Obstructive Jaundice etiology and management the lect.ppt

OBSTRUCTIVE
OBSTRUCTIVE
JAUNDICE
JAUNDICE
HAMED RASHAD
HAMED RASHAD
Professor of surgery Banha faculty of medicine - Egypt

JAUNDICE
JAUNDICE
JA
JA
U
U
N
N
D
D
I
I
C
C
E
E

Anatomy of biliary system
Anatomy of biliary system

JAUNDICE
It is yellowish discoloration of
Skin, mucous membranes, sclera
Due to excess plasma bilirubin
Is not a disease but rather a sign
that can
occur in many different diseases
Normal
range
5-17 m
mol/l
Clinically
obvious
50 mmol/l
(2.5mg/dl)
The differential diagnosis for
yellowing of the skin is limited.
In
addition to jaundice, it includes
Carotenoderma
The use of the drug Quinacrine
Excessive exposure to phenols
in carotenoderma the pigment
is concentrated on the palms,
soles, forehead, and nasolabial
folds. Carotenoderma can be
distinguished from jaundice by
the sparing of the sclerae

Bilirubin Production & Metabolism:
Bilirubin Production & Metabolism:
Formation
of
Bilirubin
Mainly
in
RES
(Spleen)
Conjugation
of
bilirubin
in
Hepatocyte
About 70 to 80% of
the 250 to 300 mg
of bilirubin
produced each day
is derived from the
breakdown of
hemoglobin in
senescent red
blood cells
The remainder
comes from
prematurely
destroyed erythroid
cells in bone
marrow and from
the
turnover of
hemoproteins such
as myoglobin and
cytochromes found
in tissues
throughout the
body.
Excretion

E V Pathway for RBC Scavenging
E V Pathway for RBC Scavenging
Liver, Spleen &
Bone marrow
Hemoglobin
Globin
Amino acids
Amino acid pool
Heme Bilirubin
Fe2+
Excreted
Phagocytosis & Lysis
Through Liver
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BILE SALTS
BILE SALTS
These are synthesized by the hepatic cells. Cholic acid
These are synthesized by the hepatic cells. Cholic acid
is formed from cholesterol and is conjugated with
is formed from cholesterol and is conjugated with
either taurine or glycine to form the bile salts –
either taurine or glycine to form the bile salts –
glcyocholic and taurocholic acids.At the pH of bile
glcyocholic and taurocholic acids.At the pH of bile
7.3-7.7 taurocholate and glycocholate exist as anions.
7.3-7.7 taurocholate and glycocholate exist as anions.
They are water soluble and are necessary for the
They are water soluble and are necessary for the
digestion of fats.
digestion of fats.
In obstructive jaundice they are regurgitated into blood
In obstructive jaundice they are regurgitated into blood
and are filtered by the kidneys and so are present in
and are filtered by the kidneys and so are present in
urine
urine
I
I

Van den Burgh Test
Van den Burgh Test
 When a mixture of sulphanilic acid, HCl, and sodium
When a mixture of sulphanilic acid, HCl, and sodium
nitrite is added to sierum containing an excess of
nitrite is added to sierum containing an excess of
bilirubin glucuronide a reddish violet colour results max
bilirubin glucuronide a reddish violet colour results max
in 30secs. This is called the Direct reaction
in 30secs. This is called the Direct reaction
 When the reagents are mixed with serum containing an
When the reagents are mixed with serum containing an
excess of bilirubin no colour develops until alcohol is
excess of bilirubin no colour develops until alcohol is
added whereupon the reddish-violet colour appears.
added whereupon the reddish-violet colour appears.

DEFINITION
DEFINITION
 Yellow discolouration of body tissues
Yellow discolouration of body tissues

excess circulating bilirubin
excess circulating bilirubin
 Normal bilirubin
Normal bilirubin
0.2-1.2mg%(5-17umol/l)
0.2-1.2mg%(5-17umol/l)
Jaundice
Jaundice 
 2-3mg% or (>40umol/l)
2-3mg% or (>40umol/l)
S.cl.jaun.
S.cl.jaun. 
 1-2mg%
1-2mg%
 Best observed
Best observed
 sites cont. elast. Tissues
sites cont. elast. Tissues
eg.: sclera, skin, mm
eg.: sclera, skin, mm

Surgical
Surgical
Pathophysiolology
Pathophysiolology

CLASSIFICATION
CLASSIFICATION
 No satisfactory classification
No satisfactory classification
 Classically:
Classically:
Prehepatic (excess dest., hlytic)
Prehepatic (excess dest., hlytic)
Hepatic (liver damage)
Hepatic (liver damage)
Post hepatic (obst. Or surgical)
Post hepatic (obst. Or surgical)
(stasis without a lesion requiring surg..
(stasis without a lesion requiring surg..
 Conj. Or Unconj.:
Conj. Or Unconj.: little cl. Value (often mixed)
little cl. Value (often mixed)
 D
D
 Surgical or Non-surgical
Surgical or Non-surgical

CLASSIFICATION
CLASSIFICATION
 Old standard classification
Old standard classification :
: pre
prehepatic
hepatic (hemolytic)
(hemolytic) ,
,
hepatic
hepatic (hepatocellular )&
(hepatocellular )& post
posthepatic
hepatic (obstructive )
(obstructive )
 New classification
New classification :
: cholestatic
cholestatic
(inrta & extra hepatic cholestasis)
(inrta & extra hepatic cholestasis)
VS
VS non-cholestatic
non-cholestatic
(hepatocellular insufficiency)
(hepatocellular insufficiency)

Jaundice – Classification
Jaundice – Classification
 Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg%
Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg%
 Jaundice is increased levels of SB > 1.0 mg%
Jaundice is increased levels of SB > 1.0 mg%
 Over production of Bilirubin (Hemolytic)
Over production of Bilirubin (Hemolytic)
 From hemolysis of RBC
From hemolysis of RBC
 Lysis of RBC precursors – Ineffective erythropoesis
Lysis of RBC precursors – Ineffective erythropoesis
 Impaired hepatic function (Hepatitic)
Impaired hepatic function (Hepatitic)
 Hepatocellular dysfunction in handling bilirubin
Hepatocellular dysfunction in handling bilirubin
 Uptake, Metabolism and Excretion of bilirubin
Uptake, Metabolism and Excretion of bilirubin
 Obstruction to bile flow (Obstructive)
Obstruction to bile flow (Obstructive)
 Intrahepatic cholestasis
Intrahepatic cholestasis
 Extrahepatic Obstruction (Surgical Jaundice
Extrahepatic Obstruction (Surgical Jaundice)
)
13
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Etiology Of Jaundice:
Etiology Of Jaundice:
Increase
of
production
Impaired
of
Clearance

Pre-Hepatic
Pre-Hepatic
 Haemolytic anaemia – hereditary spherocytosis,
Haemolytic anaemia – hereditary spherocytosis,
sickle cell, thalassaemia, Gilbert’s syndrome
sickle cell, thalassaemia, Gilbert’s syndrome
 High levels of unconjugated bilirubin, normal
High levels of unconjugated bilirubin, normal
LFTs, raised reticulocytes
LFTs, raised reticulocytes
 Investigate further with blood film and
Investigate further with blood film and
autoantibody screen
autoantibody screen

Hepatic
Hepatic
 Hepatic injury – viral hepatitis, sclerosis,
Hepatic injury – viral hepatitis, sclerosis,
cirrhosis, poisons, drugs
cirrhosis, poisons, drugs
 Bilirubin tends to be conjugated, (jaundice
Bilirubin tends to be conjugated, (jaundice
occurs out of failure to excrete, not conjugate)
occurs out of failure to excrete, not conjugate)
 Abnormal LFTs (raised ALT/AST)
Abnormal LFTs (raised ALT/AST)
 Investigate further with viral titres, USS, liver
Investigate further with viral titres, USS, liver
biopsy
biopsy

Post-Hepatic (Your Turn)
Post-Hepatic (Your Turn)
Wall Lumen Outside Lumen
Sclerosing cholangitis
Gallstones Tumour (pancreatic,
ampullary, duodenal)
Benign stricture Schistosomiasis Chronic pancreatitis
Cholangiocarcinoma Clonorchis Portal lymphadenopathy
•Raised conjugated bilirubin (absorbed from biliary tree)
•Decreased urinary urobilinogen (bilirubin does not make it to
the small bowel)
•Obstructed LFTs (raised ALP and GGT)
•Further investigation with USS, and then ERCP/CT as appropriate

