Obstructive Jaundice surgical cause

1. OBSTRUCTIVE
JAUNDICE
Presenter : Dr Adithi S Rao(PG)
Moderator: Dr Murali Mohan
Assoc Professor
Dept of General Surgery
MIMS , Mandya

2. Contents
Anatomy
Physiology
Bilirubin metabolism
Patho-physiology of Obstructive
Jaundice
Classification
Clinical features
Investigations
Individual Diseases

3. Definition
 Cholestasis is defined as failure of normal amounts of
bile to reach duodenum.
 Extrahepatic biliary disease which is often amenable to
surgical treatment is called “SURGICAL JAUNDICE” or
“OBSTRUCTIVE JAUNDICE”.

4. Anatomy

5. Physiology
 Bile is composed of water, electrolytes, bile salts,
proteins, lipids, and bile pigments.
 The primary bile salts, cholate and
chenodeoxycholate, are synthesized in the liver by
cholesterol.
 Bile salts are formed from bile acids aid in the
digestion and absorption of fats in the intestines.
 About 95% of the bile acid pool is reabsorbed and
returned through the portal venous system to the
liver, also known as the enterohepatic circulation

6. …
 The color of bile is due to the presence of the pigment bilirubin
diglucuronide, which is the metabolic product from the breakdown
of hemoglobin
 Once in the intestine, bacteria convert it into urobilinogen, a small
fraction of which is absorbed and secreted into the bile.

7. BILIRUBIN
METABOLISM

8. Pathophysiology-Physical effects
of biliary obstruction
Increased pressure
Bile reflux across the hepatocyte
Hepatocellular damage
Reduced hepatic blood flow

9. Biochemical effect
 Conjugated hyperbilirubinemia
 Elevation of alkaline phosphatase
 Reduced blood fibrinogen, prothrombin and factor VIII leading to
impaired blood coagulation process
 Reduced serum albumin & prealbumin

10. Patho physiology Systemic
effect
 Abnormal serum lipids- cell membrane defects
 Bile acids, bilirubin- exert direct toxic effects on cells
 ENDOTOXEMIA d/t raised absorption of endotoxins from intestine
d/t absent bile salts

11. Systemic effects of long standing
obstructive Jaundice
 Impaired wound healing
 Coagulopathies- vit K def, platelet dysfunction
 Reduced immunity- sepsis
 Acute renal failure
 Hypotension

12. Site of obstruction
A. In the lumen of duct
• Choledocholithiasis
• Parasitic infestation due to: Hydatid disease, Ascariasis
• Hemobilia
Classification

13. B. In the wall of duct
1. Congenital: Biliary atresia,Choledochol cyst
2. Acquired: Papillary stenosis,Strictures ,Mirrizzi’s syndrome
3. Malignant causes: Ca Gall bladder, Cholangiocarcinoma

14. C. Outside the wall
1. Benign: Pseudocyst of pancreas
2. Malignant:
• Ca head of pancreas
• Enlarged lymph nodes at porta hepatitis
• Periampullary Ca
• Extra biliary malignancy

15. Type of obstruction
Type I: Complete obstruction, producing overt jaundice.
e.g. Ca head of pancreas
Cholangio carcinoma

16. Type II: Intermittent obstruction, which produces symptoms
and typical biochemical changes, but may or may not be
associated with attacks of clinical jaundice.
e.g.
Cbd stones
Periampullary tumor
Duodenal diverticula
Choledochal cyst
Intra biliary parasites
Hemobilia

17. Type III: Chronic incomplete obstruction, with or without
classic symptoms or the observation of biochemical changes
which will eventually produce pathological changes in the
bile duct or the liver.
e.g. s
Strictures of the CBD
Stenosed biliary enteric anastamosis
Cystic fibrosis
Chronic pancreatitis
Stenosis of the Sphincter of Oddi

18. Type IV: Segmental obstruction, in which one or more anatomical
segments of the intrahepatic biliary tree are obstructed.
Traumatic ,
Hepato docho lithiasis = intra hepatic stones,
Sclerosing cholangitis

19. Clinical features
SYMPTOMS
 Jaundice:
 Itching :
Frequent with malignant obstruction- cause is obscure
??Bile acids which cause injury to the membrane of skin cells
and a release of pruritogenic proteases.

