kathmandu medical college, department of surgery

1. Investigation in a case of Obstructive
jaundice and Approach
Dr uttam Laudari
2014/12/12

2. Aims of Investigation
• Detection of disease
• Assessment of severity
• Assess prognosis
• Assess effect of therapy/ recurrence/ follow up

3. Questions faced
• Is it obstructive jaundice?
• Where is the obstruction?
• What is the cause of obstrution? ( benign/ malignant)

4. Liver Function Test
• Bilirubin
• Aspartate Transaminase
• Alanine Transanaminae
• Alkaline Phosphatase
• Albumin
• PT/INR

5. Bilirubin
• Hallmark of obstructive jaundice
• Measured Direct and indirect bilirubin level at same time
• Van Den Berg test- assess direct
• these days both fraction calculated separately by
spetrophotometry

6. • Conjugated hyperbilirubinemia  hall mark of obstructive
jaundice
• Differentiates hemolytic cause from other hepatic and post
hepatic causes of jaundice
• D/D- viral hepatitis/ Dubin-johnson’s Syndrome
• Presence of bilirubin on urine analysis is also marker of
conjugated hyperbilirubinemia

7. AST/ALT
• AST( SGOT)- is intracellular enzyme
responsible for amino acid metabolism
• Two isoenzymes
– Type 1- cytosolic
– Type 2- mitochodrial  more specific to liver
• AST is found in liver, cardiac muscles, skeletal
muscles, RBCs, kidney and brain
• I.E less specific than ALT

8. ALT(SGPT)
• Intracellular enzyme
• Responsible of amino acid metabolism
• Primarily present in liver cells
ALT/AST elevation is marker of cellular damage
Isolated elevation of AST non hepatic cause for jaundice
( muscle injury, MI)

9. • AST/ALT ratio indicator in alc. Liver disease 2:1
• Wilsons Disease- Ratio 4:1
• Raise AST and ALT indicates liver cellular injury liberating
intracellular enzymes
– Liver trauma
– Hepatitis
– Liver ischemia ( right hepatic artery clipped during Lap. Chole)
• raise in obstructive jaundice too
• Marked rise suspicious of Cholangitis

10. • AST > 10 times the normal
• Hepatic hypoxia
• CBD calculi
• Glutathione-S- Transferase (GST-a) more sensitive to
liver injury in assessing injury
• Has short half life (90min)

11. Alkaline phosphatase (ALP)
• Canaliucular enzyme
• Normally expressed by apical parts of hepatocytes
• Cleaved and secreted in space of Disse and then in bile
• Bile flow obstruction ALP overflow in vascular channels

12. • ALP also produced by osteoblasts, kidney and salivary glands
• also raised in bone metastasis
• GGT and 5’ nucleotidase estimation required to confirm its
elevation due to obstructive jaundice

13. Serum albumin
• Marker of chronic liver disease
• Half life -21 days
• Reduced value idicated malnutrition >3 weeks
• Prealbumin estimation
– Short half life (7 days)
– Low value indicated recent loss of synthetic function of liver

14. Prothrombin timed Raito (PTI)
• Factors I, II, V, VII, and X synthesized in liver
• Factors II,VII,IX and X vitamin K dependent factors
• PTI measures the extrinsic pathway of coagulation

15. • Bile flow obstruction
• Vit k cannot be absorbed from intestine
• hence II, VII, IX, X deficent
• PTI/INR is an indicator of liver function
• If PTI doesn’t Improve with parenteral Vit. K supplementaiton-
 likely liver cell damage

16. Tumor markers
• Value is suspicion of HCC, Ca. GB or pancreatic cancer
• AFP, Ca 19-9, Ca-125
• Monitoring response and follow up

17. Imaging modalities
• Ultrasound
– Detection of GB stones, possiblleCBD calculi
– CBD diameter
– Presence of intrahepatic biliary dilatation
– GB massses, liver metastasis,
– Not accurate for pancreatic lesion
• Intrahepatic bile duct – 2mm
• Common heaptic duct-<4mm
• CBD <5-7mm

18. Ultrasound
• Advantage- noninvasive, portable, least expensive
• disadvantage-
– bowel gas may boscure CBD
– diffcult in obese person

19. CT scan
• Indicated in malignant lesions of GB, liver or pancreas
• Not good for GB stone, usg more accurate than CT
• Good for liver, nodes
• MRCP good for biliary tree

20. CT - Scan
• Advantage
– Noninvasive
– Higher resolution than USG
– Not operator dependent
• Disadvantage
– IV contrast ( potential nephrotoxicity)