Lab Diagnosis of Jaundice – D.D
Lab Diagnosis of Jaundice – D.D
18
Features
Prehepatic
(Heamolytic)
Intrahepatic
(Hepatocellular)
Posthepatic
(Obstructive)
Unconjugated ↑ Normal Normal
Conjugated Normal ↑ ↑
AST or ALT Normal ↑ ↑ Normal
Alkaline phos.
and GGT
Normal Normal ↑ ↑
Urine bilirubin Absent Present Increased
Urobilinogen Increased Present Absent
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OBSTRUCTIVE
OBSTRUCTIVE
JAUNDICE
JAUNDICE

Definition
Definition
 Jaundice is the yellowish pigmentation of the skin, the
Jaundice is the yellowish pigmentation of the skin, the
conjunctival membranes over the sclerae, and other mucous
conjunctival membranes over the sclerae, and other mucous
membranes caused by hyperbilirubinemia.
membranes caused by hyperbilirubinemia.
 Total serum bilirubin values are normally 0.2-1.2 mg/dL.
Total serum bilirubin values are normally 0.2-1.2 mg/dL.
Jaundice may not be clinically recognizable until levels are at
Jaundice may not be clinically recognizable until levels are at
least 3 mg/dL.
least 3 mg/dL.
 Jaundice is not a diagnosis.
Jaundice is not a diagnosis.
 Surgical jaundice is any jaundice amenable to surgical treatment.
Surgical jaundice is any jaundice amenable to surgical treatment.
The majority are due to extrahepatic biliary obstruction.
The majority are due to extrahepatic biliary obstruction.
 Not all obstructive jaundice is surgical jaundice e.g hepatitis and
Not all obstructive jaundice is surgical jaundice e.g hepatitis and
not all surgical jaundice is due to
not all surgical jaundice is due to obstruction e.g congenital
obstruction e.g congenital
spherocytosis
spherocytosis

Epidemiology
Epidemiology
RACE
RACE
•
• The racial predilection depends on the cause of the biliary
The racial predilection depends on the cause of the biliary
obstruction.
obstruction.
•
• Gallstones are the most common cause of biliary obstruction.
Gallstones are the most common cause of biliary obstruction.
•
• Persons of Hispanic origin and Northern Europeans have a
Persons of Hispanic origin and Northern Europeans have a
higher risk of gallstones compared to people from Asia and
higher risk of gallstones compared to people from Asia and
Africa.
Africa.
•
• Native Americans (particularly Pima Indians)have a lifetime
Native Americans (particularly Pima Indians)have a lifetime
chance of developing gallstones as high as 80%.
chance of developing gallstones as high as 80%.

Epidemiology
Epidemiology
SEX
SEX
•
• Women are much more likely to develop gallstones than men.
Women are much more likely to develop gallstones than men.
•
• This increased risk is likely caused by the effect of estrogen on
This increased risk is likely caused by the effect of estrogen on
the liver, causing it to remove more cholesterol from the blood
the liver, causing it to remove more cholesterol from the blood
and diverting it into the bile.
and diverting it into the bile.

Pathophysiolog
Pathophysiology
y
 To better understand these disorders, a brief discussion of the normal
To better understand these disorders, a brief discussion of the normal
structure and function of the biliary tree is needed.
structure and function of the biliary tree is needed.
 Bile is the exocrine secretion of the liver and is produced continuously by
Bile is the exocrine secretion of the liver and is produced continuously by
hepatocytes. It contains cholesterol and waste products, such as bilirubin
hepatocytes. It contains cholesterol and waste products, such as bilirubin
and bile salts, which aid in the digestion of fats. Half the bile produced
and bile salts, which aid in the digestion of fats. Half the bile produced
runs directly from the liver into the duodenum via a system of ducts,
runs directly from the liver into the duodenum via a system of ducts,
ultimately draining into the common bile duct (CBD). The remaining 50%
ultimately draining into the common bile duct (CBD). The remaining 50%
is stored in the gallbladder.
is stored in the gallbladder.
 In response to a meal, this bile is released from the gallbladder via the
In response to a meal, this bile is released from the gallbladder via the
cystic duct, which joins the hepatic ducts from the liver to form the CBD.
cystic duct, which joins the hepatic ducts from the liver to form the CBD.
The CBD courses through the head of the pancreas for approximately 2 cm
The CBD courses through the head of the pancreas for approximately 2 cm
before passing through the ampulla of Vater into the duodenum
before passing through the ampulla of Vater into the duodenum

Causes
Causes
 Causes of biliary obstruction can be separated into
Causes of biliary obstruction can be separated into
intrahepatic and extrahepatic.
intrahepatic and extrahepatic.
 intrahepatic causes are most commonly hepatitis and
intrahepatic causes are most commonly hepatitis and
cirrhosis, Drugs e.g thiazides, chlorpromazine,
cirrhosis, Drugs e.g thiazides, chlorpromazine,
augmentin, etc
augmentin, etc
 Extrahepatic causes may be further subdivided into
Extrahepatic causes may be further subdivided into
intrinsic, intraluminal, and extrinsic
intrinsic, intraluminal, and extrinsic

Obstructive Jaundice etiology and management the lect.ppt

Obstruction of common
bile duct leading to pain
& jaundice
May Complicate to
Charcot’s Triad:
1-Pain
2-Jaundice
3-Fever
Reynold’s Pentad:
1-Pain
2-Jaundice
3-Fever
4-Altered Mental State
5-Shock
Abdominal Ex:
1-Gall Bladder: in 80%Not Distended
When gall bladder be distended??
Murphy’s sign +ve
2-Liver:Enlarged?????

Incidence According to large study
Incidence According to large study

Causes of Cholestatic Jaundice
Causes of Cholestatic Jaundice
29
Intrahepatic
Intrahepatic Extrahepatic
Extrahepatic
Acute liver injury, Viral hepatitis
Acute liver injury, Viral hepatitis Choledocholithiasis
Choledocholithiasis
Alcohol hepatitis, Drugs
Alcohol hepatitis, Drugs Stone obstructing CBD, CD
Stone obstructing CBD, CD
Chronic liver injury, PBC, PSC
Chronic liver injury, PBC, PSC Biliary strictures
Biliary strictures
Autoimmune cholangiopathy
Autoimmune cholangiopathy Cholangiocarcinoma
Cholangiocarcinoma
Drugs, Total parenteral nutrition
Drugs, Total parenteral nutrition Pancreatic carcinoma
Pancreatic carcinoma
Systemic infection, Postoperative
Systemic infection, Postoperative Pancreatitis, Periampullary Ca
Pancreatitis, Periampullary Ca
Benign causes, Amyloid, lymphoma
Benign causes, Amyloid, lymphoma PSC, Biliary atresia, duct cysts
PSC, Biliary atresia, duct cysts
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Aetiology of obstructive jaundice
Aetiology of obstructive jaundice
Common
Common
 Common bile duct
stones
 Carcinoma of the head of
pancreas
 Malignant porta
hepatis lymph nodes
 Ampullary
carcinoma

Pancreatitis ,pseudocysts
 Benign strictures
 Iatrogenic, trauma
 Recurrent cholangitis
 Mirrizi's syndrome
 Sclerosing cholangitis
 Cholangiocarcinoma
 Biliary atresia
 Choledochal cysts

Drugs causing Cholestasis
Drugs causing Cholestasis
www.drsarma.in 31
 Anabolic steroids (testosterone, norethandrolone)
Anabolic steroids (testosterone, norethandrolone)
 Antithyroid agents (methimazole)
Antithyroid agents (methimazole)
 Azathioprine (Immunosuppressive drug)
Azathioprine (Immunosuppressive drug)
 Chlorpromazine HCI (Largactil)
Chlorpromazine HCI (Largactil)
 Clofibrate, Erythromycin estolate
Clofibrate, Erythromycin estolate
 Oral contraceptives (containing estrogens)
Oral contraceptives (containing estrogens)
 Oral hypoglycemics (especially chlorpropamide)
Oral hypoglycemics (especially chlorpropamide)