20.  Steatorrhea:
Malabsorption of fats due to absence of bile salts- pale,
bulky, offensive stools.
 Biliary pain :
Epigastrium, radiates to right hypochondrium and to right
sub-scapular region, most commonly constant in
nature with only minor fluctuation in intensity.

21.  Hepatic failure
Long standing cholestasis- months to years.
Edema, hypoalbuminemia, deep jaundice, bleeding
unresponsive to parenteral vit K, decrease of itching.

22. ■ Signs of liver failure: Late stages

23. General examination
1. Icterus
2. Xanthomas : are due to increased serum cholesterol for
> 3 months. Appear as whitish macular lesions due to
cholesterol deposition in skin. Xanthelesma are raised
and seen around the eyes.
3. Per abdomen:
1. HEPATOMEGALY: Liver enlarged – SHARP EDGE Palpable
gall bladder (courvoisier’s law).
2. Ascites may be related to liver disease, hypoalbuminemia
with portal hypertension or malignancy.

24. Courvoisier’s law
 In the presence of Jaundice , a palpable Gall bladder
is seldom due to stones.
Virchow’s node
• Left supraclavicular lymph nodes .
• Troisier’s sign

25. Investigations
 BIOCHEMICAL investigations
 LFT :
Sclera 2.5mg/dl

27. Clinical Approach

29. USG
 GALLBLADDER
1. IOC for GB pathology
2. After fasting for 6 hour- distend GB
3. Gallstones: acoustic shadow, postural variation
4. Cholecystitis: wall > 5 mm, distended GB, peri
cholecystic fluid, sludge , subserosal edema ,
sonographic murphy’s
5. Polyps
6. Ca

30. Sludge in GB
Stones
Polyp

31. Endoscopic Ultrasound
 Requires a special endoscope with an ultrasound
transducer at its tip.
 It offers noninvasive imaging of the bile ducts and
adjacent structures. It is of particular value in the
evaluation of STAGE of tumors and their
resectability.
 The ultrasound endoscope has a biopsy channel,
allowing needle biopsies of a tumor under
ultrasonic guidance.

32. Computed Tomography
(CT)
 One disadvantage is gallstones and bile appear nearly
isodense on CT; that is, it is difficult to distinguish
gallstones from bile, unless the stones are heavily
calcified.
 CT identifies gallstones within the biliary tree and
gallbladder with a sensitivity of only about 55% to 65%.

33.  Conversely, CT is more accurate at identifying the site
and cause of extrahepatic biliary obstruction.
 Abdominal CT is a powerful tool for evaluating
hepatobiliary or pancreatic neoplasm, liver
abscess, or hepatic parenchymal disease (e.g.,
biliary cirrhosis, organ atrophy).
 Use of CT cholangiogram provides improved
definition of the biliary tract comparable to magnetic
resonance cholangiography

35. ERCP
 INVASIVE
 IOC for distal CBD obstruction
 Pt is kept NPO for 6 hrs
 Under sedation
 Side viewing duodenoscope
 Cannula is inserted into papilla & contrast
(IOPROMIDE/IOGLYCAMATE) is injected
 Films taken fluoroscopy

36. ERCP: Diagnostic
 Inspection of stomach, duodenum, pancreatic ducts, biliary tract in
one sitting
 Manometry of sphincter of oddi
 Bile / pancreatic juice for culture
 Stricture / growths – brush cytology / biopsy

37. ERCP- Therapeutic
 Endoscopic sphincterotomy- with/without stone extraction
 Endoscopic biliary endoprosthesis
 Endoscopic NBD
ERCP Failure
• Ampullary diverticulum/stricture/tumor
• Billroth 2 surgery

