Surgical jaundice

1. OBSTRUCTIVE / SURGICAL JAUNDICE

2. Jaundice
• It’s a French word meaning Yellow.
• Jaundice is a term used for yellow pigmentation of sclera skin or
mucus membrane due to deposition of Bilirubin.
• Normal Bilirubin is 0.2-1.0mg/dL.
• Jaundice clinically detected in sclera when S.Billirubin is >2.5mg/dl.
• Jaundice is clinically detected in Skin/Mucus Membrane when S.
Billirubin is >6.0mg/dl.

3. Billirubin Metabolism
• Bile contains
1. Bile salt.
2. Lecithin
3. Cholesterol
4. Bile Pigment
• Biles Salt are
1. Primary(Cholate & Chenodeoxycholate)
2. Secondary(Deoxycholate & Lithocholate)

4. Entero hepatic Circulation
Bile salt in Bile
Jejunum & Ileum it
help in fat Digestion
Reabsorption in
terminal Ileum
Portal Vein Blood
Liver
• Entire Bile Salt Pool of 2.5-4.0gm
circulates twice through the
enterohepatic circulation during
each Meal.

5. Bilirubin Metabolism

6. Difference Between the types of Jaundice
HEMOLYTIC HEPATIC OBSTRUCTIVE
AGE YOUNG YOUNG/MIDDLE AGE OLDER AGE GROUP
ABDOMINAL PAIN NO +/- +
COLOR OF URINE Normal Yellow Dark Yellow
COLOR OF STOOL Normal Normal Clay Colour
PRURITUS -- -- +
ICTERUS Lemon Yello Yellow Greenish/Dark Yellow
LIVER -- + +
GALL BLADDER -- -- +
S BILLIRUBIN 4-5mg/dl(Indirect) Up to 10-
12mg/dl(Indirect/Direct)
15-20mg/dl(Direct)
SGOT/SGPT Elevated Markedly Elevated Normal/Elevated
ALK PHOSPHATASE Noraml Normal/Elevated Elevated
S PROTEINS Normal Decrease Normal

7. Causes of Obstructive Jaundice
• Most Common is
1. Common Bile Duct Stone
2. Periampullary Carcinoma( Ca
Head Pancreas most Common)
Periampullary Malignancy
includes Malignancy of Head
Pancreas Ampulla of Vater
Malignancy Lower End CBD
Malignancy & Duodenal
Malignancy

8. Causes
• Hepatic Duct
1. Cholangiocarcinoma e.g KLATSKIN TUMOR( TUMOR involving
Hepatic Duct Bifurcation).
2. Extrinsic Pressure by Portal Lymphnodes due to Metastasis or
Lymphoma.

9. • Common Bile Duct
1. Common Bile Duct Stone.
2. Common Bile Duct Stricture.
3. Gall Bladder Carcinoma.(Extrinsic Compression)
4. Choledochal Cyst
5. Obstruction by Ascaris Lumbricoides & Clonorchis Sinensis.
6. Mirrizi’s Syndrome Stone in Cystic Duct or Hartmann’s Pouch
causing pressure obstruction of Common Bile Duct.

10. • Pancreas
• Periampullary Carcinoma
1. Carcinoma of Head of Pancreas.
2. Pseudocyst of Pancreas.(Extrinsic Compression)

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

12. History
• Age
• Abdominal Pain
• Fever
• Urine
• Stool
• Pruritus
• Anorexia & Weight Loss

13. CLINICAL FEATURES
• Icterus: Usually dark yellow may have a greenish tinge if bilirubin is
reduced to billiverdin.
• Jaundice
1. Fluctuant in case of CBD Stones & Ampullary Growth.
2. Progressive in case of malignant obstruction by Carcinoma of Head
of Pancrease
• Hepatomegaly

