approach to a case of obstructive jaundice and the rationale of doing these investigations a simplified approach

1. INVESTIGATIONS AND THEIR
RATIONALE
IN OBSTRUCTIVE JAUNDICE

2. INTRODUCTION
Jaundice, or icterus, is a yellowish discoloration of tissue
resulting from the deposition of bilirubin.
Tissue deposition of bilirubin occurs only in the presence of
serum hyperbilirubinemia and is a sign of either liver disease or,
less often, a hemolytic disorder

3. I. INDIRECT HYPERBILIRUBINEMIA
A. Hemolytic disorders
1. Inherited
a. Spherocytosis, elliptocytosis
Glucose-6-phosphate dehydrogenase and pyruvate kinase deficiencies
b. Sickle cell anemia
2. Acquired
a. Microangiopathic hemolytic anemias
b. Paroxysmal nocturnal hemoglobinuria
c. Spur cell anemia
d. Immune hemolytic
B. Ineffective erythropoiesis
1. Cobalamin, folate, thalassemia, and severe iron deficiencies
C. Drugs
1. Rifampicin, probenecid, ribavirin
D. Inherited conditions
1. Crigler-Najjar types I and II
2. Gilbert's syndrome
II. DIRECT HYPERBILIRUBINEMIA
A. Inherited conditions B. Acquired conditions C. Extra hepatic obstrn
1. Dubin-Johnson syndrome
2. Rotor's syndrome

4. CAUSES
Intrahepatic extrahepatic
intraductal extraductal Cirrhosis
 Hepatitis
 Drugs  Neoplasm
 Stone disease
 Biliary stricture
 Parasites
 PSC
 Aids related
cholangiopathy
 Biliary TB
 Secondary
to neoplasm
 Pancreatitis
 Cystic duct
stones

5. drugs
cholestasis
gallstone
Acute
cholestatic
injury
Hepatocellular
necrosis
• Anabolic steroids
• chlorpromazine
• Thiazide
diuretics
• amoxyclav
• Acetaminophen
• isoniazid
 Typically, drug-induced jaundice appears early with
associated pruritus, but the patient's well-being shows
little alteration.
 Generally, symptoms subside promptly when the
offending drug is removed

6. Clinical classification Of Obstructive
Jaundice
(Benjamin Classification)

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

8. 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

9. TYPE III : Chronic incomplete
obstruction
With 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
Stenosis of the Sphincter of Oddi

10. TYPE IV : Segmental Obstruction
one or more segment of intrahepatic biliary tract
is obstructed
Traumatic
Sclerosing cholangitis
Intra hepatic stones
Cholangio carcinoma

11. INVESTIGATIONS IN OBSTRUCTIVE
JAUNDICE
LABORATORY
INVESTIGATIONS
RADIOLOGICAL
INVESTIGATIONS

12. Goals
of investigations
Determine
level of
obstruction
Severity of
jaundice
Ductal
dilatation
jaundice
Cause of
obstruction

13. ROUTINE INVESTIGATIONS
1. HB
2. TLC
3. DLC
4. RFT ( serum urea, serum creatinine, serum sodium, serum
potassium )
5.BLOOD SUGAR

14. TESTS FOR ASSESSMENT OF LIVER FUNCTION

15. Tests for liver functioning
Based on
detoxification
& excretory
function
Enzymes
indicating
liver injury
Measure
biosynthetic
function
Damage to
hepatocytes
cholestasis
Serum
bilirubin
Urine
bilirubin
Blood
ammonia Aspartate
aminotransferase
Alanine
aminotransferase
Alkaline
phosphatase
5 nucleotidase
GGT
Serum albumin
Serum globulin
Coagulation
factors

16.  Bilirubin
Rise by 25-43 micromol/litre/day
Mechanism of hyperbilirubinemia
--- Biliary venous & biliary regurgitation of conjugated bilirubin due to
disruption of tight intracellular junction
--- Trans hepatocytic regurgitation due to reversal of the secretory
polarity of hepatocytes
--- Rupture of dilated canaliculi in to sinusoids due to necrosis of
hepatocytes

17. BILIRUBIN METABOLISM

18. SGOT AND SGPT LEVELS
SGOT (AST)/ ASPARTATE TRANSAMINASE
* Marker for hepatocellular toxicity
* Along with ALT is considered biomarker for liver health
* Non specific
* 2 isoenzymes
* Normal Values….
MALES 8-40 IU/L
FEMALES 6-34 IU/L

19. SGPT ( ALT ) / ALANINE AMINOTRANSFERASE
* Better predictor of hepatic injury than SGOT alone
* Significant elevations in HEPATITIS
INFECTIOUS MONONUCLEOSIS
CHF
* NORMAL VALUES IN
MALES < 50 IU/L
FEMALES < 32 IU/L