38. ERCP complications
 2-5%
 Technical errors, unsterile
 Pancreatitis: M/C ,raised serum amylase, esp if pancreatic duct
cannulated
 Cholangitis: 2nd M/C
 Bleeding – procedure
 Perforation– procedure

39. ERCP-CBD STONES

40. PTC- percutaneous trans
hepatic cholangiogram
 Proximal biliary obstruction /ERCP is not technically
possible.
 PTC involves advancement of a 21- or 22-gauge
needle from the right MAL into the expected
location of the central intrahepatic biliary tree using
fluoroscopic or ultrasound guidance.
 When a bile duct is engaged, it is filled with contrast.
Images are obtained from multiple projections
 PTBD/anatomical landmarks during surgical
reconstruction, /access for nonoperative dilation of
strictures.

41. PTC

42. Criterion ERCP PTC
Success rate 80-90% 80-90%
Complications 5% 5%
Mortality 0.2% 0.2%
Conditions for use
skilled
personnel
distal lesion
failed PTC
skilled personnel
proximal lesion
abnormal anatomy
failed ERCP

43. MRCP
 MRCP v/s ERCP without the added risk of
pancreatitis, sedation, and perforation.
 Image quality is less with MRCP
 Intervention not possible
 MRCP is of value in patients with a low
probability of gallstones or obstruction in the bile
ducts or pancreas, or in patients who are too sick
for the anesthesia required for ERCP
.

44. Magnetic resonance
cholangiopancreatography
(MRCP).
Liver metastasis (M)
common bile duct (CBD)
pancreatic duct (PD).

45. MRCP
ERCP

46. FDG-PET
 Well established for differentiation of benign from
malignant lesions, staging malignant lesions, detection of
malignancy recurrence, and monitoring therapy for various
malignancies
 Accurate in predicting the presence of nodular cholangiocarcinoma
(mass >1 cm) and gallbladder carcinoma (sensitivity, 78%).

48. MEDICAL TREATMENT
 PRURITIS
 Bile drainage
 CHOLESTYRAMINE: DOC binds bile salts in intestine
 Doubtful value ?? URSODIOL, RIFAMPIN

49. NUTRITION
 Calorie + Protein supplementation
 FATS : (Restrict other fats-Steatorrhea) Medium Chain Triglycerides
MCT rich in coconut oil supplemented – 40 g/day
 Vit K-10mg/day
 Vit D-4000 U /day
 Vit A-25000U/day

50. Choledocholithiasis
 PRIMARY : Stones are formed in CBD. -
associated with biliary stasis and infection and
are more commonly seen in Asian populations.
 The causes of biliary stasis that lead to the
development of primary stones include biliary
stricture, papillary stenosis, or tumors.

51. …
 SECONDARY: Stones formed primarily in
gallbladder & migrate into CBD.
 More common than primary

52. …
 IOC is ERCP, also therapeutic :cannulation
of the ampulla of Vater and diagnostic
cholangiography are achieved in more
than 90% of cases.
 MRC provides excellent anatomic detail

53. Management of CBD stones
 Endoscopic Cholangiography
 Endoscopic clearance of stones from the common bile duct can
avoid the need for an open surgery
 Patients with worsening cholangitis, ampullary stone impaction,
biliary pancreatitis, multiple co morbidities, and cirrhosis are
considered good candidates for endoscopic therapy.
 Endoscopic sphincterotomy is done followed by extraction of
stones using Dormia basket.
 If the stones are large or impacted mechanical lithotripsy can be
done.
 Prompt cholecystectomy after endoscopic clearance of the
common bile duct should be performed to prevent recurrences

54.  Laparoscopic CBD Exploration :
 Lap CBDE comb with lap cholecystectomy - through the cystic
(5mm choledohoscope) or with formal choledochotomy allows the
stones to be retrieved during the same procedure.
 If a choledochotomy is performed, a T tube is left in place.

