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Obstructive jaundice: concerned investigations


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Obstructive jaundice: concerned investigations

  1. 1. CONCERNED Obstructive jaundice INVESTIGATIONS
  2. 2. definition  Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine.  This can occur at various levels within the biliary system.  The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination.  Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin causes jaundice  Conjunctival icterus is generally more sensitive  Jaundice may not be clinically recognizable until levels are at least 2 mg/dL
  3. 3.  Urine bilirubin is normally absent.  When it is present, only conjugated bilirubin is passed into the urine.  This may be evidenced by dark-colored urine seen in patients with obstructive jaundice or jaundice due to hepatocellular injury..  The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction.  The cause of pruritus associated with biliary obstruction is due to accumulation of bile salts in the skin.
  4. 4. CAUSES Intrahepatic extrahepatic intraductal extraductal  Cirrhosis  Hepatitis  Drugs  Neoplasm  Stone disease  Biliary stricture  Parsites  PSC  Aids related cholangiopathy  Biliary TB  Secondary to neoplasm  Pancreatitis  Cystic duct stones
  5. 5. Evaluation of obstructive jaundice begins with careful history & physical examination JAUNDICE- hallmark of obstruction Pruritis, fever, weight loss, color of feces & urine Previous h/o pancreatitis, ulcerative colitis, hepatitis, or cholangitis INTERMITTENT JAUNDICE- stone related disease ampullary Ca papillary cholangioCa Prior h/o biliary surgery s/o stricture possibility Late jaundice after pancreaticoduodenectomy s/o recurrent disease technical anastomotic failure iatrogenic stricture if radiation is administered
  6. 6. Medical causes of jaundice : Hepatitis Cirrhosis Alcohol Hemolysis Impaired uptake or conjugation of bilirubin Drugs
  7. 7. 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
  8. 8. Other physical findings are: Lymphadenopathy Evidence of nutritional deprivation A palpable non tender GB in a jaundiced pt. s/o malignant obstruction CURVOISIER’S LAW Signs of cirrhosis or portal HTN as ascites, spleenomegaly  Cirrhosis is characterized by generalized disorganization of hepatic architecture with nodule formation and scarring on the parenchyma.  Cirrhosis may be a result of intrinsic liver disease or secondary to biliary obstruction
  9. 9. Goals of investigations Determine level of obstruction Severity of jaundice Ductal dilatation jaundice Cause of obstruction
  10. 10. investigations LFT GGT PT Hepatitis serology Antimitochondrial antibody Urine bilirubin Imaging studies
  11. 11. Imaging studies  USG  CT  MRCP  ERCP  Endoscopic ultrasound (EUS)  Percutaneous transhepatic cholangiogram (PTC)
  12. 12. Tests for liver functioning Based on detoxification & excretory function Enzymes indicating liver injury Measure biosynthetic function Damage to hepatocytes cholestasis Serum bilirubin Urine bilirunin Blood ammonia Aspartate aminotransferase Alanine aminotransferase Alkaline phosphatase 5 nucleotidase GGT Serum albumin Serum globulin Coagulation factors
  13. 13. Features Hepato cellular injury cholestasis Alanine aminotransferase 10–40(U/L) in males 7–35 U/L in females >10 URL , persists for weeks in most forms Transient increase to >10URL with complete obstruction falls quickly ALP (20 to 140 IU/L) <3 URL in most forms >3URL, may be normal in early obstruction GGT (0-30 IU/L) <5URL >5URL, may be lower in early obstruction Bilirubin 0.1-1.2 Direct , 0.1-0.4 mg/dL (< 7 μmol/L); Indirect, 0.2- 0.7 mg/dL (< 12 μmol/L) 50-80% direct 50-80% direct PT (10 to 14 seconds) Normal or slightly increased , no response to vit-k Normal maybe incresead with prolonged obstruction uaually respond to vit-k Imaging studies Normal ducts Abnormal ducts with complete obstruction
  14. 14. Imaging studies may be used to look for presence of dilated biliary ducts However bile duct obstruction without dilatation may occur when there is : Recent obstruction Chronic low grade obstruction Intermittent obstruction Primary sclerosing cholangitis Suspicion of obstruction should prompt cholangiography even when ducts are of normal caliber Some may present with dilated ducts without obstruction if there was previous obstruction Percutaneous liver biopsy may be required in some cases to exclude hepatitis