20. ALKALINE PHOSPHATSE
*Most sensitive indicator Of EXTRA HEPATIC BILIARY OBSTRUCTION
* Factor responsible are
Biliary component regurgitation
Increase in hepatic synthesis
* Biliary component is secreted by BILIARY DUCTULAR ENDOTHELIUM
* Normal range 20-140 IU/L
* May remain elevated for a long time even after the obstruction is
relieved

21. GAMMA GLUTAMYL TRANSFERASE & 5’NUCLEOTIDASE
GGT
* Predominantly used as a marker for liver diseases
* enhanced sensitivity for detection of BILIARY OBSTRUCTION if
correlated with ALKALINE PHOSPHATASE
* NORMAL VALUE 0-51 IU/L
5’ NUCLEOTIDASE
* An enzyme synthesized in liver
* Values if grossly elevated is indicative of biliary obstruction
* NORMAL VALUE 2-17 UNITS/L

22. Measure biosynthetic function
serum albumin
normal value 3.5 – 5.5 gm /dl
prothrombin time
normal value 12 – 14 sec

23. URINE ANALYSIS
1 Bile salts
2 Bile pigments
3 Urobilinogen
STOOL EXAMINATION
1 Occult blood

24. RADIOLOGICAL EVALUATION OF BILIARY TRACT
INTRA OP METHODSPRE OPERATIVE METHODS
PLAIN ABDOMINAL X RAY
ABDOMINAL USG
ENDOSCOPIC USG
CT
M R C P
ERCP
PTC
BILIARY SCINTILLOGRAPHY
PER OP
CHOLANGIOGRAPHY
INTRA OP BILIARY
ENDOSCOPY
LAPROSCOPIC USG

25. 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

26. PLAIN X RAY
* Cholelithiasis in 10-20 % of patients with radio opaque stones
* Radiolucent gas in a BI and TRI RADIATE FISSURE, in centre of
stone
* May sometimes show rare cases of calcification of GB
(PORCELAIN GB )
* Gas in wall of GB ( EMPHYSEMATOUS CHOLECYSTITIS)
* SPECKLED CALCIFICATION in the head of pancreas suggestive
of CHRONIC PANCREATITIS
* DUCT DILATATION WILL NOT BE REVEALED IN PLAIN FILMS

27. RADIO OPAQUE STONES IN GALL BALDDER

28. PORCELAIN GALL BLADDER

29. GAS IN GALL BLADDER AND ITS WALLS

30. ABDOMINAL ULTRASONOGRAPHY
* Is the initial imaging modality of choice as
- it is accurate
- readily available
- quick to perform
- inexpensive
OPERATOR DEPENDANT AND MAY GIVE SUBOPTIMAL RESULTS DUE TO
EXCESSIVE BODY FAT AND BOWEL GAS
* Biliary obstruction is characterized by BILIARY DILATATION
THIS DILATATION MAY BE CONSPICUOUSLY ABSENT IN 15 % OF
PATIENTS
* Prospective evaluation of USG suggests that level of obstruction can be
defined in 90 % of the cases

31. * COLOR FLOW DOPPLER SONOGRAPHY may assist in distinguishing dilated
ducts from Portal venous and Hepatic arterial branches
* Provides useful information about the nature and etiology of BILIARY
OBSTRUCTION
* Mass lesion visualization is possible
THE RELIABILITY WITH WHICH A BENIGN DISEASE MAY BE
DISTINGUISHED FROM A MALIGNANT PROCESS REMAINS UNCLEAR
*Upper limits of normal diameter of
CBD-8mm
CHD-6mm

33. ENDOSCOPIC ULTRASOUND (EUS)
Combines Endoscopy and US
Higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs. 20 MHz)
and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-
FNA).
EUS has been reported to have up to a 98% diagnostic accuracy in patients with
obstructive jaundice
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 biliary stricture, EUS has been reported to be
more specific (100% vs. 76%) and to have a much greater positive predictive value
(100% vs. 25%), although the two have equal sensitivity (67%).
The positive yield of eus-fna for cytology in patients with malignant obstruction has
been reported to be as high as 96%.

34. Endoscopic ultrasonography.
CBD, common bile duct; PD, pancreatic duct.

35. COMPUTED TOMOGRAPHY
* Unlike USG CT is less affected by body habitus and is less operator
dependant
* It allows visualisation of the liver,
bile ducts, gall bladder and pancreas and is particularly
useful in detecting hepatic and pancreatic lesions and
is the modality of choice in the staging of cancers of the liver,
gall bladder, bile ducts and pancreas.
* It can identify the extent
of the primary tumour and defines its relationship to other
organs and blood vessels
*Improvements in CT technology, such as multidetector scanners,
which allow for three-dimensional reconstruction of the
biliary tree have led to greater diagnostic accuracy and have
increased the accuracy of CT in assessing benign disease.

