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OBSTRUCTIVE JAUNDICEPresented by: Dr. Anum ArifResident 1 (Surgical Unit 2)

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OBJECTIVES

1. DEFINITION

2. TYPES

3. OBSTRUCTIVE

JAUNDICE

4. CAUSES

5. SIGN/SYMPTOMS

6. DIAGNOSIS

7. TREATMENT

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1. DEFINITION

Jaundice is the yellow discoloration of the sclera and skin, as a result of raised serum bilirubin and is usually detectable clinically when the bilirubin is greater than 3 .g/dl.

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2. TYPES

1. PREHEPTIC

2. HEPATIC

3. POST HEPATIC

JAUNDICE TYPES

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2. TYPES

1. PREHEPTIC

2. HEPATIC

3. POST HEPATIC

JAUNDICE TYPES

1. HEMOLYTIC DISEASES

• Intravascular and extravascular

hemolytic disease.

• Autoimmune hemolytic disease.

• Paroxymal nocturnal

hemoglobinuria

2. INEFFECTIVE ERYTHROPESIS

1. IMPAIRED OR ABSENT

CONJUGATION OF

BILIRUBIN.

2. HEREDITIARY DISORDERS.

3. ACQUIRED DISORDERS

1. INTRAHEPATIC-LIVER CELL

DAMAGE/BLOCAKGE OF

BILE CANALICULI

2. EXTRAHEPATIC-

OBSTRUCTION OF BILE

DUCTS

Features Prehepatic (hemolytic)

Intrahepatic Heptocellular

Post-hepatic (Obstructive)

UCB ↑ ↑ Normal

CB Normal ↑ ↑

AST or ALT Normal ↑↑ Normal

ALPO Normal Normal ↑↑

Urine Bilirubin

Absent Present Increased

Urobilinogen Increased Present Absent

Features Prehepatic (hemolytic)

Intrahepatic Heptocellular

Post-hepatic (Obstructive)

Plasma Albumin

Normal Decreased Normal or decreased

PT Normal Increased Increased but correctted by Vitamin K

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OBSTRUCTIVE JAUNDICE

• Also called as surgical jaundice.

• Most important in surgical setting.

• Obstruction may be

intrahepepatic or extrahepatic.

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CAUSES

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CLASSIFICATION OF OBSTRUCTIVE JAUNDICE

# CLASSIFICATION DESCRIPTION

1. CONGENITAL Biliary atresiacholedochal cyst

2. INFLAMMATORY Ascending cholangitisSclerosing cholangitis

3. OBSTRUCTIVECBD stonebiliary stricture,parasitic infestation

4. NEOPLASTIC

Carcinoma head of pancreasPeriampullary carcinomacholangiocarcinomaKlatskin tumor

5. EXTRINSIC COMPRESSION OF CBD Lymph node or tumor(Mirzzi’s syndrome)

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CHOLEDOCHOLETHIASIS

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CA PANCREAS

DILATED CBD DUE TO CA PANCREAS

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CA PANCREAS

CA HEAD OF PANCREAS

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PRIMRY SCLEROSING CHOLANGITIS

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HEPATOCELLULAR CARCINOMA

HEPATOCELLULAR CARCINOMA

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CHOLANGIOCARCINOMA

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CHOLANGIOCARCINOMA

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MIRZZI’S SYNDROME

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CHOLEDOCHAL CYST

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PARASITIC INFESTATION

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BENJAMIN CLASSIFICATION

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TYPE 1: COMPLETE OBSTRUCTION

Classical symptoms with biochemical changes:

• Ca. head of Pancreas

• Cholangiocarcinoma

• Parenchymal Liver diseases

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TYPE II : INTERMITTENT OBSRUCTION• Symptoms and typical biochemical changes • But jaundice may or may not be present

o Choledocholithiasis

o Periampullary tumor

o Duodenal diverticula

o Choledochal Cyst

o Papillomas of the bile duct

o Parasitic infestation

o Hemobilia

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TYPE III : CHRONIC INCOMPLETE OBSTRUCTIONWith or without classical symptoms but pathological changes are present in bile duct and liver

o Strictures of the CBD

• Congenital

• Traumatic

• Sclerosing cholangitis

• Post radiotherapy

o Stenosed biliary enteric anastamosis

o Cystic fibrosis

o Chronic pancreatitis

o Stenosis of the Sphincter of Oddi

ERCP showing distal common bile duct stricture

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TYPE IV : SEGMENTAL OBSTRUCTION

One or more segment of intrahepatic biliary tract is obstructed

o Traumatic

o Sclerosing cholangitis

o Intra hepatic stones

o Cholangio carcinoma

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SYMPTOMS• Yellowish discoloration of sclera• Epigastric pain• Fever • Pruritis• Loss of weight• Loss of appetite• Increased bleeding tendency• Steatorrhoea or Dark stool• Dark orange urine

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SYMPTOMS

SIGNS• Charcot’s triad• Reynold’s pentad• palpable and / or tender

gallbladder (Courvioser’s law)• Hepatomegaly• Spleenomegaly• xanthomas• xanthelasma • scratch marks: excoriation • finger clubbing • loose, pale, bulky, offensive

stools • dark orange urine

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INVESTIGATIONS

• Serum Direct Bilirubin

• Feceal urobilinogen (incomplete

obstruction)

• Feceal urobilinogen absence

(complete obstruction)

• urobilinogenuria is absent in

complete obstructive jaundice

• bilirubinuria

• ALP

• cholesterol

• (GGT) is a sensitive marker of biliary

tract disease and its raised

• 5’nucleotidase is raised and its more

specific

• ALT AST may rise

• Albumin decreased

• PT prolonged

• clotting factor decreased

• Tumor markers Ca19-9 and CEA raised

according to underlying cause.