  15. 15. Causes based on level of obstruction Proximal obstruction Distal obstruction Biliary Extrinsic Biliary Extrinsic •cholangioCa. •Choledocholithiasis •GB cancer •Biliay stricture •Malignant masquerade •Mirrizzi syndrome •Sclerosing cholangitis •Hepatic neoplasm •Extra hepatic mass •lymphadenopathy •cholangioCa •Choledocholithiasis •Choledochal cyst •Biliary stricture •Periampullary neoplasm •Pancreatitis •Pancreatic cyst
  16. 16. Imaging studies Usg  initial test of choice in biliary obstruction  Determine  level of biliary dilatation in 92% cases  Cause of obstruction in 71%cases  Limited in distal biliary tree by overlying bowe gas  Upper limits of normal diameter of  CBD-8mm  CHD-6mm CT  95% accurate in determining level & cause of an obstruction  Segmental or lobar atrophy of liver from portal vein or duct obstruction best visualised
  17. 17. DIRECT CHOLANGIOGRAPHY Done via percutaneous transhepatic cholangiography (PTC) & endoscopic retrograde cholangiopancreaticography(ERCP) Provides most anatomical detail of biliary tree Enables inspection for : • Filling defects • Stenoses • Occlusion • Masses
  18. 18. ERCP is preferred for distal duct obstruction , PTC for proximal Both ERCP & PTC have similar accuracy in diagnosing jaundice GB isn’t visualized by direct cholangiography & better examined with USG mrcp Provides detail of liver parenchyma, biliary tree, pancreas, & vasculature & identify anatomical variants Noninvasive Averts risk of pancreatitis, bleeding, perforation
  19. 19. Can be employed when ERCP/PTC is contraindicated or when they are failed Can be used when there is biliary enteric anastomosis MRCP enables visualization of biliary tree both above & below the level of obstruction When therapeutic intervention is required ERCP or PTC is preferred MRCP 95% sensitive in detecting obstruction Inaccurate in assessing grade of obstruction Strictures can’t be well characterized
  20. 20. Endoscopic ultrasound (EUS)  combines endoscopy and USG to provide remarkably detailed images of the pancreas and biliary tree.  EUS has been reported to have up to a 98% diagnostic accuracy in patients with obstructive jaundice. This makes ERCP unnecessary in patients who are found not to have extrahepatic obstruction.  In addition, those patients who may require operative biliary drainage are reliably identified and similarly need not undergo ERCP for further evaluation.  EUS provides highly detailed imaging of the pancreas.  EUS is more portable than ERCP or MRCP EUS-FNA
  21. 21. Choledocholithiasis • May be asymptomatic or present with jaundice, cholangitis, or pancreatitis • Direct cholangiography is the gold standard investigation appear as filling defects • ERCP film showing choledocholithiasis
  22. 22. MRCP Showing choledocholithiasis
  23. 23. MRCP is also highly accurate  MRCP sensitivity 88-92%, specificity 91-98% in detecting choledocholithiasis
  24. 24. USG showing choledocholithiasis Not reliable in visualizing duct stones due to sound wave distortion from valves of heister 56% sensitive, 68%specific in detecting choledocholithiasis
  25. 25. Intraductal stones appear as target sign on ct CT. 75-88% sensitive, 97%specific for choledocholithiasis 79%sensitive, 100% specific for gallstones
  26. 26. In suspected cases of cholangitis due to choledocholithiasis evaluation should begin with USG to define level of obstruction Emergent drinage by ERCP, PTC or operation may be required in who don’t improve with resuscitation & antibiotics
  27. 27. Biliary strictures
  28. 28.  Long, smooth tapered strictures are usually benign  MC cause is iatrogenic injury following cholecystectomy or less frequently rt. Upper quadrant surgery  Other causes are: • pancreatitis • Radiation • Inflammation due to stone disease • PSC
  29. 29. Level of stricture Proximal duct stricture Mid bile duct stricture Low ductal stricture cholangioCa. Malignant masquerade GB cancer cholangioCa. Mirizzi syndrome Periampullary neoplasm Pancreatitis Cholelithiasis
  30. 30. ERCP films showing stricture and further dilatation of stricture •PTC is used for proximal ductal disease whereas ERCP for distal •MRCP provides same information
  31. 31. Primary sclerosing cholangitis OProgressive fibrosis of biliary of unknown etiology OFound in association with ulcerative colitis OMC in men OPSC is best diagnosed by ERCP
  32. 32. Primary sclerosing cholangitis USG picture of PSC showing thickening of the wall of the bile duct
  33. 33. CT film showing mild bile duct dilatation with a discontinuous pattern.
