For medical students

1. OBSTRUCTIVE
JAUNDICE
DR KOSAMU P.M

2. CONTENTS

3. DEFINITIONS
 Jaundice (icterus) is defined as yellowing of the
skin and sclera from accumulation of the pigment
bilirubin in the blood and tissues. The bilirubin level
has to exceed 35–40 mmol/L before jaundice is
clinically apparent.
 Jaundice can be classified simply as pre-hepatic
(haemolytic), hepatic (hepatocellular) and post-
hepatic (obstructive).
 Most of the surgically treatable causes of jaundice
are post-hepatic (obstructive).
 Painless progressive jaundice is highly likely to be
due to malignancy.

4. POST-HEPATIC/OBSTRUCTIVE JAUNDICE
 Post-hepatic conjugated hyperbilirubinaemia
 Anything that blocks the release of conjugated
bilirubin from the hepatocyte or prevents its delivery
to the duodenum.

5. EPIDEMIOLOGY
 Gallstones are the most common cause of biliary
obstruction.
 increased incidence of obstructive jaundice is seen
in obesity and diabetes. This group of people are
especially prone to developing gallstones.
 women are much more likely to develop gallstones
than men
 This increased risk is likely caused by the effect of
estrogen on the liver, causing it to remove more
cholesterol from the blood and diverting it into the
bile.

6.  Approximately 20% of men aged 75 years have
gallstones.
 By the sixth decade, almost 25% of women develop
gallstones, with as many as 50% of women aged
75 years developing gallstones.
 Gallbladder cancer is also more common in
females than in males.

7. CAUSES OF OBSTRUCTIVE JAUNDICE
1. MURAL / INTRINSIC
 Liver cell transport abnormalities
 Sclerosing cholangitis
 Cholangiocarcinoma
 Mirrizi’s syndrome (gallstone in neck with
associated CHD compression)
 Benign stricture
 • Post inflammatory
 • Postoperative
 • Post radiotherapy

8. 2. INTRALUMINAL
 Infestation
1. Clonorchis
2. Schistosomiasis
 Gallstones

9. 3. EXTRINSIC
 Portal lymphadenopathy
 Chronic pancreatitis
 Pancreatic tumour
 Ampullary tumour
 Duodenal tumour

10. CHOLELITHIASIS
 Cholelithiasis is the medical term for gallstone
disease. Gallstones are concretions that form in the
biliary tract, usually in the gallbladder.
 Choledocholithiasis refers to the presence of one or
more gallstones in the common bile duct. Usually,
this occurs when a gallstone passes from the
gallbladder into the common bile duct

11. PATHOPHYSIOLOGY
 Gallstone formation occurs because certain substances
in the bile are present in concentrations that approach
the limits of their solubility.
 When bile is concentrated in the gallbladder, it can
become supersaturated with these substances, which
then precipitate from the solution as microscopic
crystals.
 The crystals are trapped in the gallbladder mucus,
producing gallbladder sludge. Over time, the crystals
grow, aggregate, and fuse to form macroscopic stones.
 Occlusion of the ducts by sludge and/or stones
produces the complications of gallstone disease.

12. TYPES OF GALLSTONES
1. Cholesterol gallstones [80%]
2. Calcium,
3. bilirubin,
4. pigment gallstones
5. Mixed gallstones

13. RISK FACTORS
 Cholesterol gallstones are associated with female
sex. Other risk factors include the following:
1. Fat- Obesity
2. Fetus-Pregnancy
3. Fair-
4. Forty- common in women around 40yrs
 Gallbladder stasis
 Drugs- chlopromazine/ steroids
 Heredity

14. CLINICAL MANIFESTATION
 Patients commonly complain of:
1. yellow skin and eyes,
2. pale stools,
3. dark urine,
4. jaundice,
5. pruritus.
6. fever,
7. anorexia,
8. weight loss

15. CLINICAL MANIFESTATION CONT…..
 Courvoisier’s law-‘A palpable gallbladder in the
presence of jaundice is unlikely to be due to
gallstones.’
 It usually indicates the presence of a neoplastic
(tumour of pancreas, ampulla, duodenum, CBD) or
chronic pancreatic stricture.

16. DIAGNOSIS
 FBC: haemolysis.
 LFTs: alkaline phosphatase (cholestasis), -GT and
transaminases (hepatocellular).
 Clotting: PT (elevated in cholestatic and
hepatocellular jaundice).
 Urinary urobilinogen
 Serum bilirubin level
 Ultrasound (abdominal)
 ERCP
 CT scan

17. TREATMENT
 Admit the patient for prompt necessary diagnostic
testing, supportive care, and surgical intervention if
indicated.
 Transfer may be required for further diagnostic
evaluation and treatment.
 Treatment of the underlying cause is the objective
of the medical treatment of biliary obstruction.
 Do not subject patients to surgery until the
diagnosis is clear.