56. CBD stone extracted

57.  Open Common Bile Duct Exploration
 CHOLEDOCHOTOMY & stone extraction
 Stones impacted in the ampulla may be difficult for
complete ductal clearance and common bile duct
exploration. In these cases, transduodenal
sphincteroplasty and stone extraction should be
performed; alternatively, if this is not successful, a
choledochoduodenostomy or a Roux-en-Y
choledochojejunostomy should be performed.

59. Side-to-side choledochoduodenostomy

60. Choledochojejunostomy using a loop
of jejunum to the distal common hepatic
duct. A loop of jejunum just distal to the
ligament of Treitz is brought over the
(antecolic) to the dilated bile duct. A side-
to-side or end-to-side
choledochojejunostomy is performed using
a two-layer anastomosis. The jejunum is
usually secured to the liver capsule to
tension on the anastomosis. A
jejunojejunostomy is performed to
minimize reflux into the bile duct.

61. Choledochojejunostomy
with a Roux-en-Y loop.
The jejunum is transected about
cm distal to the ligament of
and the distal end is oversewn
and mobilized to the bile duct.
end-to-side anastomosis is
performed between the dilated
bile duct and the antimesenteric
border of the jejunum. Intestinal
continuity is established with a
jejunojejunostomy 45 cm from
choledochojejunostomy to
prevent reflux into the biliary tree.
. This drainage procedure is preferred to a
loop because reflux of enteric contents
into the bile ducts rarely occurs.

62. BILIARY STRICTURES-BENIGN
CAUSES
 BILE DUCT INJURIES
Postoperative bile duct strictures
 Cholecystectomy :exploration of common bile duct
 Other operative procedures: Biliary enteric anastamosis,
liver transplant
 Strictures Related to Endoscopic or Percutaneous Biliary
Manipulations
Stricture after blunt or penetrating injury
 POST-INFLAMMATORY STRUCTURE: Cholangitis,
Pancreatitis, Duodenal ulcer
 Primary Sclerosing Cholangitis
 Radiation-induced Cholangitis

63. Iatrogenic bile duct injury
 SURGERY-
Commonest
cause of biliary
stricture
 Factors -
Anatomical
Variation, Use of
diathermy near
Calot’s triangle,
Technical errors,
Bile duct
ischemia,
Pathological
factors.

64.  Most benign strictures follow iatrogenic bile duct injury,
most commonly during laparoscopic cholecystectomy.
 Long-term sequel may lead to recurrent cholangitis,
secondary biliary cirrhosis, and portal hypertension.

65. Ways of injuring the extrahepatic biliary ducts at operation.
A, Quick clamping at a hemorrhage from the cystic artery area in a field
obscured by blood.
B, Too much traction on the gallbladder with knuckling of the common
duct and the forceps applied too low.
C, Cystic duct clamped too close to the common duct. A tie will then
completely obstruct the duct.
D, Inadvertent clamping of long cystic duct closely adherent to the
common hepatic duct.

66. Strasberg classification

68. Primary end-to-end repair of
a bile duct injury over a T-
tube.

69. Choledochal Cyst
 Congenital cystic dilation of the biliary ducts
 ? Cause
 Weakness of the wall/distal obstruction /Reflux of pancreatic
enzymes into the CBD secondary to an anomaly of the
pancreaticobiliary junction (APBJ)

70. C/F
 Infantile group consisting of babies younger than 1 year, with or
without obvious hepatomegaly, with prolonged jaundice and
acholic stools.
 adult form of choledochal cyst - classic triad: pain, jaundice, and a
palpable mass.