  34. 34. Discontinuous dilatation Bile wall thickening at the level of the porta hepatis Lymphadenopathy
  35. 35. intrahepatic bile duct dilatation with strictures and only mild dilatation, the first diagnosis we think of is primary sclerosing cholangitis (PSC).
  36. 36. Choledochal cyst choledochocele extrahepatic and intrahepatic disease saccular or fusiform dilatations of CBD  MC type is fusiform dilatation of EHBD  Presents with jaundice, pain and mass  Manifests in childhood & usually involves lower bile duct
  37. 37. Carolis disease: congenital condition of dilatation of intra hepatic ducts may be diagnosed with CT, USG, PTC, ERCP ERCP: severe intra hepatic dilatation without any obstruction
  38. 38. Caroli’s disease  The hallmark of Caroli disease is intrahepatic duct dilatation.  The dilatation can be very large and saccular as seen in the case on the left or it can be very linear.
  39. 39. central dot sign and the segmental involvement (portal vein that is surrounded by dilated bile ducts)
  40. 40. Cholangiocarcinoma  Often discovered as a result of obstructive jaundice  Papillary variant produces intermittent jaundice  USG is the preferred initial test  Detects hilar tumors  Predicts extent of bile duct involvement in 87% cases
  41. 41.  Duct dilatation  Ill-defined mass  Lobar atrophy  Vascular invasion
  42. 42.  Duplex USG may be accurate in determining extent of disease & vascular involvement  MRCP is also one of the best investigation available  Determine resectability of tumour through visualisation of tumor extension along the biliary tract
  43. 43.  Combination of MRCP and duplex USG is sufficient for diagnosis & staging CT may be used instead of MRCP but direct cholangiography may be preferred  Features determing resectability: • Vascular involvement, • local extension, • liver metastasis, • liver lobe atrophy, • extent of intraductal disease
  44. 44. CECT scan is showing a hypoattenuating irregular large cholangiocarcinoma (arrow) with peripheral rim enhancement (arrowheads) in left lobe
  45. 45. Gallbladder carcinoma  When a gallbladder cancer is discovered preoperatively MRCP & usg are required for diagnosis & staging  CT may be used instead of MRCP
  46. 46. PERIAMPULLARY NEOPLASMS Distal bile duct obstruction is seen with: • Periampullary neoplasm • Pancreatitis • Pseudocyst • Biliary stricture Periampullary neoplasms include • Cholangiocarcinoma • Pancreatic adenocarcinoma • Duodenal adenocarcinoma • Ampullary adenocarcinoma • Lymphoma or mets
  47. 47. USG demonstrates distal nature of obstruction and is the intial test of choice Helical CT is best over all for assessing periampullary lesions & determing resectability On occasion MRCP is needed to define the mass ERCP is not typically required Routine preoperative bilairy drinage with a stent should be avoided as it is associated with higher incidence of post-op infections