OBSTRUCTIVE JAUNDICE

Dr.B.Selvaraj MS;Mch;FICS;Professor Of Surgery

Melaka Manipal Medical collegeMelaka 75150 Malaysia

CHOLEDOCHOLITHIASIS

Choledocholithiasis- Overview

Causes of obstructive jaundiceClassical clinical vignetteEtiopathogenesisClinical features & complicationsInvestigationsTreatmentMindmap of CholedocholithiasisDiagnostic Algorithm in obstructive jaundiceManagement algorithm in choledocholithiasis

Obstructive Jaundice- Causes

• Intraluminal causes: - Choledocholithiasis - Clonorchis sinensis - Ascariasis & Schitosomiasis• Mural causes: - Malignant stricture-cholangiocarcinoma - Benign stricture- Scelerosing cholangitis• Extrinsic Causes: - Ca Head of Pancreas - Periampullary Carcinoma, Portal LN

Classical Clinical Vignette

A 40-year-old female presents with a 24 hour history of right upper quadrant (RUQ) and epigastric pain, associated with nausea and vomiting. She has had similar pain in the past, particularly after eating fatty foods. According to her family, over the last few hours, the patient has become slightly confused. Past medical history is negative.

O/E: She is moderately tender in the RUQ to deep palpation. She has slight scleral icterus. She has noted dark- coloured urine. The remainder of her abdominal exam is negative.

Vitals: BP-90/60 mms of Hg; PR-110/mt; RR-16/mt;T:102*F

Classical Clinical Vignette

Laboratory examination: TWBC- 15,000/μL(4 to 11,000/μL), Total bilirubin-4mgm/dl(0.1 to 1.2mgm/dl) Direct bili- 3mgm/dl ALP- 350μ/L (33-131μ/L); GGT- 330μ/L (8-88μ/L) AST- 300μ/L(5-35μ/L); ALT- 280μ/L(7-56μ/L) Sr Amylase- 100μ/L( 30-110μ/L)Urine is positive for bilirubin

CHOLEDOCHOLITHIASIS WITH CHOLANGITIS

Choledocholithiasis-Etiology

It is stones in the CBD and biliary tree.Primary—Rare 5%—brown pigment stones. They are formed in

CBD and biliary tree itself, and are multiple, often sludge like, commonly pigment or mixed type, extends into hepatic ducts.

Causes: Biliary stasis, biliary dyskinesia, caroli’s disease, choledochal cyst, clonorchiasis, ascariasis EtcSecondary—Common 95%—black pigment stones/cholesterol

stones. It is seen in 15% of gallstone disease; 75% are cholesterol stones, 25% are pigment stones.

Choledocholithiasis-Etiology

Clinical Features

50% asymptomaticBiliary colic because of CBD obstruction by

stone- pain in RHC & epigastrium Intermittent chills, fever, or jaundice

accompanies biliary colic Charcot’s triad Ascending cholangitis

Suppurative cholangitis Reynold’s pentad Persistent pain, fever, jaundice, shock & AMS

Painful jaundice with dark color urine, clay colored stool and pururitus.

Features of Ac Pancreatitis in distal CBD stone impaction

Clinical Features

Patient may be icteric and toxic, with high fever and chills, or may appear to be perfectly healthy.

A palpable gallbladder is unusual in patients with obstructive jaundice from common duct stone because the obstruction is transient and partial, and scarring of the gallbladder renders it inelastic and non distensible.

Courvoisier’s Law: “ In a jaundiced patient if GB is palpably enlarged it is not due to Gall stone”

Tenderness in the right upper quadrant is not often as marked as in acute cholecystitis, DU perforation or Ac Pancreatitis

Tender enlarged liver +

Differential diagnosis

Obstructive jaundice due to other causes:Carcinoma of head of pancreas Periampullary carcinomaCarcinoma of biliary tree- cholangiocarcinomaBiliary stricture- Scelerosing cholangitisIntrahepatic cholestasis from drugs, pregnancy, chronic active

hepatitis, or primary biliary cirrhosis may be difficult to distinguish from extrahepatic obstruction. ERCP would be appropriate to make the distinction.

COMPLICATIONS Liver dysfunction and biliary

cirrhosis. White bile formation and liver

failure. Suppurative cholangitis.Liver abscess. Septicaemia. Pancreatitis if CBD stone is near

sphincter of Oddi blocking drainage of bile and pancreatic duct.

Investigations- Labs

In cholangitis, leukocytosis of 15,000/mL is usual, and values above 20,000/mL are common.

T bilirubin level usually remains under 10 mg/dL, and most are in the range of 2-4 mg/dL. The direct fraction exceeds the indirect, but the latter becomes elevated in most cases.

Bilirubin levels do not ordinarily reach the high values seen in malignant tumors because the obstruction is usually incomplete and transient. In fact, fluctuating jaundice is so characteristic of choledocholithiasis.

Serum alkaline phosphatase & GGT levels usually risesMild increases in AST and ALT are often seen

Investigations-Imaging

AXR & USG abdomen- ineffective to pick up CBD stones USG abdomen may indicate dilated CBD >1cm CECT- can pick up CBD stone MRCP- best non-invasive diagnostic investigation ERCP- Gold standard- diagnostic & therapeutic EUS- can pick up CBD stone and can take biopsy if there is a

mass

Investigations-Imaging

ERCP MRCP

TREATMENT In absence of cholangitis:ERCP, Sphincterotomy, CBD stone removal by dormia basket or

balloon followed by Lap cholecystectomy.Lap cholecystectomy with Lap CBD exploration In presence of cholangitis:ERCP with sphincterotomy and stone extraction or stent

placement-decompression PTBD- Percutaneous transhepatic biliary drainage in ERCP failed

casesSurgical treatment: Only when above two procedures not possible. Decompression of CBD with T tube.

TREATMENT

TREATMENT Open cholecystectomy, intra op cholangiogram,

choledocholithotomy with T tube placement. Remove T tube—10 to 14 days after T tube cholangiogramMissed/retained/residual stones (< 2 years): If T tube present Percutaneous stone extraction via T tube tract

after 4-6 weeks (Burhenne technique) using choledochoscopeIf T tube absent ERCP stone removalRecurrent stones (> 2 years):ERCP—first approachIf duct dilated > 2 cm—choledochoduodenostomy or transduodenal sphincteroplasty

TREATMENTBurhenne Technique

Cholelithiasis Vs Choledocholithiasis

Choledocholithiasis - Mindmap

Obstructive Jaundice- Diagnostic Algorithm

Choledocholithiasis Treatement Algorithm

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