DDx: Conjugated Bilirubinemia
DDx: Conjugated Bilirubinemia
 Intrahepatic cholestasis/impaired excretion
Intrahepatic cholestasis/impaired excretion
 Hepatitis (viral, alcoholic, and non-alcoholic)
Hepatitis (viral, alcoholic, and non-alcoholic)
 Any cause of hepatocellular injury
Any cause of hepatocellular injury
 Primary biliary cirrhosis or end-stage liver dz
Primary biliary cirrhosis or end-stage liver dz
 Sepsis and hypoperfusion states
Sepsis and hypoperfusion states
 TPN
TPN
 Pregnancy
Pregnancy
 Infiltrative dz: TB, amyloid, sarcoid, lymphoma
Infiltrative dz: TB, amyloid, sarcoid, lymphoma
 Drugs/toxins i.e. chlorpromazine, arsenic
Drugs/toxins i.e. chlorpromazine, arsenic
 Post-op patient or post-organ transplantation
Post-op patient or post-organ transplantation
 Hepatic crisis in sickle cell disease
Hepatic crisis in sickle cell disease

DDx: Obstructive Jaundice
DDx: Obstructive Jaundice
Obstructive Jaundice– extrahepatic cholestasis
Obstructive Jaundice– extrahepatic cholestasis
 Choledocholithiasis
Choledocholithiasis (CBD or CHD stone)
(CBD or CHD stone)
 Cancer
Cancer (peri-ampullary or cholangioCA)
(peri-ampullary or cholangioCA)
 Strictures
Strictures after invasive procedures
after invasive procedures
 Acute and chronic
Acute and chronic pancreatitis
pancreatitis
 Primary sclerosing cholangitis (PSC)
Primary sclerosing cholangitis (PSC)
 Parasitic infections
Parasitic infections
 Ascaris lumbricoides, liver flukes
Ascaris lumbricoides, liver flukes
Just remember top 5 (not parasites)
Just remember top 5 (not parasites)

Common causes
Common causes
 Gallstones and carcinoma of pancreas
Gallstones and carcinoma of pancreas
 Rare cholangiocarcinoma, pancreatitis
Rare cholangiocarcinoma, pancreatitis
 USS > 90% gallstones
USS > 90% gallstones
 No gallstones or significant pain – CT
No gallstones or significant pain – CT
 Avoid knee-jerk ERCP
Avoid knee-jerk ERCP
 Serial LFTs vital – fluctuant or progressive
Serial LFTs vital – fluctuant or progressive
 GS in GB but history equivocal - MRCP
GS in GB but history equivocal - MRCP

Haemolytic Hepatocellular Obstructive
Long standing Constitutional
symptoms
Progressive
Low bilirubin levels Blood transfusion High bilirubin
levels
Anaemia Epidemic Pruritus
hepatosplenomegaly Exposure to
toxins
Wt. loss/malena
Ulcerations over legs Septicemia Abdominal lump
Splenomegaly Colour of stools
Previous biliary
surgery

ERCP
ERCP
Ampullary carcinoma
stone

Clinical Picture & Diagnosis
Diagnosis established by the triad:
Diagnosis established by the triad:
HISTORY
HISTORY
EXAMINATION
EXAMINATION
INVESTIGATIONS
INVESTIGATIONS

History of presenting illness
History of presenting illness
 •
• Gradually progressive jaundice
Gradually progressive jaundice
 •
• Recurrent episodes of itching
Recurrent episodes of itching
 •
• White stools for the last 2 months
White stools for the last 2 months
 •
• Dark yellow urine
Dark yellow urine
 •
• Generalized weakness & fatigability- 6
Generalized weakness & fatigability- 6
months
months
 •
• Weight loss in the last 1 year
Weight loss in the last 1 year
 •
• Reduced appetite
Reduced appetite
 •
• No fever
No fever

H/o past illness
• No h/o DM, HT, TB, Chest pain
• No previous surgery(no history of
cholelithiasis)
Personal History
• Decreased appetite with pale stools
• Normal bladder habits but deep
yellowish
• Smoker – 25 yrs
• Non-alcoholic

General Physical Examination
General Physical Examination
–
– Pulse 88/min, BP 110/70
Pulse 88/min, BP 110/70
–
– anemia +, Jaundice ++
anemia +, Jaundice ++
–
– No Lymphadenopathy
No Lymphadenopathy
–
– Scratch marks
Scratch marks
Per abdomen
Per abdomen
–
– Soft non-tender
Soft non-tender
–
– Gall bladder palpable
Gall bladder palpable
–
– No free fluid
No free fluid

 A. HISTORY:
A. HISTORY:
Age, sex, parity, habits
Age, sex, parity, habits
Occupation
Occupation 
sheep farmer
sheep farmer
hydatid
hydatid
Fam.hist.
Fam.hist.
 anae.,stones,splenect.(her.sph.)
anae.,stones,splenect.(her.sph.)
Pers.Hist.:Histort of bil.surg.
Pers.Hist.:Histort of bil.surg.
stricture/resid.stone
stricture/resid.stone
alcohol
alcohol 
cirrhosis, chr. Pancreatitis.
cirrhosis, chr. Pancreatitis.
drugs
drugs
chloropromazine hlysis/stasis
chloropromazine hlysis/stasis

Symptoms:
Symptoms:
-Jaundice:
-Jaundice: sudden
sudden:=stones,
:=stones, grad
grad=cirrho,,panc ca,
=cirrho,,panc ca,
progressive
progressive=malignant i
=malignant intermittent
ntermittent=stone,ca amp.
=stone,ca amp.
-Pain:
-Pain:painless
painless
-Fever & chills:
-Fever & chills: stasis & infection
stasis & infection
-Pruritis:
-Pruritis: bile salt irrit. Of cut nerves
bile salt irrit. Of cut nerves
-Wt. loss:
-Wt. loss: malig. / chr. Hep-cellular.
malig. / chr. Hep-cellular.

 B.EXAMINATION(signs)
B.EXAMINATION(signs)
/
/
General Local
General Local 

Depth of J
Depth of J.
.
 Lem. yellow=hlyt ,orange=Hep.cell deep=
Lem. yellow=hlyt ,orange=Hep.cell deep=
obst.
obst.
Anaemia
Anaemia
 malig./cirrhosis/ hlytic
malig./cirrhosis/ hlytic
L failure
L failure
palm erythema, spid. nevi,foetor hep
palm erythema, spid. nevi,foetor hep
gynecom., test atrophy, clubbing, flapping trermor
gynecom., test atrophy, clubbing, flapping trermor
Supra. LN
Supra. LN
metas.
metas. Skin
Skin
scratches
scratches Fever
Fever
itis,sept.
itis,sept.

Local signs:
Local signs:
Scar
Scar
 previous surg
previous surg. Caput med.
. Caput med.
PHT
PHT
Site of tend.(Murphy’s) GB
Site of tend.(Murphy’s) GB

 Liver
Liver 
 Hard nod= 2ries , small nod=
Hard nod= 2ries , small nod=
cirrhosis,smooth=cholestasis,tender=hitits
cirrhosis,smooth=cholestasis,tender=hitits

Spleen
Spleen 
 cong hlytic an, PHT
cong hlytic an, PHT
MASS
MASS
 hard irreg
hard irreg. Ascites
. Ascites 
malig & liver
malig & liver
PR
PR
colour ,1ry, deposits.
colour ,1ry, deposits.

Investigations
Investigations
 C. INVESTIGATIONS
C. INVESTIGATIONS:
:
Aim
Aim 
 define aetiology, assess cond.,
define aetiology, assess cond.,
proper ttt.
proper ttt.
LABORATORY
LABORATORY
IMAGING
IMAGING
ENDOSCOPIC
ENDOSCOPIC
HISTOPATH.
HISTOPATH.
SPECIFIC
SPECIFIC

Laboratory:
Laboratory:
LABORATORY:
LABORATORY:
1
1.
. CBC
CBC:
: 
WBC= cholangitis, anaem=Malig.
WBC= cholangitis, anaem=Malig.
spherocytosis, RC fragility, reticulocytes
spherocytosis, RC fragility, reticulocytes
glucose tol. Curve
glucose tol. Curve 
 dist in panc ca.
dist in panc ca.
urine
urine
 liquorice,
liquorice, 
bilirubin in ob, bile salts,
bilirubin in ob, bile salts,
no urobilinogen
no urobilinogen
stool
stool: clay colour, no or
: clay colour, no or 
stercobilin,
stercobilin,

fat, occult bld=malig.
fat, occult bld=malig.