71. Choledochal Cyst-
Classification
 Type I - Cystic or fusiform dilatation of the common bile
duct (CBD); most frequent type (90-95% of the cases).
 Type II - Diverticulum of the CBD, with normal size CBD
 Type III - Choledochocele, a cystic dilatation of the distal
intramural portion of the CBD, typically protruding into
the second portion of the duodenum
 Type IV - Cystic or fusiform dilatation of the CBD
associated with cystic, fusiform, or saccular dilatation of
intrahepatic bile ducts, also termed form fruste
 Type V - Cystic, fusiform, or saccular dilatation of the
intrahepatic bile ducts associated with a normal CBD; may
be associated with hepatic fibrosis (referred to as Caroli
disease)

72. Todani modification of the classic Alonso-Lej classification

73. …
 Ultrasonography – dilated ducts & type 1 cysts
 ERCP is the standard diagnostic study. It clearly shows the anatomy
of the pancreaticobiliary junction
 CT scanning may also be useful to delineate the cyst and its
relationship to surrounding structures.

74. CT scan shows a large cyst
with wall thickening.

75. Rx of choledochal cysts
 Total excision of the cyst in types I, II, and IV
followed by reconstruction of the biliary tree with
hepaticojejunostomy in a Roux-en-Y fashion
 Internal drainage, either with cystoduodenostomy or
cystojejunostomy. :high incidence of calculi, recurrent
cholangitis, anastomotic strictures, and carcinoma
arising from the cyst.
 Lilly’s technique: inflammation – entire cyst cant be
removed-resection of the anterolateral part of the cyst
followed by an endocystic resection of the lining, leaving
the back wall adjacent to the portal vein in place.

76. …
 Type III choledochal cysts, lateral duodenotomy with unroofing of
the choledochocele followed by ductoplasty
 Type V choledochal cysts, patients with localized disease may
benefit from a hepatic lobectomy.
 If the disease is diffuse, involving both lobes of the liver, treatment
is palliative and liver transplantation may be required.

77. Extra hepatic Biliary atresia
 Failure of vacuolization of the solid embryonic bile ducts. most
common surgically treatable cause of cholestasis encountered
during the newborn period
 Causes prolonged neonatal jaundice, for more than 2 weeks.

78. …
 There are three main types of extrahepatic biliary atresia:-

Type I: atresia restricted to the common bile duct.
Type II: atresia of the common hepatic duct.
Type III: atresia of the right and left hepatic duct.

79. TREATMENT OF BILIARY
ATRESIA
 The Kasai procedure consists of mobilizing the
extrahepatic ducts and anastomosing a jejunal Roux en-Y
loop to the liver hilum. Complications include progressive
biliary cirrhosis, ascending cholangitis, and portal
hypertension.
 Liver transplantation is indicated in cases of failed
portoenterostomy, progressive fibrosis, or biliary cirrhosis. In
fact, biliary atresia is the most common cause of end-stage
liver disease in infants and a leading indication for liver
transplantation.

80. Ca GALLBLADDER
 One of the most aggressive malignancy – survival poor
 Jaundice : Direct invasion into CBD
Nodes at porta hepatis or pressure effect on CBD

81. Rx of Ca GALLBLADDER
 T1 – Cholecystectomy
 T2/T3 - Extended cholecystectomy – GB +lymphadenectomy of the
cystic duct, pericholedochal, portal, right celiac, and posterior
pancreatoduodenal lymph nodes +hepatic parenchyma - at least a
2-cm margin OR extended right hepatectomy

82. PALLIATIVE TREATMENT FOR
UNRESECTABLE GB Ca
 Endoscopic or percutaneously placed biliary stent to relieve
obstruction

83. Cholangiocarcinoma
 ? Etio: Long standing Primary sclerosing cholangitis, choledochal
cysts, and hepatolithiasis
 Cholangiocarcinoma is best classified anatomically into three broad
groups:
1. Intrahepatic
2. Perihilar
3. Distal
Most commonly at the hepatic duct bifurcation (60%-80% of
cases) – PERI HILAR also known as KLATSKIN TUMOR

