3. 1. DEFINITION
Jaundice is the yellow
discoloration of the sclera and
skin, as a result of raised serum
bilirubin and is usually
detectable clinically when the
bilirubin is greater than 3 .g/dl.
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8. OBSTRUCTIVE JAUNDICE
• Also called as surgical
jaundice.
• Most important in surgical
setting.
• Obstruction may be
intrahepepatic or extrahepatic.
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22. TYPE 1: COMPLETE OBSTRUCTION
Classical symptoms with biochemical changes:
• Ca. head of Pancreas
• Cholangiocarcinoma
• Parenchymal Liver diseases
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23. TYPE II : INTERMITTENT OBSRUCTION
• Symptoms and typical biochemical changes
• But jaundice may or may not be present
o Choledocholithiasis
o Periampullary tumor
o Duodenal diverticula
o Choledochal Cyst
o Papillomas of the bile duct
o Parasitic infestation
o Hemobilia
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24. TYPE III : CHRONIC INCOMPLETE OBSTRUCTION
With or without classical symptoms but pathological changes are present in bile duct and liver
o Strictures of the CBD
• Congenital
• Traumatic
• Sclerosing cholangitis
• Post radiotherapy
o Stenosed biliary enteric anastamosis
o Cystic fibrosis
o Chronic pancreatitis
o Stenosis of the Sphincter of Oddi
ERCP showing distal common bile duct
stricture
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25. TYPE IV : SEGMENTAL OBSTRUCTION
One or more segment of intrahepatic biliary tract is obstructed
o Traumatic
o Sclerosing cholangitis
o Intra hepatic stones
o Cholangio carcinoma
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26. SYMPTOMS
• Yellowish discoloration of sclera
• Epigastric pain
• Fever
• Pruritis
• Loss of weight
• Loss of appetite
• Increased bleeding tendency
• Steatorrhoea or Dark stool
• Dark orange urine
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29. INVESTIGATIONS
• Serum Direct Bilirubin
• Feceal urobilinogen (incomplete
obstruction)
• Feceal urobilinogen absence
(complete obstruction)
• urobilinogenuria is absent in
complete obstructive jaundice
• bilirubinuria
• ALP
• cholesterol
• (GGT) is a sensitive marker of biliary
tract disease and its raised
• 5’nucleotidase is raised and its more
specific
• ALT AST may rise
• Albumin decreased
• PT prolonged
• clotting factor decreased
• Tumor markers Ca19-9 and CEA raised
according to underlying cause.
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30. RADIOLOGY
• IMAGING GOALS
• To confirm the presence of obstruction
• To determine the level of the obstruction
• 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?
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32. Ultrasound abdomen
• More sensitive than CT for gallbladder stones and other pathology of gall
bladder
• Sensitive for dilated ducts (Dilation of the extrahepatic (>10 mm) or
intrahepatic (>4 mm) bile ducts suggests biliary obstruction.)
• Liver parenchymal mass and mets
PortableThe sensitivity of EUS for the identification of focal mass lesions in
pancreas is superior to that of CT scanning
Cheap
no radiation,
• Operator dependant
36. CT SCAN ABDOMEN
• Main role in malignant conditions
mainly for localization of primary
tumors and mets.
• Best for Pancreatic Carcinoma(Highly
sensitive for lesion >1mm.)
•Mainly done when ultrasound fail or
when there is ductal dilation on
ultrasound.
•level and cause of obstruction.
Carcinoma head of pancreas
37. MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
• Noninvasive test to visualize the hepato biliary
tree
• Entire biliary tree and pancreatic duct can be
seen
• Best for Intra Hepatic stones and
CHOLEDOCHAL CYST
• SINGLE BEST FOR CHOLANGIOCARCINOMA
• MRCP is better to determine the extent and
type of tumor as compared to ERCP
38. Percutaneous Transhepatic Cholangiogram (PTC)
• PTC is indicated when percutaneous
intervention is needed and ERCP either
is inappropriate or has failed.
• Can be used to drain biliary
obstructions.
39. SUPPORTIVE MANAGEMENT
• Preoperative biliary decompression (ERCP or PTC)
• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop
diuretics to prevent hepatorenal syndrome/ renal failure(12 to 24 hours prior to
surgery)
• catheterization to monitor output
• Broad spectrum antibiotic prophylaxis with 3rd generation cephalosporins
• Parenteral vitamin K +/- fresh frozen plasma
• Need careful fluid balance to correct dehydration
• Correction of hypokalemia and other electrolyte imbalance.
• Cholestyramine and antihistamine for symptomatic relief of pruritis
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41. CHOLOEDOCHOLITHISIS
• Ideally ERCP follwed by laproscopic
Cholecystectomy.
• Open exploration of common bile duct is
indicated in:
Presence of multiple stones (more than 5) and Stones > 1 cm
Multiple intra hepatic stones
Distal bile duct strictures
Failure of ERCP
Recurrence of CBD stones
42. 2. Ca HEAD OF PANCREAS
• Whipple resection:
• Removal of head & neck of pancreas,
duodenum, distal 40% of stomach, lower
CBD, GB, upper 10 cm of jejunum, regional
L.Ns and reconstruction through
gastrojejunostomy,choledochojejunostmy
and pancreaticojejunostomy
• If not operable then we go for ?????biliary
drainage
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43. CARCINOMA GALLBLADDER
• if involving cbd then whipple resection is done
• And in case of inoperable cases Endoscopic / Radiological stenting is done
44. 4)CHOLEDOCHAL CYST
Surgical excision of the cyst with
Reconstruction of the
extra hepatic biliary tree
Biliary drainage is accomplished by
Choledocho–jejunostomy
with a Roux – en – Y anastamosis
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45. 5) Cholanchiocarcinoma
Surgery depends on the stage of tumor and may involve
• Removal of the bile ducts
In Stage 1 tumor ,just the bile ducts containing the cancer are removed.
• Partial liver resection
If the tumor has begun to spread into the liver, the affected part of the
liver is removed, along with the bile ducts.
• Whipple procedure
If the tumor is larger and has spread into nearby structures, whipples
proceedure is done.
• Inoperable cases it may be possible to relieve the blockage through
stents via ERCP or PTC.
46. CHOLEDOCHOLITHISIS
Treatment of choice is stone extraction through ERCP
Open exploration of common bile duct is indicated in
Presence of multiple stones (more than 5) and Stones > 1 cm
Multiple intra hepatic stones
Distal bile duct strictures
Failure of ERCP
Recurrence of CBD stones
47. 7)STRICTURE
• Treated by endoscopic stenting.
• Therefore, surgery should probably be reserved for those patients
with complete ductal obstruction or for those in whom endoscopic
therapy has failed.
• Surgery with Roux-en-Y choledochojejunostomy or
hepaticojejunostomy is the standard of care.