Laboratory
Laboratory
 2.Liver Function tests:
2.Liver Function tests:

 Serum bilirubin
Serum bilirubin 
 total & direct> 20%
total & direct> 20%

Alk. Phosph.
Alk. Phosph. 
 35 KAU= calc ./ 50KAU= malig
35 KAU= calc ./ 50KAU= malig

Proth act.
Proth act. 
 Cholestatic & H cellular
Cholestatic & H cellular
correctable by vit K
correctable by vit K

ALT & ALA enz
ALT & ALA enz
5 nucleotidase &
5 nucleotidase & 
-GT
-GT

Laboratory
Laboratory
 3. Serum amylase:
3. Serum amylase:
N
N 
 calc.,
calc., 
pancitis. &malig.
pancitis. &malig.
4. Tumours markers:
4. Tumours markers:
+ve in malig.
+ve in malig.
 CA 19.9, CEA, panc.
CA 19.9, CEA, panc.
oncofoetal antigen
oncofoetal antigen

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
-ULTRA SOUND
-ULTRA SOUND
-CT & MRI
-CT & MRI
-Ba meal
-Ba meal
-CHOLANGIOGRAPHY
-CHOLANGIOGRAPHY
ERCP/PTC/MRCP
ERCP/PTC/MRCP
- D. LAPAROSCOPY
- D. LAPAROSCOPY

Plain x-ray abdomen
Plain x-ray abdomen

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
-
-ULTRASOUND
ULTRASOUND:
:
1 or X stones, intra or extra hep bil.dil
1 or X stones, intra or extra hep bil.dil
CBD caliber & thickness
CBD caliber & thickness
(
(>10mmw contrast or >7mm wout)
>10mmw contrast or >7mm wout)

panc. Head/ T at porta hep./Ascites/liver
panc. Head/ T at porta hep./Ascites/liver
-
-CT & MRI
CT & MRI:
: panc & retroperit.
panc & retroperit.
-
-Ba meal
Ba meal (
(hypot.duod)
hypot.duod)
wide D curve & inv 3 of ca amp
wide D curve & inv 3 of ca amp

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
 CHOLANGIOGRAPHY:
CHOLANGIOGRAPHY:
ERCP
ERCP 
low CBD
low CBD
advantage:
advantage:
D visualise bili passage & panc d
D visualise bili passage & panc d (db
(db
duct sign)
duct sign)
detect any path.
detect any path.
cytology
cytology
ttt sphincterotomy, stone extra,
ttt sphincterotomy, stone extra,
NB drainage, stenting
NB drainage, stenting
comps: pitis, perforation, bleeding
comps: pitis, perforation, bleeding

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
 PTC:
PTC: replaced by ERCP & MRCP
replaced by ERCP & MRCP
DIAGNOSIS
DIAGNOSIS
Stone
Stone 
 smooth crescent, filling defect
smooth crescent, filling defect
Stricture
Stricture 
 smooth tapered CBD
smooth tapered CBD
CBDT
CBDT 
 irreg. defect
irreg. defect
Ca head
Ca head 
 obst & dil.
obst & dil.
COMPS
COMPS
Peritonitis, he, cholangitis
Peritonitis, he, cholangitis

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
CBD filling defect (stone)
CBD filling defect (stone) Choledochal Cyst
Choledochal Cyst
PTC

IMAGING & ENDOSCOPY
IMAGING & ENDOSCOPY
 MRCP
MRCP
non invasive
non invasive
accurate diag.
accurate diag.
non operator dependent
non operator dependent
non therapeutic
non therapeutic

MRCP
MRCP

Non Contrast Angiography
Non Contrast Angiography 


MRCP
MRCP
Excellent visualization of
Excellent visualization of
intra luminal lesions , as
intra luminal lesions , as
well as clear anatomical
well as clear anatomical
imaging
imaging

SPECIAL TESTS
SPECIAL TESTS
SPECIAL TESTS:
SPECIAL TESTS:
 if biochemical point to:
if biochemical point to:
parenchymal
parenchymal
 liver biopsy & immunof.
liver biopsy & immunof.
obst J.:
obst J.: 
US
US 
D dil i.hep D
D dil i.hep D
GB, CBD, panc,Liver
GB, CBD, panc,Liver
CT
CT
panc lesion, obese, gases
panc lesion, obese, gases

SPECIAL TESTS
SPECIAL TESTS
 If Dilated i.hep. Duct:
If Dilated i.hep. Duct:
PTC(
PTC(coag profile,antibs)
coag profile,antibs) 
D & drain
D & drain
 Non dilated ducts or equivocal US
Non dilated ducts or equivocal US
ERCP + sphincterotomy or stone
ERCP + sphincterotomy or stone
removal
removal

Physical examination
Physical examination
 General : signs of liver cell failure
General : signs of liver cell failure
Spider naevi, palmer erythema,scanty axillary and pubic
Spider naevi, palmer erythema,scanty axillary and pubic
hair foetor hepaticus ,neurological changes
hair foetor hepaticus ,neurological changes
supraclavicular swelling(Virchow’s sign) scratch marks
supraclavicular swelling(Virchow’s sign) scratch marks
 Ascitis (associated ALD, Malignant)
Ascitis (associated ALD, Malignant)
 Hepatosplenomegaly Splenomegaly may be due to splenic
Hepatosplenomegaly Splenomegaly may be due to splenic
vein thrombosis secondary to pancreatic malignancy
vein thrombosis secondary to pancreatic malignancy
 Palpable Gall bladder ,Abdominal lump
Palpable Gall bladder ,Abdominal lump

Jaundice with distended palpable Gall bladder
Periampullary/Ca head of pancreas
Cholangiocarcinoma of lower CBD
Carcinoma Gallbladder
Jaundice without palpable gall bladder
Choledocholithiasis (shrunken Gall bladder)
Hilar cholangiocarcinoma
Nodes at porta hepatis

Courvoisier’s Law
Courvoisier’s Law
 If in a jaundiced
patient,the gall bladder is
palpable,
the case is not of stone
impacted in CBD for
previous cholecystitis
existed when stone was in
the gall bladder rendered
gall bladder fibrotic and
incapable of dilatation

Exceptions to Courvoisier’s law
Exceptions to Courvoisier’s law
 Double impaction
Double impaction
 Oriental
Oriental
Cholangiohepatitis
Cholangiohepatitis
 Earlier
Earlier
Cholecystectomy
Cholecystectomy
 Malignant nodes at
Malignant nodes at
Porta hepatis
Porta hepatis

Choledocholithiasi
s
Clinical Features
Cholangitis: Pain,Fever Jaundice,Shock
Cloudy Sensorium (Reynold’s Pentad)
Backache due to pancreatitis acholic stools pruritus
,high colored urine malnutrition and weight loss
Alkaline Phosphatase,raised liver Enzymes in
Cholangitis Leukocytosis
Real-Time Mode Ultrasound is the single most important
Investigation

Clinical classification Of Obstructive
Clinical classification Of Obstructive
Jaundice
Jaundice
(
(Benjamin Classification)
Benjamin Classification)

Type I: Complete obstruction
Type I: Complete obstruction
Classical symptoms with
Classical symptoms with
biochemical changes
biochemical changes
Tumors: Ca. head of
Tumors: Ca. head of
Pancreas
Pancreas
Ligation of the CBD
Ligation of the CBD
Cholangiocarcinoma
Cholangiocarcinoma
Parenchymal Liver
Parenchymal Liver
diseases
diseases

Type II: Intermittent obstruction
Type II: Intermittent obstruction
•
• Symptoms and typical
Symptoms and typical
biochemical changes
biochemical changes
•
• But jaundice may or may
But jaundice may or may
not be present
not be present
Choledocholithiasis
Choledocholithiasis
Periampullary tumor
Periampullary tumor
Duodenal diverticula
Duodenal diverticula
Choledochal Cyst
Choledochal Cyst
Papillomas of the bile duct
Papillomas of the bile duct
Intra biliary parasites
Intra biliary parasites
Hemobilia
Hemobilia