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RADIOLOGY

• IMAGING GOALS• To confirm the presence of obstruction

• To determine the level of the obstruction

• cause of the obstruction

• To provide complementary information relating to the underlying

diagnosis (eg., Staging information in cases of malignancy).

• What is the best therapeutic approach?

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• IMMAGING MODALITIES are:• Ultrasound • ERCP• MRCP• PTC

Ultrasound abdomen• More sensitive than CT for gallbladder stones and other pathology of gall

bladder

• Sensitive for dilated ducts (Dilation of the extrahepatic (>10 mm) or intrahepatic (>4 mm) bile ducts suggests biliary obstruction.)

• Liver parenchymal mass and mets

PortableThe sensitivity of EUS for the identification of focal mass lesions in pancreas is superior to that of CT scanning

Cheap

no radiation,

• Operator dependant

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Ultrasound showing gallbladder stonesEndoscopic ultrasound showing CBD stone

Endoscopic retrograde cholangiogram (ERCP)

• invasive procedure • Diagnostic and therapeutic

potential. • biopsy • brush cytology • Stone extraction • stenting.

COMPLICATIONS Pancreatitis Cholangitis Hemorrhage SepsiS

CT SCAN ABDOMEN

• Main role in malignant conditions mainly for localization of primary tumors and mets.

• Best for Pancreatic Carcinoma(Highly sensitive for lesion >1mm.)

•Mainly done when ultrasound fail or when there is ductal dilation on ultrasound. •level and cause of obstruction.

Carcinoma head of pancreas

MAGNETIC RESONANCE

CHOLANGIOPANCREATOGRAPHY (MRCP)• Noninvasive test to visualize the hepato biliary

tree

• Entire biliary tree and pancreatic duct can be seen

• Best for Intra Hepatic stones and CHOLEDOCHAL CYST

• SINGLE BEST FOR CHOLANGIOCARCINOMA

• MRCP is better to determine the extent and type of tumor as compared to ERCP

Percutaneous Transhepatic Cholangiogram (PTC)

• PTC is indicated when percutaneous intervention is needed and ERCP either is inappropriate or has failed.

• Can be used to drain biliary obstructions.

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SUPPORTIVE MANAGEMENT

• Preoperative biliary decompression (ERCP or PTC)

• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop

diuretics to prevent hepatorenal syndrome/ renal failure(12 to 24 hours prior to

surgery)

• catheterization to monitor output

• Broad spectrum antibiotic prophylaxis with 3rd generation cephalosporins

• Parenteral vitamin K +/- fresh frozen plasma

• Need careful fluid balance to correct dehydration

• Correction of hypokalemia and other electrolyte imbalance.

• Cholestyramine and antihistamine for symptomatic relief of pruritis

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DEFINITVE MANAGEMENT DEPENDS ON THE CAUSE

CHOLOEDOCHOLITHISIS

• Ideally ERCP follwed by laproscopic Cholecystectomy.

• Open exploration of common bile duct is indicated in: Presence of multiple stones (more than 5) and Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones

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2. Ca HEAD OF PANCREAS

• Whipple resection:

• Removal of head & neck of pancreas,

duodenum, distal 40% of stomach, lower

CBD, GB, upper 10 cm of jejunum, regional

L.Ns and reconstruction through

gastrojejunostomy,choledochojejunostmy

and pancreaticojejunostomy

• If not operable then we go for ?????biliary

drainage

CARCINOMA GALLBLADDER

• if involving cbd then whipple resection is done

• And in case of inoperable cases Endoscopic / Radiological stenting is done

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4)CHOLEDOCHAL CYST

Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree Biliary drainage is accomplished by Choledocho–jejunostomy with a Roux – en – Y anastamosis

5) Cholanchiocarcinoma

Surgery depends on the stage of tumor and may involve • Removal of the bile ducts

In Stage 1 tumor ,just the bile ducts containing the cancer are removed.

• Partial liver resectionIf the tumor has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts.

• Whipple procedureIf the tumor is larger and has spread into nearby structures, whipples proceedure is done.

• Inoperable cases it may be possible to relieve the blockage through stents via ERCP or PTC.

CHOLEDOCHOLITHISIS

Treatment of choice is stone extraction through ERCP

Open exploration of common bile duct is indicated in Presence of multiple stones (more than 5) and Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones

7)STRICTURE

• Treated by endoscopic stenting.• Therefore, surgery should probably be reserved for those patients

with complete ductal obstruction or for those in whom endoscopic therapy has failed.

• Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care.

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8)STRICTURE OF SPINCHTER OF ODDI

• Endoscopic or operative sphincterotomy

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SUMMARY

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