14. Physical Examination

15. COURVOISIER’S LAW
• PALPABLE GALL BLADDER
 A nontender palpable gall bladder in a patient of jaundice is normally not due to
stone obstructing the bile duct whereas other causes are common by comparison.
 Explanation of Courvoisier's Law:: If in a jaundice patient GB is enlarged it is not
a case of stone impacted in the CBD as previous inflammation leads to Gall Bladder
Fibrotic and non distensible.
Causes are Carcinoma of Head of Pancreas & Periampullary Carcinoma.
Exceptions of Curvoisier’s Law
1. Double Impaction of Stone( CBD & Cystic Duct)
2. Stone at Ampulla Of Vater
3. Oriental Cholangiohepatitits
4. Mirrizi’s Syndrome

17. Bio Chemical Test 1
• S Billirubin: In Surgical Jaundice there will be(Direct)
hyperbilirubinemia.
• Normal 0.2 -1.0mg/dl
• Usually in CBD Stones S Bil(Total) is <10mg/dl.
• Usually in Neoplastic Obstruction S Bil(Total) is >10mg/dl.
• Total Billirubin rise upto a plateau level of 25-30mgdl at this lever
patient has loss in urine=daily Production.
• Liver Function Test Interpretation is (Total B/Direct B/AST/ALT/Alk
Pho)

18. Bio Chemical Test 2
• SGOT/SGPT(AST/ALT) : Normal level is 5-35IU/L
• Modest rise in Surgical Jaundice.
• AST if more than 1000IU/L s/o Medical Jaundice due to Hepatitis.
• ALT (SGPT) more specific for Liver Injury due to any cause.

19. Biochemical Test 3
• Serum Alkaline Phosphatase
• Normal level 3-13 KA Units/L or 60-300 IU/L.
• S ALK Phosphatase is usually raised in obstructive jaundice but not so
in hepatocellular Jaundice.
• If the level is more than >30 KA Units S/O Significant Obstructive
Jaundice.
• Increased value are because of increase production so it may be
elevated before the S Billirubin value raises.
• Serum Alk Phosphatase also increased in disease of intestine and
bone.

20. Bio Chemical Test 4
• Serum 5’ Nucleotidase.
• Leucine Aminopeptidase
• Gamma Glautamyl Transpeptidase
 All of the above enzymes are more specific for Biliary Obstruction.

21. Bio Chemical Test 5
• Serum Albumin : Noraml level is 3.0 to 5.5 gm/Dl
• Usually normal in Obstructive Jaundice but low value suggest
parenchymal dysfunction as in hepatocellular Jaundice.
• It may decrease when liver is affected by metastatic Nodules.

22. Bio Chemical Test 6
• Prothrombin Time
• It is usually expressed as INR
• Normal: Control is 15 Seconds & Normal INR is <1.5
• PT is elevated because of decrease in synthesis of VIT K depedent
clotting factors( which is a fat soluble vitamins which is not absorbed
in obstructive jaundice)

23. Bio Chemical Test 7
• Urine Examination :
Froth’s Test to detect Conjugated Billirubin.
Hay’s Test to detect presence of Bile Salt in Urine.
Fouchet’s Test to detect Bile Pigment in Urine.
ABSENT UROBILLINOGEN IN URINE
• Stool:: Clay Color
• Stool for Occult blood in case of Ampullary Malignancy

24. Radiological Investigation: USG
• Findings will be
1. Presence of Dilated IHBR is s/o of Obstructive Jaundice.
2. CBD Diameter (Normal is 7-8 mm) if it is more than 8 mm
suggestive of dilatation.
3. Gall Stone and CBD Stone Can be identified.
4. Mass in CBD can be detected if it is >2 cm.
5. Pancreatic Head Malignancy detected if >2 cm.
6. Presence of Liver Metastasis and Ascites.

25. USG Images

26. Radiological Investigation CECT Abdomen
• Higher Sensitivity and Specificity than USG for detection of bile
duct/pancreatic masses of 1-2 cm diameter.
• It is useful in determining resectability of cancer of Bile Duct or
Pancreatic Head Masses.
• It visualise the course of Bile Duct better than USG and hence more
likely demonstrated the level & Cause of Ductal Obstruction.
• Although USG better (more Sensitive )than CT Scan for detecting GB
Stone CECT is better(More Sensitive) for documenting CBD Stone.