TYPE III: Chronic incomplete obstruction
TYPE III: Chronic incomplete obstruction
With or without classical symptoms but
With or without classical symptoms but
pathological changes are present in the
pathological changes are present in the
bile duct and liver
bile duct and liver
Strictures of the CBD
Strictures of the CBD
- Congenital
- Congenital
- Traumatic
- Traumatic
- Sclerosing cholangitis
- Sclerosing cholangitis
- Post radiotherapy
- Post radiotherapy
Stenosed biliary enteric anastamosis
Stenosed biliary enteric anastamosis
Cystic fibrosis
Cystic fibrosis
Chronic pancreatitis ERCP
Chronic pancreatitis ERCP
Stenosis of the Sphincter of Od
Stenosis of the Sphincter of Od
showing distal common
showing distal common
bile duct stricture
bile duct stricture

TYPE IV: Segmental Obstruction
TYPE IV: Segmental Obstruction
one or more segment of the intrahepatic biliary tract
one or more segment of the intrahepatic biliary tract
is obstructed
is obstructed
Traumatic
Traumatic
Sclerosing cholangitis
Sclerosing cholangitis
Intra hepatic stones
Intra hepatic stones
Cholangiocarcinoma
Cholangiocarcinoma

Pathophysiology Of
Pathophysiology Of
Obstructive Jaundice
Obstructive
Obstructive
jaundice is a
jaundice is a
condition in which
condition in which
there is blockage of
there is blockage of
the flow of bile out
the flow of bile out
of the liver. This
of the liver. This
results in an
results in an
overflow of bile and
overflow of bile and
its by-products into
its by-products into
the blood, and bile
the blood, and bile
excretion from the
excretion from the
body is incomplete
body is incomplete
 Hepatic functions
Hepatic functions
- Protein synthesis
- Protein synthesis, -
, - Reticulo-endothelial function -
Reticulo-endothelial function -
Hepatic metabolism Coagulation defect..
Hepatic metabolism Coagulation defect..increased
increased
prothrombin time(Decreased absroption of fat solube
prothrombin time(Decreased absroption of fat solube
vitamins A,D,E,
vitamins A,D,E,K
K(decreased factor XI ,XII ,platelets)
(decreased factor XI ,XII ,platelets)
 Renal functions - Renal vasoconstriction -
Renal functions - Renal vasoconstriction -
Activation of complement system causing
Activation of complement system causing peritubular
peritubular
and glomerular fibrin deposition leading to tubular and
and glomerular fibrin deposition leading to tubular and
cortical necrosis
cortical necrosis
 Cardiovascular effects -Decreased peripheral vascular
Cardiovascular effects -Decreased peripheral vascular
resistance - Bradycardia due to direct effect of bile
resistance - Bradycardia due to direct effect of bile
salts on SA node - Decreased cardiac contractability
salts on SA node - Decreased cardiac contractability
Delayed wound healing due to defective synthesis of
Delayed wound healing due to defective synthesis of
collagen
collagen

ROUTINE
ROUTINE Investigations
Investigations
 Haemoglobin usually decreased in case of malignancy
Haemoglobin usually decreased in case of malignancy
 •
• Rfts are usually arranged
Rfts are usually arranged

BIOCHEMICAL PROFILE
BIOCHEMICAL PROFILE
1. Conjugated bilirubin> increased
1. Conjugated bilirubin> increased
2. Urine bilirubin +
2. Urine bilirubin +
3. Urobilinogen will be absent
3. Urobilinogen will be absent
4. S.ALK PHOSPH RAISED
4. S.ALK PHOSPH RAISED (most sensitive, levels are
(most sensitive, levels are
elevated in nearly 100 % of patients with extrahepatic obstruction
elevated in nearly 100 % of patients with extrahepatic obstruction
except in some cases of intermittent obstruction. Values are
except in some cases of intermittent obstruction. Values are
usually greater than 3 times the upper limit of the reference
usually greater than 3 times the upper limit of the reference
range, and in most typical cases, they exceed 5 times the upper
range, and in most typical cases, they exceed 5 times the upper
limit)
limit)

BIOCHEMICAL PROFILE
BIOCHEMICAL PROFILE
5. GAMMA–GLUTAMYL TRANSPEPTIDASE(GGT) is a
5. GAMMA–GLUTAMYL TRANSPEPTIDASE(GGT) is a
sensitive marker of biliary tract disease is raised 6.5’nucleotidase
sensitive marker of biliary tract disease is raised 6.5’nucleotidase
is raised and it’s more specific
is raised and it’s more specific
7. ALT AST may rise
7. ALT AST may rise
8. Albumin decreased
8. Albumin decreased
9 . PT prolonged clotting factor decreased
9 . PT prolonged clotting factor decreased
10. RFTs are usually impaired
10. RFTs are usually impaired

Investigations
Investigations
Liver Function Tests
Alk.Phos.
Direct Hyperbilirubinemia
Serum Proteins
Normal Enzymes
Absent Urobilinogen in urine
Prolonged P.T.which returns to normal
after Vit.K admin.
Tumor markers like CA 19-9

Intra/Extra? Ultrasound Examination
C.T.
MRCP/ERCP
Site:
USG
ERCP
MRCP
EUS

Radiology
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?


– More sensitive than CT for gallbladder stones and
other pathology of gallbladder
– Sensitive for dilated ducts (Dilation of the
extrahepatic (>10 mm) or intrahepatic (>4 mm) bile
ducts suggests biliary obstruction.)
– Liver parenchymal mass and Mets
– Portable, cheap, no radiation,
– But it is operator dependant
-- Result is affected by bowel gas and Obesity.
Ultrasound Abdomen
Ultrasound Abdomen

Spiral CT Scan
Spiral CT Scan
 Contrast-enhanced triple phase helical abdominal CT scan. This should be
Contrast-enhanced triple phase helical abdominal CT scan. This should be
carried out with thin cuts to provide arterial (3mm cuts) and venous phase (3
carried out with thin cuts to provide arterial (3mm cuts) and venous phase (3
or 5mm cuts) cross sectional imaging Hypo dense lesion ,Dilated CBD and
or 5mm cuts) cross sectional imaging Hypo dense lesion ,Dilated CBD and
PD with or without pancreatic mass
PD with or without pancreatic mass
 Accurate assessment of spread,involvement of vessels Hepatic mets free
Accurate assessment of spread,involvement of vessels Hepatic mets free
fluid False +ve (10%)focal pancreatitis ,sarcoidosis Tuberculosis, lymphoma
fluid False +ve (10%)focal pancreatitis ,sarcoidosis Tuberculosis, lymphoma
secondary tumors
secondary tumors.
.
 MRI does not score over CT. Hypointense T1 weighted images,and Hyper
MRI does not score over CT. Hypointense T1 weighted images,and Hyper
intense T2 images. It detects vascular encasement. MRCP is can image the
intense T2 images. It detects vascular encasement. MRCP is can image the
CBD and PD without
CBD and PD without cannulation
cannulation

CT SCAN
CT SCAN
Main role in malignant conditions
Main role in malignant conditions
mainly for localization of primary
mainly for localization of primary
tumors and mets
tumors and mets
•
• Best for Pancreatic
Best for Pancreatic
Carcinoma(Highly sensitive for
Carcinoma(Highly sensitive for
lesion >1mm)
lesion >1mm)
•
•Mainly done when ultrasound
Mainly done when ultrasound
fail or when there is ductal
fail or when there is ductal
dilation on ultrasound also to find
dilation on ultrasound also to find
level and cause of obstruction and
level and cause of obstruction and
in malignant conditions
in malignant conditions

MAGNETIC RESONANCE
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
CHOLANGIOPANCREATOGRAPHY (MRCP)
•
• Noninvasive test to visualize
Noninvasive test to visualize
the hepatobiliary tree
the hepatobiliary tree
•
• Entire biliary tree and
Entire biliary tree and
pancreatic duct can be seen
pancreatic duct can be seen
•
• Best for Intra Hepatic stones
Best for Intra Hepatic stones
and CHOLEDOCHAL cysts
and CHOLEDOCHAL cysts
•
• SINGLE BEST FOR
SINGLE BEST FOR
CHOLANGIOCARCINOMA
CHOLANGIOCARCINOMA
•
• MRCP is better to determine
MRCP is better to determine
the extent and type of tumor as
the extent and type of tumor as
compared to ERCP
compared to ERCP

