OBSTRUCTIVE JAUNDICE

Dr Fazal Hussain Khalil

Post Graduate Trainee

SBW KTH

OBJECTIVES

• clinical presentation of surgical Jaundice

• Review the Causes of Jaundice

• Pathophysiology of obstructive jaundice

• Important Investigations

• Management

Case Scenario

• 82 yr old male patient presents with progressive jaundice, itching, loss of weight .

History of presenting illness

• Gradually progressive jaundice

• Recurrent episodes of itching

• White stools for last 2 months

• Dark yellow urine

• Generalized weakness & fatigability- 6 months

• Weight loss in last 1 year

• Reduced appetite

• No fever

H/o past illness• No h/o DM, HT, TB, Chest pain

• No previous surgery(no history of cholelethiasis)

Personal History• Decreased appetite with pale stools

• Normal bladder habits but deep yellowish

• Smoker – 25 yrs

• Non-alcoholic

ExaminationGeneral Physical Examination:

– Pulse 88/min,BP 110/70

– anemia +, Jaundice ++

– No Lymphadenopathy

– Scratch marks

Per abdomen– Soft non-tender

– Gall bladder palpable

– No free fluid

Routine Investigations

• Hgb: 11.7

• Hct: 35

• WBC: 6000;

• normal differential count

• Platelet: 350,000

• Serum Crea: 1.2 mg

• Total bil: 20 mg; B1(unconj): 2 mg

B2 (conj): 18 mg

• Alkaline phosphatase: 990 U/L

• CA 19-9: 350 units/ml

• Total protein: 6.5 grams;

• USG-Abd: solid mass in distal CBD, dilated CBD, Intrahepatic Biliarydistension and distended GB

• Ct abdomenCt abdomen show grossly dilated

intra and extrahepatic biliary channels

With distended gall bladder

And possibilty of periampullary mass

ADVISE ERCP

Causes of obstructive jaundice

Causes of Obstructive Jaundice

Obstructive jaundice is caused by conditions that block the normal flow of bile from the liver into the intestines including:

• Cholelithiasis (gallstones)• Cholangiocarcinoma• Carcinoma pancreas• Biliary stricture (mainly iatrogenic)• Cholangitis (inflammation of the common bile duct)• Congenital structural defects• Choledochal cysts(Cysts of the bile duct)• Lymph node enlargement• Pancreatitis• Parasitic infection• Trauma, including surgical complications

Most common cause of obstructive jaundice in our set up

Clinical classification Of Obstructive Jaundice

(Benjamin Classification)

Type I : Complete obstructionClassical symptoms with biochemical changes

Tumors : Ca. head of Pancreas

Ligation of the CBD

Cholangio carcinoma

Parenchymal Liver diseases

Type II : Intermittent obstruction• Symptoms and typical biochemical changes

• But jaundice may or may not be present

Choledocholithiasis

Periampullary tumor

Duodenal diverticula

Choledochal Cyst

Papillomas of the bile duct

Intra biliary parasites

Hemobilia

TYPE III : Chronic incomplete obstructionWith or without classical symptoms but pathological

changes are present in bile duct and liver

Strictures of the CBD Congenital

Traumatic

Sclerosing cholangitis

Post radiotherapy

Stenosed biliary enteric anastamosis

Cystic fibrosis

Chronic pancreatitis ERCP showing distal common bile duct stricture

Stenosis of the Sphincter of Oddi

TYPE IV : Segmental Obstructionone or more segment of intrahepatic biliary tract is obstructed

Traumatic

Sclerosing cholangitis

Intra hepatic stones

Cholangio carcinoma

Pathophysiology of obstructive jaundice

PATHOPHYSIOLOGY OF OBSTRUCTIVE JAUNDICE

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the liver. This results in an overflow of bile and its by-products into the blood, and bile excretion from the body is incomplete

Hepatic functionsProtein synthesis,Reticulo-endothelial function Hepatic metabolism

Coagulation defect..increased prothrombin time(Decreased absroption of fat solube vitamins A,D,E,K(decreased factor XI ,XII ,platelets)

Renal functionsRenal vasoconstrictionActivation of complement system causing peritubular and glomerular fibrin deposition leading totubular and cortical necrosis

Cardiovascular effectsDecreased peripheral vascular resistanceBradycardia due to direct effect of bile salts on SA nodeDecreased cardiac contractability

Delayed wound healing due to defective synthesis of collagen

Investigations

ROUTINE

• Haemoglobin usually decreased in case of malignancy

• Rfts are usually derranged

BIOCHEMICAL PROFILE

1.Conjugated bilirubin> increased

2.Urine bilirubin +

3.Urobilinogen will be absent

4.S.ALK PHOSPH RAISED (most sensitive, levels are elevated in nearly 100 % of patients with extra

hepatic obstruction except in some cases of intermittent obstruction.Values usually greater than 3 times

the upper limit of reference range, and in most typical cases, they exceed 5 times the upper limit)

5. GAMMA –GLUTAMYL TRANSPEPTIDASE(GGT) is a sensitive marker of biliary tract disease is raised

6.5’nucleotidase is raised and its more specific

7.ALT AST may rise

8.Albumin decreased

9.PT prolonged clotting factor decreased

10.RFTs are usually impaired

Radiology

• IMAGING GOALS

To confirm the presence of an extrahepatic obstruction

To determine the level of the obstruction, to identify the specific

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

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 biliaryobstruction.)