27. CECT Abdomen

28. CECT
• Best for Pancreatic
Carcinoma(Highly sensitive for
lesion >1mm).

29. Gallbladder
Dilated bile ducts
Mass in head of
the pancreas

30. Radiological Investigation:
• Barium Meal: Reverse 3 Sign of Frostberg.
• Hypotonic Duodenography::Rose Thorn appearance

31. Clinical Classification of Obstructive Jaundice
• Type I Complete
Obstruction(Classical Symptoms
with Biochemical Changes)
1. Malignancy of Head of Pancreas.
2. Ligation of Common Bile Duct.
3. Cholangiocarcinoma.
4. Parenchymal Liver Disease.
• Type II Intermittent
Obstruction(Symptoms with
Biochemical Changes But Jaundice
may or may not be Present).
1. Choledocholithiasis
Periampullary tumor
Duodenal diverticula
Choledochal Cyst
Papillomas of the bile duct
Intra biliary parasites
Hemobilia

32. Clinical Classification
• Type III Chronic Intermittent
Obstruction(With or without classical
symptoms but pathological changes
are present in bile duct and liver )
1. Strictures of the CBD
Congenital
Traumatic
Sclerosing cholangitis
Post radiotherapy
Stenosed biliary enteric anastomosis
Cystic fibrosis
Chronic pancreatitis
Stenosis of the Sphincter of Oddi
• Type IV Segmental Obstruction( One
or more segment of IHB Radical)
1. Traumatic
2. Slerosing Cholangitis
3. IntraHepatic Abscess
4. Cholangiocarcinoma

33. Endoscopic Retrograde
Cholangiopancreatography(ERCP)
• It is combined Endoscopic & Radiological Approach.
• IND:: When USG s/o dilated IHBR with dilated CBD i.e Obstruction is
suspected to be at the lower biliary tract or near
pancreatic head.

34. ERCP

35. ERCP
Normal ERCP Normal ERCP

37. Biliary stricture due to
cholangiocarcinoma
Bile duct obstruction
from chronic pancreatitis

38. ERCP
• Advantages::
• Endoscopic Visualization of
duodenum to rule out duodenal
obstruction.
• Endoscopic Sphincterotomy with
dormia basket removal of CBD
Stone.
• Biopsy & Cytology.
• Endoscopic Biliary Stent placement
for non surgical palliation.
• It is contraindicated in Recurrant
Acute Pancreatitis & Unfavourable
anatomy.
• Complication
1. Pancreatitis
2. Cholangitis
3. Hemorrhage
4. Sepsis

39. Radiological Investigation ENDO USG
• It is more accurate than
combined ERCP & CT Scan in
defining the nature & extent of
the cause of Biliary Obstruction.
• It is also quite sensitive in
determining the resectability in
periampullary malignancy.
• EUS 98% Sensitivr in diagnosis of
etiology of Obstructive Jaundice.
• It allows us to take tissue
sampling by EUS guided FNAC.

40. EUS
• 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%).

41. Technique of PTC & corresponding Cholangiogram

42. Percutaneous Transhepatic Cholangiography
• For Visualization of Biliary Tract by
instillation of contrast material
directly into a bile duct.
• IND: PTC indicated when USG
shows dilated IHBR but the CBD is
not dilated i.e Obstruction is
suspected in the upper Biliary
Tract.
• CI: Coagulopathy & Ascites
• Complication: Bleeding Bile Leak
Hemobilia
Cholangitis

43. PTC & ERCP
• PTC & ERCP are not contradictory to each other they are
supplementary investigation to each other.

44. MRCP(Magnetic Resonance
CholangioPancreatography)
• MRCP is based on principle of
visualization of ducts containing
bile on T2 Weighted Images.
• Advnatages:
1. Non Invasive
2. No Contrast media is required.
3. Will show both upper & Lower
level of obstruction .
4. Excellent ductal anatomy is
visualized .