Endoscopic retrograde cholangiogram
(ERCP)
(ERCP)
 Its an invasive
Its an invasive
procedure and has
procedure and has
therapeutic potential
therapeutic potential.
.
 Allows biopsy or brush
Allows biopsy or brush
cytology
cytology
 Stone extraction or
Stone extraction or
stenting It’s
stenting It’s

(ERCP)
(ERCP)

COMPLICATIONS
COMPLICATIONS
 Pancreatitis
Pancreatitis
Cholangitis
Cholangitis
Hemorrhage
Hemorrhage
Sepsis
Sepsis

 CONTRAINDICATIONS
CONTRAINDICATIONS
Unfav anatomy
Unfav anatomy
 Pseudocyst
Pseudocyst
Rec a/c pancreatitis
Rec a/c pancreatitis

ERCP vs MRCP
ERCP vs MRCP
 Routine ERCP may not be required if diagnosis is certain on CT scan
Routine ERCP may not be required if diagnosis is certain on CT scan
 ERCP can provide direct visualization of ampullary tumor and biopsy can be
ERCP can provide direct visualization of ampullary tumor and biopsy can be
taken
taken
 Preop biliary drainage is required as a therapeutic measure under following
Preop biliary drainage is required as a therapeutic measure under following
circumstances
circumstances
 Severe cholangitis
Severe cholangitis
 Patients whose surgery is delayed due to sepsis ,abnormal coaglation or
Patients whose surgery is delayed due to sepsis ,abnormal coaglation or
malnutrition
malnutrition
 a mode of palliation for obstructive jaundice.
a mode of palliation for obstructive jaundice.
 MRCP gives information about site of obstruction without injection of contrast
MRCP gives information about site of obstruction without injection of contrast
 No therapeutic potential, no tissue diagnosis is possible
No therapeutic potential, no tissue diagnosis is possible

Percutaneous
Percutaneous
Transhepatic
Transhepatic
Cholangiogram (PTC)
Cholangiogram (PTC)
•
• PTC is indicated when
PTC is indicated when
percutaneous intervention
percutaneous intervention
is needed and ERCP either
is needed and ERCP either
is inappropriate or has
is inappropriate or has
failed.
failed.
•
• Can be used to drain
Can be used to drain
biliary obstructions.
biliary obstructions.

Other Investigations
Other Investigations
 •
• Oral Cholecystography (OCG)>>>
Oral Cholecystography (OCG)>>> useful when patient has
useful when patient has
symptoms of cholelithiasis, but a negative ultrasound.
symptoms of cholelithiasis, but a negative ultrasound.
 •
• also is useful for counting the number of stones present.
also is useful for counting the number of stones present.
 •
• HIDA SCAN- useful in a/c cholecystitis
HIDA SCAN- useful in a/c cholecystitis,
,
 •
• DIAGNOSTIC LAPAROSCOPY-
DIAGNOSTIC LAPAROSCOPY-
 •
• ANGIOGRAPHY- abnormal vasc.anatomy
ANGIOGRAPHY- abnormal vasc.anatomy
 •
• Tumor markers- CA19-9 , CEA
Tumor markers- CA19-9 , CEA

Endoscopic Ultrasound
Endoscopic Ultrasound
 Much Superior to Conventional CT & comparable with
Much Superior to Conventional CT & comparable with
Latest Generation spiral CT
Latest Generation spiral CT
 Can differentiate small stone from tumor in periampullary
Can differentiate small stone from tumor in periampullary
region
region
 Biopsies are possible
Biopsies are possible
 Highly Operator dependent,costly
Highly Operator dependent,costly
 Echoendoscope is bigger hence uncomfortable for the
Echoendoscope is bigger hence uncomfortable for the
patient
patient
 It is mainly useful for pancreatic imaging and biopsies
It is mainly useful for pancreatic imaging and biopsies
assessment of nodal involvement & Vascular encasement
assessment of nodal involvement & Vascular encasement
 Prior to endoscopic treatment of pseudocysts.
Prior to endoscopic treatment of pseudocysts.

Biopsy not possible Biopsy Possible

Management of Obstructive
Management of Obstructive
Jaundice
Jaundice

Initial Evaluation: History
Initial Evaluation: History
 Jaundice, acholic stools, tea-colored urine
Jaundice, acholic stools, tea-colored urine
 Fever/chills, RUQ pain (cholangitis)
Fever/chills, RUQ pain (cholangitis)
 Could lead to life-threatening septic shock
Could lead to life-threatening septic shock
 Reasons to have hepatitis or cirrhosis?
Reasons to have hepatitis or cirrhosis?
 Alcohol, Viral, risk factors for viral hepatitis
Alcohol, Viral, risk factors for viral hepatitis
 Exposure to toxins or offending drugs
Exposure to toxins or offending drugs
 Inherited disorders or hemolytic conditions
Inherited disorders or hemolytic conditions
 Recent blood transfusions or blood loss?
Recent blood transfusions or blood loss?
 Is patient septic or on TPN?
Is patient septic or on TPN?
 Recent gallbladder surgery? (CBD injury)
Recent gallbladder surgery? (CBD injury)

Initial Evaluation: Physical Exam
Initial Evaluation: Physical Exam
 Signs of end stage liver disease (cirrhosis)
Signs of end stage liver disease (cirrhosis)
 Ascites, splenomegaly, spider angiomata, and
Ascites, splenomegaly, spider angiomata, and
gynecomastia
gynecomastia
 Jaundice evident first underneath the tongue,
Jaundice evident first underneath the tongue,
also evident in sclerae or skin
also evident in sclerae or skin
 Courvoisier’s sign = painless, but palpable or
Courvoisier’s sign = painless, but palpable or
distended gallbladder on exam
distended gallbladder on exam
 Could indicate
Could indicate malignant
malignant obstruction
obstruction

Perioperative management of obstructive
Perioperative management of obstructive
jaundice
jaundice
 •
• Preoperative biliary decompression improves postoperative morbidity
Preoperative biliary decompression improves postoperative morbidity
(usually causes increased hemorrhage & infections and is mainly Indicated in
(usually causes increased hemorrhage & infections and is mainly Indicated in
severe jaundice or when there are signs of impending liver failure. Endoscopic
severe jaundice or when there are signs of impending liver failure. Endoscopic
internal drainage is preferred over per-cutaneous external drainage
internal drainage is preferred over per-cutaneous external drainage
 •
• Intravenous administration of 5% dextrose saline followed by
Intravenous administration of 5% dextrose saline followed by
10%mannitol or loop diuretics to prevent renal failure(12 to 24 hours
10%mannitol or loop diuretics to prevent renal failure(12 to 24 hours
prior to surgery)
prior to surgery)
 •
• catheterization to monitor output
catheterization to monitor output
 •
• Broad spectrum antibiotic prophylaxis
Broad spectrum antibiotic prophylaxis
 •
• Parenteral vitamin K +/- fresh frozen plasma
Parenteral vitamin K +/- fresh frozen plasma
 •
• Need careful post-operative fluid balance to correct dehydration
Need careful post-operative fluid balance to correct dehydration
 •
• Correction of hypokalemia
Correction of hypokalemia
 •
• Cholestyramine and antihistamine for symptomatic relief of pruritis
Cholestyramine and antihistamine for symptomatic relief of pruritis

Summary of Treatment of
Summary of Treatment of
based on the cause
based on the cause

Treatment of Obstructive Jaundice is
Treatment of Obstructive Jaundice is
based on the cause
based on the cause
1) Cholelithiasis (gallstones
1) Cholelithiasis (gallstones)
)
Ideally ERCP followed by laparoscopic
Ideally ERCP followed by laparoscopic
Cholecystectomy Or open cholecystectomy with
Cholecystectomy Or open cholecystectomy with
CBD exploration
CBD exploration