84. Perihilar cholangiocarcinoma / Klatskin s
tumor’s
Bismuth – Corlette classification :
 Type I – involving common hepatic duct
 Type II – involving bifurcation of common hepatic
duct
 Type III a – involving common hepatic duct with
right hepatic duct
 Type III b – involving common hepatic duct with
left hepatic duct
 Type IV – involving common hepatic duct with
right and left hepatic duct

86. (TNM) classification
 Stage IA tumors are limited to the bile duct, Stage
IB tumors invade periductal tissues.
 Stage IIA tumors are locally advanced without
lymph node metastases, and stage IIB tumors
have regional lymph node metastases.
 Stage III tumors are locally advanced and
unresectable,
 Stage IV tumors have distant metastases.

87. Treatment of peri hilar
cholangio carcinoma
 For type I and II lesions, the procedure is en bloc
resection of the extrahepatic bile ducts and
gallbladder with 5- to 10-mm bile duct margins,
and regional lymphadenectomy with Roux-en-Y
hepaticojejunostomy.

88. …
 Type III and IV tumors are amenable to
potentially curative resection in centers with
expertise in these procedures. Aggressive
techniques such as hepatectomy and portal vein
resection to achieve negative margins are now
routine in specialized centers.
 Palliative : Stenting to relieve obstruction

89. MALIGNANT PANCREATIC
TUMORS
 Ductal adenocarcinoma and its variants account
for 80% to 90% of all pancreatic neoplasms
 70% of ductal cancers arise in the pancreatic head
or uncinate process.
 80% of pts with pancreatic head ca present with
jaundice & pruritis
 Palpable gallbladder in a patient with painless
jaundice (i.e., Courvoisier's sign)

90. Investigations for pancreatic
Ca
 CECT, MPCP, EUS
 Biopsy to confirm the presence and identify the type of
cancer is usually required before chemoradiation
therapy of unresectable pancreatic tumors or
neoadjuvant treatment of resectable tumors.

91. Endoscopic ultrasound of pancreatic
adenocarcinoma of the head of the
pancreas

92.  Stage I and II cancers are amenable to
resection
 WHIPPLE s Procedure – Pancreatico
duodenectomy

93. Modified Whipples – Pylorus sparing
pancreaticoduodenectomy
Resection of head of
pancreas, distal bile duct,gall
bladder and distal
duodenum with
reconstruction – Hepatico
jejunostomy+
duodenojejunostomy
+pancreaticojejunostomy

94. PALLIATION OF
UNRESECTABLE PANCREATIC
Ca
 ERCP - transpapillary stent is placed across the obstructed segment
of bile duct.
 For lesions that are not amenable to stents, surgical cholecysto
jejunostomy or choledocho jejunostomy may be required.

95. Peri ampullary carcinoma
 Periampullary cancers can be broadly considered as
tumors arising within 1 cm of the ampulla of Vater
and include ampullary, distal bile duct, pancreatic,
and duodenal cancers ,it is difficult to differentiate the
tumor type.
 Jaundice is observed in 80% of cases. Unlike the
jaundice observed with cancer of the pancreas,
jaundice produced by papillary cancers may
fluctuate, especially early in the course of the
obstructive process.

96.  ERCP and duct cytology (91%)
 Percutaneous transhepatic cholangiography (100%) –
mainstay in diagnosis
 Treatment –Pancreaticoduodenectomy if resectable
 Palliative – stenting / surgical bypass

97. Rare causes of obstructive
jaundice
 Chronic pancreatitis: Duodenal ulcer - perforation
with adhesive peritonitis
 Duodenal diverticulum
 Hemobilia – bleed into biliary tract
 Intra biliary parasites
 Papillary stenosis,Strictures ,
 Mirrizzi’s syndrome
“TREAT THE CAUSE”

98. Bibiliography
 Bailey and Love 27th ed
 Sabiston Textbook of Surgery 21st ed
 Schakleford’s Surgery of Ailmentary Tract ,6th ed
 Maingot’s Abdominal Operations