21. MRCP/MRI
• Defines structural abnormalities in jaudice
• Very accurate for CBD calculi,mural disease of CBD (
strictures, sclerosing cholangitis, choledochal cyst)
• Drawback
– Gadolinium contrast nephrogenic fibrosis later
– In presnce of gross ascitis image quality will be poor

22. MRCP
• Advantage
– Noninvasive
• Disadvantage
– Requires breath holding
– May miss small caliber bile duct disease

23. Endoscopic Ultrasound
• Has miniature ultrasound transducer mounted on its tip
• As sensitive as ERCP in detecting stone and strictures
• Sensitivity and accuracy of endoscopic USG for
choledocholithiasis is > 90%
• More accurate than transabdominal USG

24. ERCP
• Not be used as diagnostic modality
• Definite morbidity and mortality has been reported
• Combined with therapeutic procedures such as stent
placement or extraction
• Diagnostic and interventional procedures such as biopsy or
stone extraction is useful to the union of right and left hepatic
ducts
• Proximal to that PTC is helpful

25. ERCP
• Advantage
– Provides direct imaging of bile ducts
– Permits direct visualization of periampullary region and
acquisition of tissue distal to bifurcation of hepatic duct
– Potential for simultaneous therapeutic intervention
– Useful in lesion distal to bifurcation of hepatic ducts

26. ERCP
• Disadvantage
– Cannot be performed if altered anatomy precluded
endoscopy access to ampulla
– Morbidity 3%
– Mortality 0.2%

27. NBD-gram
• Nasobiliary drainage for external drainage
• Advantages
• Sample for culture in purulent cholangitis
• Injection of radio opaque dye  delineate CBD without need for
repeated ERCP

28. PTC/PTBD
• PTC
– Indicated to image proximal biliary tree
– Replaced by MRCP
– PTC alone rarely indicated
– Performed with PTBD
– PTBD- relief of cholangitis

29. PTC
• Advantages
– Provides direct imaging of bile ducts
– Potential for simulataneous therapeutic intervention
– Useful for lesion proximal to common hepatic duct
– Disadvantages
– more difficult with non-dilated intrahepatic bile duct
– Morbidity- 3%
– Mortality 0.2%

30. HIDA Scan
• No role in evaluation of jaundice
• Since it is not taken up by liver once bilirubin levels exceeds 7-
9gm%
• Value in diagnosis of acute Cholecystitis and
• For follow up after bilio-enteric anastomosis to confirm
patency of anastomosis

31. Comparison of different imaging
modalities
Test Sensitivity % Specificity %
Ultrasound 55-91 82-95
CT scan 63-96 93-100
MRCP 82-100 92-98
ERCP 89-98 89-100
PTC 98-100 89-100

32. Approach
• First step is to detemine if jaundice is medical or surgical
• Commonest disease is viral hepatitis in which there is
prodrome of malaise, anorexia
• Sensistivitiy of history, physical examination, blood test alone
range from 70-90%
• Specificity approx. 75%

33. Obstructive janudice VS Viral hepatitis
Obstructive jaundice Viral hepatitis
History RUQ pain
Fever, rigors
Prior biliary surgery
Older age
Anorexia, malaise, myalgis
Known infectious exposure
Receipt of blood
products/iv drugs
Jaundice in family/locality
Examination Abdominal tenderness
Fever
Abdominal masses
Scar of previous surgery
Ascitis
Stigmata of Liver disease
Investigations Elevated ALP
PTI normalizes with VIT K
Positive imaging
Elevated AST/ALT
PTI does not normalizes
with Vit K
Positive serological tests

34. Approach
• Clinical impression confirmed with investigations  LFT
• Provisional Dx obstructive jaundice
• Investigations are directed towards the casue
• USG good modality gives provisional DX in most cases
– And guides what future investigations should be done
• MRCP is done in next step
• Tumor markers are required only if imaging suggests a malignancy

35. Child Pugh Score
• Most widely used and best validated prognostic index
• Correlated with individual survival
• predicts the operative risk
• Applicable for all intervention
• Elective surgery should not be done in grade B or C

36. Variable 1 2 3
Encephalopathy Nil Slight to moderate Mod - severe
Ascites Nil Slight Mod- severe
Bilirubin mg.dl <2 2-3 >3
Albumin g/dl >3.5 2.8-3.5 <2.8
Prothrombin index >70% 40-70% <40%
Grade A 5 0r 6
Grade B 7-9
Grade C 10-15