and sclerae | Conjugated bilirubin in blood and tissues |
| Itching (pruritus) | Bile salts deposited in the skin |
| Dark urine | Water-soluble conjugated bilirubin excreted by the kidneys |
| Pale stools | No bilirubin reaching the intestine |

Why the other substances are wrong
Urea accumulates in severe kidney failure and can crystallize on the skin as uremic frost; uremic pruritus is a kidney problem, not a biliary one. Ammonia accumulates in liver failure and crosses into the brain, causing hepatic encephalopathy with confusion and asterixis, not itching. Watch out! Conjugated bilirubin is tempting because it is the most familiar word linked to jaundice, but it explains the color, not the pruritus.

Nursing care for pruritus
Comfort measures include cool baths or tepid showers, mild soap, emollients, loose cotton clothing, a cool room, and keeping the nails short to reduce skin damage from scratching. Cholestyramine may be ordered; it binds bile salts in the intestine so they are excreted. The definitive treatment is relieving the obstruction, after which itching subsides. Key point! In obstructive jaundice, bilirubin causes the yellow color and bile salts cause the itch.

## 임상 시나리오

Pruritus in Obstructive JaundiceBile salts versus bilirubin
A common bile duct stone blocks bile flow, so bile salts accumulate in blood and skin and cause pruritus.

Conjugated bilirubin causes yellow skin and dark urine; lack of bilirubin in the gut causes pale stools.

Care: cool baths, emollients, short nails, loose clothing, and cholestyramine as ordered until the obstruction is relieved.

CautionBroken skin from scratching becomes a portal for infection; keep nails short and skin moisturized.

## 핵심 개념

- **Obstructive jaundice** — Jaundice caused by blocked bile flow from the liver to the duodenum, as with a common bile duct stone.
- **Bile salts** — Bile acids that aid fat digestion; when retained in obstruction they deposit in the skin and cause itching.
- **Pruritus** — Itching of the skin, a common symptom of cholestasis and obstructive jaundice.
- **Cholestyramine** — A bile acid sequestrant that binds bile salts in the intestine and is used to relieve cholestatic itching.

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