– Liver parenchymal mass and mets

– Portable, cheap, no radiation,

– But it is operator dependant

ENDOSCOPIC ULTRASOUND (EUS)

• EUS has been reported to have up to a 98% diagnostic accuracy in patients with obstructive jaundice

• it allows diagnostic tissue sampling via EUS

guided fine-needle aspiration (EUS-FNA)• The sensitivity of EUS for the identification of

focal mass lesions in pancreas has been reported to be superior to that of CT scanning, both traditional and spiral, particularly for tumors smaller than 3 cm in diameter.

• Compared to MRCP for the diagnosis of biliarystricture, EUS has been reported to be more specific (100% vs 76%)

Ct scan

• 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

•also to find level and cause of obstruction

•and in malignant conditions

MAGNETIC RESONANCE

CHOLANGIOPANCREATOGRAPHY (MRCP)

• Noninvasive test to visualize the hepato biliarytree

• 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

Endoscopic retrograde cholangiogram(ERCP

• Its an invasive procedure and has therapeutic potential.

• Allows biopsy or brush cytology

• Stone extraction or stenting

COMPLICATIONS Pancreatitis

Cholangitis

Hemorrhage

Sepsis

CONTRAINDICATIONS Unfav anatomy

Pseudocyst

Rec a/c pancreatitis

Percutaneous TranshepaticCholangiogram (PTC)

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

• Can be used to drain biliaryobstructions.

Other investigations

• Oral Cholecystography (OCG)>>> useful when patient has symptoms of cholelithiasis,

but a negative ultrasound.

• also is useful for counting the number of stones present.

• HIDA SCAN- useful in a/c cholecystitis,

• DIAGNOSTIC LAPAROSCOPY-

• ANGIOGRAPHY- abnormal vasc.anatomy

• Tumor markers- CA19-9 , CEA

Management of Obstructive Jaundice

Management

Perioperative management of obstructive jaundice

• Preoperative biliary decompression improves postoperative morbidity (usually cause increased hemorrhage & infections and is mainly Indicated in severe jaundice or when there are signs of impending liver failure.Endoscopic internal drainage preferred over per-cutaneous external drainage

• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop diuretics to prevent renal failure(12 to 24 hours prior to surgery)

• catheterization to monitor output

• Broad spectrum antibiotic prophylaxis

• Parenteral vitamin K +/- fresh frozen plasma

• Need careful post operative fluid balance to correct dehydration

• Correction of hypokalemia

• Cholestyramine and antihistamine for symptomatic relief of pruritis

Treatment of Obstructive Jaundice is based on the cause

1) Cholelithiasis (gallstones)

Ideally ERCP follwed by laproscopicCholecystectomy

Or open cholecystectomy with

CBD exploaration

2) Ca Head of Pancreas / Periampullary Carcinoma/malignancy

of lower 3rd of CBD

a) Whipple resection (pancreaticoduodenectomy) is mainly done which involves 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

b) If not operable then we go for Endoscopic sphincterotomy + stenting with Percutaneous transhepatic biliary drainage

3) Ca gall bladder

a) if involving cbd then whipple resection is done

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

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

Long term follow up is necessary because of complications

like cholangitis , lithiasis , anastomotic stricture

5) Cholanchiocarcinoma

Surgery depends on the stage of tumor and may involve

• Removal of the bile ductsIf the tumor is at a very early stage (Stage 1), just the bile ducts containing the cancer are removed. The remaining ducts in the liver are then joined to the small bowel, allowing the bile to flow again.

• 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, the bile ducts, part of the stomach, part of the small bowel (duodenum), the pancreas, gall bladder and the surrounding lymph nodes are all removed

• If surgery to remove the tumour is not possible, it may be possible to relieve the blockage through stents through ERCP or PTC

6)Choledocholithiasis (stones in the CBD)

a)Treatment of choice is stone extraction through ERCP

b) Mechanical lithotripsy – through modified dormia basket

c)Through shock waves laser technology

d)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)Strictures are usually treated by endoscopic stenting

which is comparable to that of surgery, with similar recurrence rates. 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 with good or excellent results in 80 to 90% of patients.

8) Stenosis of the Sphincter of Oddi endoscopic or

operative sphincterotomy will yield good results

Prognostic factors( Pitt’s score)

Parameters• Type of

obstruction(malignant or benign)

• Age > 60 yrs

• S.Alb< 3gm/dl

• S.Bil > 10mg%

• S.Alk P > 100 IU

• S.Creatinine >1.3mg%

• TLC >10000/mm3

• Hematocrit < 30%

Factors Mortality

Upto 2 0%

3 4%

4 7%

5 44%

6 67%

8 100%

Thank You