2) Ca Head of Pancreas / Periampullary
2) Ca Head of Pancreas / Periampullary
Carcinoma/malignancy
Carcinoma/malignancy
of lower 3rd of CBD
of lower 3rd of CBD
a) Whipple resection
a) Whipple resection
(pancreaticoduodenectomy) is
(pancreaticoduodenectomy) is
mainly done which involves
mainly done which involves
removal of the
removal of the head & neck of
head & neck of
pancreas, duodenum, distal
pancreas, duodenum, distal
40% of the stomach, lower
40% of the stomach, lower
CBD, GB, upper 10 cm of
CBD, GB, upper 10 cm of
jejunum, regional L.Ns, and
jejunum, regional L.Ns, and
reconstruction through
reconstruction through
gastrojejunostomy,
gastrojejunostomy,
choledochojejunostmy and
choledochojejunostmy and
pancreaticojejunostomy
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
extrahepatic biliary tree
 Biliary drainage is accomplished by Choledocho–
jejunostomy with a Roux – en – Y anastomosis
 Long-term follow-up is necessary because of
complications like cholangitis, lithiasis, anastomotic
stricture

5) Cholangiocarcinoma
5) Cholangiocarcinoma
Surgery depends on the stage of the tumor and may involve
Surgery depends on the stage of the tumor and may involve
Removal of the bile ducts
Removal of the bile ducts If the tumor is at a very early stage (Stage 1), just
If the tumor is at a very early stage (Stage 1), just
the bile ducts containing the cancer are removed. The remaining ducts in the
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.
liver are then joined to the small bowel, allowing the bile to flow again.
Partial liver resection
Partial liver resection If the tumor has begun to spread into the liver, the
If the tumor has begun to spread into the liver, the
affected part of the liver is removed, along with the bile ducts.
affected part of the liver is removed, along with the bile ducts.
Whipple procedure
Whipple procedure If the tumor is larger and has spread into nearby
If the tumor is larger and has spread into nearby
structures, the bile ducts, part of the stomach, part of the small bowel
structures, the bile ducts, part of the stomach, part of the small bowel
(duodenum), the pancreas, gall bladder, and the surrounding lymph nodes are
(duodenum), the pancreas, gall bladder, and the surrounding lymph nodes are
all removed
all removed
If surgery to remove the tumor is not possible
If surgery to remove the tumor is not possible, it may be possible to
, it may be possible to
relieve the blockage through stents through ERCP or PTC
relieve the blockage through stents through ERCP or PTC

6)Choledocholithiasis
6)Choledocholithiasis (stones in the CBD)
(stones in the CBD)
a)Treatment of choice is stone extraction through ERCP
a)Treatment of choice is stone extraction through ERCP
b)
b) Mechanical lithotripsy – through modified Dormia basket
Mechanical lithotripsy – through modified Dormia basket
c)Through shock waves laser technology
c)Through shock waves laser technology
d)Open exploration of the common bile duct is indicated in
d)Open exploration of the common bile duct is indicated in


Presence of multiple stones (more than 5) and Stones > 1 cm
Presence of multiple stones (more than 5) and Stones > 1 cm

Multiple intrahepatic stones
Multiple intrahepatic stones

Distal bile duct strictures
Distal bile duct strictures

Failure of ERCP
Failure of ERCP

Recurrence of CBD stones
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
Prognostic factors
( Pitt’s score)
( Pitt’s score)
Parameters
Parameters
Type of obstruction
Type of obstruction
(malignant or benign)
(malignant or benign)
Age > 60 yrs
Age > 60 yrs
S.Alb< 3gm/dl
S.Alb< 3gm/dl
S.Bil > 10mg%
S.Bil > 10mg%
S.Alk P > 100 IU
S.Alk P > 100 IU
S.Creatinine >1.3mg%
S.Creatinine >1.3mg%
TLC >10000/mm3
TLC >10000/mm3
Hematocrit <
Hematocrit < 30%
30%
Factors Mortality
Factors Mortality
Up to 2 0%
Up to 2 0%
3 4%
3 4%
4 7%
4 7%
5 44%
5 44%
6 67%
6 67%
8 100%
8 100%

Choledocholithiasis known before Surgery
Clear the common bile duct with an initial
Endoscopic papillotomy followed by
laparoscopic cholecystectomy.
Open Cholecystectomy with common bile duct
exploration.
Lap. Chole with Lap CBD Exploration
History & Pre-op. Investigations
Therapeutic Options

Choledocholithiasis Identified
during Cholecystectomy.
(1) Conversion to an open operation with
Common bile duct exploration,
(2) Laparoscopic common bile duct exploration,
(3) completion of the laparoscopic cholecystectomy
with postoperative endoscopic sphincterotomy
and stone extraction
Lap.U.S.
Cholangiogram
Transcystic
Choledochoscopy
Therapeutic Options

Choledocholithiasis Identified After
Cholecystectomy.
Theses patients are best managed with
endoscopic sphincterotomy and stone extraction.
If a T tube is still present from a recent common bile
duct exploration radiologic extraction of the stone
via the T tube tract is usually possible
Open Surgery is usually avoided
Therapeutic Options

Interventional Radiology
For retrieving the stone from
CBD by balloon Catheter

Imaging for Obstructive Jaundice
Imaging for Obstructive Jaundice
 RUQ Ultrasound
RUQ Ultrasound
 See stones, CBD diameter
See stones, CBD diameter
 CT scan
CT scan
 Identify both type & level of obstruction
Identify both type & level of obstruction
 ERCP
ERCP
 Direct visualization of biliary tree/panc ducts
Direct visualization of biliary tree/panc ducts
 Procedure of choice for choledocholithiasis
Procedure of choice for choledocholithiasis
 Diagnostic –AND- therapeutic (unlike MRCP)
Diagnostic –AND- therapeutic (unlike MRCP)
 PTC useul of obstruction is prox to CHD
PTC useul of obstruction is prox to CHD
 Endoscopic Ultrasound or EUS
Endoscopic Ultrasound or EUS

Extra-hepatic cholestasis:
Pancreatic tumor
Pancreatic tumor -
- Tumor Detection
Tumor Detection
 Focal enlargement of the gland
Focal enlargement of the gland
 Hypodense mass on enhanced CT
Hypodense mass on enhanced CT
Secondary signs
Secondary signs:
:
 Mass effect or convex contour abnormality
Mass effect or convex contour abnormality
 Atrophic distal pancreatic parenchyma
Atrophic distal pancreatic parenchyma
 Dilatation of CBD and MPD in the absence of obstructive
Dilatation of CBD and MPD in the absence of obstructive
calculus (interupted duct sign)
calculus (interupted duct sign)

Ampulary tumor
Ampulary tumor
 Malignant epithelial tumor , ampula of vater
Malignant epithelial tumor , ampula of vater
 Presents with jaundice, weight loss. Abd or
Presents with jaundice, weight loss. Abd or
back pain
back pain
 Age: mean 65 yrs, no sex predeliction
Age: mean 65 yrs, no sex predeliction
 Prognosis: depends on nodeal status and
Prognosis: depends on nodeal status and
differentiation of tu, better than panc ca
differentiation of tu, better than panc ca
5 yrs- 38% if resected
5 yrs- 38% if resected
Treatment: Whipple if pos.
Treatment: Whipple if pos.

Ampulary tumor
Ampulary tumor
 Imaging:
Imaging:
 Lobulated soft tissue mass at ampula
Lobulated soft tissue mass at ampula
 “
“Double duct” sign
Double duct” sign
 CT: Hypodense mass , distention of du helpful
CT: Hypodense mass , distention of du helpful

Cholangiocarcinoma
Cholangiocarcinoma
 US: dilated BD, mass hyperechogenic(75%)
US: dilated BD, mass hyperechogenic(75%)
 CT: hypodense mass, IHBD dilatation, rim
CT: hypodense mass, IHBD dilatation, rim
enhancement with prog central patchy
enhancement with prog central patchy
enhancement, persistent enhancement on
enhancement, persistent enhancement on
delayed scan
delayed scan

Gallstone disease
 15%-20% of the population
15%-20% of the population
 Passage of gallstones through
Passage of gallstones through
biliary system causes ----->
biliary system causes ----->
 Biliary colic
Biliary colic
 Acute cholecystitis
Acute cholecystitis
 Choledocholithiasis
Choledocholithiasis
 Cholecystoenteric fistula
Cholecystoenteric fistula

Biliary stone disease - summary
Biliary stone disease - summary
 US is the modality of choice for demonstrating gallstones.
US is the modality of choice for demonstrating gallstones.
 US is the very good for demonstrating biliary ducts.
US is the very good for demonstrating biliary ducts.
 CT will show biliary ducts, less reliable for filling defects. Good
CT will show biliary ducts, less reliable for filling defects. Good
for neoplastic disease.
for neoplastic disease.
 MRCP is the non invasive study
MRCP is the non invasive study
 ERCP is invasive but potentially therapeutic.
ERCP is invasive but potentially therapeutic.
 PTC even more invasive, when ERCP is limited.
PTC even more invasive, when ERCP is limited.