36. Computed tomography scan demonstrating a
gallstone
within the gall bladder (arrowed).

37. Computed tomography scan demonstrating a hilar mass.

38. Intraductal stones appear as target sign on ct
CT. 75-88% sensitive, 97%specific for Choledocholithiasis
79%sensitive, 100% specific for gallstones

39. .
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
•Noninvasive test to visualize the hepato biliary tree
•No contrast
•Fluid found in the biliary tree is hyper intense on T2-weighted images.
Surrounding structures do not enhance and can be suppressed during image
analysis.
•Sensitive in detecting biliary and pancreatic duct stones, strictures, or dilatations
within the biliary system.
•MRCP combined with conventional MR imaging of the abdomen can provide
information about surrounding structures (eg, pseudocysts, masses).
• ERCP and MRCP similarly effective in detecting malignant hilar and perihilar
obstruction
• MRCP is better able to determine the extent and type of tumor as compared to
ERCP

40. Absolute contraindications
cardiac pacemaker
cerebral aneurysm clips
ocular or cochlear implants
Fluid stasis in the adjacent duodenum or ascitic fluid
may produce image artifacts on MRCP, making it
difficult to clearly visualize the biliary tree.

41. MRCP Showing Choledocholithiasis

42. MRCP is also highly
accurate
 MRCP sensitivity
88-92%, specificity
91-98% in detecting
Choledocholithiasis

43. Endoscopic retrograde cholangio
pancreatography (ERCP )
 Its an invasive procedure
and has therapeutic
potential.
 Allows biopsy or brush cytology
 Stone extraction or stenting
COMPLICATIONS
 Pancreatitis
 Cholangitis
 Hemorrhage
 Sepsis
CONTRAINDICATIONS
 Unfavorable anatomy
 Pseudo cyst
 Red a/c pancreatitis

44. ERCP film showing Choledocholithiasis

45. Endoscopic retrograde cholangiopancreatography: partial
occlusion of the bile duct by a malignant stricture

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

47. Transhepatic cholangiogram showing a stricture of the
common hepatic duct

48. Radioisotope scanning
* Technetium-99m (99mTc)-labelled derivatives of iminodiacetic
acid (HIDA, IODIDA) when injected intravenously are selectively
taken up by the retroendothelial cells of the liver and
excreted into the bile.
* This allows for visualisation of the biliary
tree and gall bladder. In 90 per cent of normal individuals the
gall bladder is visualised within 30 minutes following injection
with 100 per cent being seen within 1 hour
* Non-visualisation of the gall bladder is suggestive of acute
cholecystitis. If the patient has a contracted gall bladder as often
seen in chronic cholecystitis, the gall bladder visualisation may
be reduced or delayed.
*Biliary scintigraphy may also be helpful in diagnosing bile
leaks and iatrogenic biliary obstruction.

49. It can identify and quantitate the leak thus helping the surgeon
determine whether or not an operative or conservative approach
is warranted
Dimethyl iminodiacetic acid (HIDA) scan.

50. INTRA OPERATIVE TECHNIQUES
A. PER OPERATIVE CHOLANGIOGRAPHY
* During open or laparoscopic cholecystectomy, a catheter can be
placed in the cystic duct and contrast injected directly into the
biliary tree. The technique defines the anatomy and in the main
is used to exclude the presence of stones within the bile ducts
*A single x-ray plate or image
intensifier can be used to obtain and review the images intraoperatively
*In addition, care should be
taken when injecting contrast not to introduce air bubbles into
the system as these may give the appearance of stones and lead
to a false-positive result

51. Normal common bile duct: gentle The common bile duct is dilated
infusion of contrast with multiple Stones
which passes without hindrance
into the duodenum.

52. Operative biliary endoscopy (choledochoscopy)
* At operation, a flexible fibre optic endoscope can be passed via
the cystic duct into the common bile duct enabling stone identification
and removal under direct vision
* The technique can
be combined with an x-ray image intensifier to ensure complete
clearance of the biliary tree.
* After exploration of the bile duct,
a tube can be left in the cystic duct remnant or in the common
bile duct (a T-tube) and drainage of the biliary tree established
*After 7–10 days, a track will be established. This track can be
used for the passage of a choledochoscope to remove residual
stones in the awake patient in an endoscopy suite.

53. LAPROSCOPIC ULTRASONOGRAPHY
* At laparoscopy the use of laparoscopic probe can be
used to image the extra hepatic biliary system
* Useful in BILIARY & PANCREATIC tumor staging and
identify the primary tumors and determine its
relationship to the major vessels such as hepatic artery,
superior mesenteric artery , portal vein and superior
mesenteric vein