45. MRCP
Distal CBD Stone PSC

46. Algorithm for Diagnostic approach to a
patient of Surgical Jaundice.
Jaundice
Physical Examination&
LFT
Surgical
Jaundice
USG Abdomen
1.CBD Stone
2. Periampullary Malignancy
3. Liver Metastasis or
Peritoneal metastasis
Dilated IHBR
(True Surgical
Jaundice)

47. Continued
Common Bile Duct
Not Dilated
PTC+CECT
Treatment Surgical
/Palliation
Dilated>8.0MM
ERCP+CECT
Treatment
Surgical/Palliation

48. Prognostic factors
( Pitt’s score)
Parameters
• Type of
obstruction(malignant or
benign)
• Age > 60 yrs
• S.Alb< 3gm/dl
• S.Bil > 10mg%
• S.Alk P > 100 IU
• S.Creatinine >1.3mg%
• TLC >10000/mm3
• Hematocrit < 30%
Factors Mortality
Upto 2 0%
3 4%
4 7%
5 44%
6 67%
8 100%

49. Treatment of CBD Stone
**Stone is the CBD & Gall Bladder
Open Cholecystectomy with
CBDExploaration(Choledochotomy
) followed by T Tube Drainage.
ERCP with Sphincterotomy with
Removal of Stone followed by Lap
Cholecystectomy.
** Stones in the CBD but Gall
Bladder is Absent (Post
Cholecystectomy) or Treatment of
Retained Stone:
ERCP with Sphincterotomy with
Removal of Stone.
BURHENNE Technique: Removal
of Stone by dilating the T tube
Tract through Cystic Duct.
Choledochoscopic Removal of
Stone.

50. Periampullary Carcinoma of Carcinoma of
Head of Pancreas
• Resectable Tumors
• Curative Surgery is to be done in
those cases where no distant
metastasis (Liver of Celiac Nodes)
& No Vascular(SMA & Portal Vein
Invasion)
• Surgery : WHIPPLE’S
Pancreaticoduodenectomy
• Resection of Distal Stomach Gall
Bladder Whole Common Bile Duct
with Head of Pancreas & 10-15 cm
of Jejunum with Regional Nodes.
• Reconstruction done with following
anastomosis
1. PancreaticoJejunostomy
/PancreatoGastrostomy
2. Hepaticojejunostomy
3. Gastrojejunostomy

51. Pylorus Preserving Panceatoduodenoctomy
• In this Procedure Pylorus is
Preserved to maintain the
physiology of GIT.
ADVANTAGES:
DISADVANTAGES:

52. Whipple’s PD
• Whipple’s Operation has high
morbidity & Mortality rates.
• Complication
1. Hemorrhage
2. Pancreatic Fistula
3. Biliary Fistula

53. Non Resectable Tumors: Palliation to
Decrease Symptoms
• Non Surgical Palliation
1. Biliary Drainage via
Percuataneous Stent
ERCP with Metal Stent
Preferred for patients in poor
general condition & patient those
not fit for surgery.
For GOO: Either Stent Placement
or Gastrojejunostomy is required.
• Surgical Palliation
1. Single Bypass:
Cholecystojejunostomy
1. Double Bypass
Choledochojejunostomy &
Jejunojejunostomy
1. Triple Bypass
Choledochojejunostomy with
Gastrojejunostomy with
jejunojejunostomy.

54. Bile Duct Cancer
• Resectable
1. Proximal Duct Cancer
Resect the involved segment with
with Roux EnY
Hepaticojejunostomy.
2. Distal Bile Duct Cancer
Whipples Procedure
• Unresectable
1.Non Surgical Palliation by Biliary
Drainage Procedure via PTBD or
ERCP.
2.Surgical Palliation by Roux En Y
Hepaticojejunostomy.

55. Complication of Obstructive Jaundice
• Renal Failure
• Bleeding
• Sepsis
• Anastamotic leak

56. Thank You !