Extra-hepatic cholestasis: Cholelithiasis
Cholelithiasis
 Sensitivity 90%-95%
Sensitivity 90%-95%
 Variable SI
Variable SI
 Water/lipids contents
Water/lipids contents
 Elevated SI on T2 in
Elevated SI on T2 in
center (
center (
 50%)
50%)
Elevated SI on T1 (
Elevated SI on T1 (
 90%)
90%)
Co
Co, Fe, Mg
, Fe, Mg
(pigmented gallstones
(pigmented gallstones
[Ca
[Ca++
++
Bilirrubinate])
Bilirrubinate])
Ukaji M
Ukaji M et al.
et al. Eur J Radiol 2002 Jan;41(1):49-56
Eur J Radiol 2002 Jan;41(1):49-56

CT:Intrahepatic biliary dilatation
CT:Intrahepatic biliary dilatation

 Sphincteerotomy
Sphincteerotomy

ERCP :
ERCP :
Stone extraction
Stone extraction

Choledocholithiasis
Choledocholithiasis
 Asymptomatic
Asymptomatic
 Symptoms: calculi in distal CBD (90%)
Symptoms: calculi in distal CBD (90%)
 CBD stones
CBD stones
 15% pts. with gallstones
15% pts. with gallstones
 15% pts. with acute cholecystitis
15% pts. with acute cholecystitis
 Diagnosis pre laparoscopic cholecystectomy
Diagnosis pre laparoscopic cholecystectomy
 ERCP
ERCP
 Stones in only 27-50% of pts with clinical suspicion
Stones in only 27-50% of pts with clinical suspicion

Choledocholithiasis MR
Choledocholithiasis MR
 Normal CBD
Normal CBD
 98% of the pts
98% of the pts
 Foci of low SI surrounded by
Foci of low SI surrounded by
bright bile (T2-WI)
bright bile (T2-WI)
 Stones
Stones 
 2 mm
2 mm
 CBD stones
CBD stones
 Sensitivity 85-100%
Sensitivity 85-100%
 Specificity 90-99%
Specificity 90-99%
 Accuracy 89-97%
Accuracy 89-97%
 PPV 77-93%
PPV 77-93%
 NPV 94-100%
NPV 94-100%

Retrograde Cholangiogram - ERCP
Bile leak from the cystic duct after cholecystectomy
Courtesy of Michael Kimmey, M.D.

Primary sclerosing cholangitis (PSC) with stricture due to
cholangiocarcinoma. Courtesy of Robert L. Carithers, Jr., M.D.

Primary Sclerosing Cholangitis
Primary Sclerosing Cholangitis
Normal Extra hepatic BD
Narrowed abnormal
intra-heptic bile ducts.

Irregular dilation of intrahepatic and extrahepatic ducts.
Courtesy of Charles Rohrmann, M.D.

Biliary tree imaging modalities: ERCP,
MRCP, PTC
MRCP, PTC
 MRCP –specific MR
MRCP –specific MR
sequence is employed
sequence is employed
to demonstrate the
to demonstrate the
biliary tree.
biliary tree.
 No IV contrast and
No IV contrast and
definitely no biliary
definitely no biliary
cannulation involved.
cannulation involved.

Magnetic Resonance Cholangio-
Magnetic Resonance Cholangio-
Pancreatography (MRCP)
Pancreatography (MRCP)
Two stones in the common bile duct
Two stones in the common bile duct
Courtesy of Udo Schmiedl, M.D.
Courtesy of Udo Schmiedl, M.D.

MRCP, PTC
MRCP, PTC
 PTC – direct
PTC – direct
cannulation of the
cannulation of the
biliary tree, and
biliary tree, and
iodinated contrast
iodinated contrast
injection.
injection.
 Advantageous over
Advantageous over
MRCP for showing
MRCP for showing
distal, small duct
distal, small duct
pathology and
pathology and
walls irregularity.
walls irregularity.

PTC
PTC
Percutaneous access to
Percutaneous access to
the biliary tree, through the
the biliary tree, through the
CBD, if possible, and into
CBD, if possible, and into
the duodenum.
the duodenum.
Downsides:
Downsides:
 External drainage
External drainage
 Procedural risks:
Procedural risks:
 Coagulopathy
Coagulopathy
 ascites
ascites

Treatment of Choledocholithiasis:
Treatment of Choledocholithiasis:
Preoperative Preparation:
Correct Clotting Dysfunction
Guard vs LCF
Guard vs RF
Definitive Treatment:
Remove Source of Obstruction (stone)
Remove Source of Stone (Gall bladder)
Reynold’s
Pentad
Obstructive Jaundice Charcot’s Triad
Chronic cholecystitis
Treatment
ttt
Of
Shock
3
rd
Generation
Cephalosporin
ERCP
Cholecystectomy

Carcinoma of head of pancreas
Symptoms Signs
Cachecxia
Criteria of obstructive jaundice
Pain which is common, characterized by starting as
vague (Lower abdomen or back)
Usually worsen in supine position & relived by lining
forward
It may be caused by
:
A) Tumor invasion of splanchnic plexuses
&
retroperitoneum
B) Obstruction of pancreatic duct
Digestive symptoms
Jaundice
Palpable liver
Palpable gall bladder
Tenderness
Ascites
Abdominal mass
In advanced cases
:
Nodular liver
Enlarged supraclavicular
lymph node
Periumblical adenopathy

Diagnosis & management of pancreatic cancer
:
It depends on results of
Spiral CT
1
)
Resectable: ask yourself if operative candidate or not
a)YES :Explore for resection
b) NO: =NONOPERATIVE: Palliation, Biliary stent &
Chemo/Radiotherapy
2
)
Unresectable: is it only Biliary or associated with
duodenal obstruction
a)only Biliary:Endobiliary stent
b)Both: Operative palliation(Biliary bypass)
Gastrojejunostomy
Celiac plexus block

Whipple operation:
Whipple operation:

Conclusion
Conclusion
•
• There are certain signs and symptoms common to all jaundiced patients (yellow
There are certain signs and symptoms common to all jaundiced patients (yellow
skin, itching).
skin, itching).
•
• Specific items from the history and physical examination along with blood work
Specific items from the history and physical examination along with blood work
can help the clinician classify jaundice into obstructive and nonobstructive
can help the clinician classify jaundice into obstructive and nonobstructive
jaundice.
jaundice.
•
• Surgical or other mechanical intervention almost exclusively is restricted to cases
Surgical or other mechanical intervention almost exclusively is restricted to cases
of obstructive (posthepatic) jaundice.
of obstructive (posthepatic) jaundice.
•
• Imaging evaluation of the gallbladder and biliary system plays an important role
Imaging evaluation of the gallbladder and biliary system plays an important role
in the evaluation of obstructive jaundice by locating the site and disclosing the
in the evaluation of obstructive jaundice by locating the site and disclosing the
nature of the obstruction.
nature of the obstruction.
•
• Ultrasound imaging usually is the first step for suspected biliary stone disease.
Ultrasound imaging usually is the first step for suspected biliary stone disease.
•
• The physician’s level of suspicion about benign versus malignant causes of
The physician’s level of suspicion about benign versus malignant causes of
obstructive jaundice will lead to different radiologic tests and interventions.
obstructive jaundice will lead to different radiologic tests and interventions.
•
• Treatment is tailored to the cause of obstruction
Treatment is tailored to the cause of obstruction.
.

Obstructive Jaundice etiology and management the lect.ppt

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