Obstructive jaundice also called surgical jaundice defined as jaundice which can be treated by any surgical procedure or by any intervention. Surgical and medical gastroenterologists play great role in treating such patients , however interventional radiologists also have great role in treating such patients.

1. SHER-I-KASHMIR INSTITUTE OF MEDICAL
SCIENCES, SOURA SRINAGAR, J&K
PATHOPHYSIOLOGY AND MANAGEMENT
OF OBSTRUCTIVE JAUNDICE
MODERATOR : DR. MUBASHIR AHMAD SHAH
PRESENTER : DR. AQIB AMIN

2. • Jaundice (derived from French word “jaune “ for yellow) or icterus (Latin word for Jaundice)
• Yellowing of sclera at 3 mg %
• Bilirubin has got high affinity for elastin and
sclera has high elastin content
• Yellowing of skin and mucous membrane at 6 mg%
• Bilirubin level rise upto 3 weeks then stabilize

4. CLASSIFICATION
PREHEPATIC OR HEMOLYTIC Abnormal red cells , antibodies ,
drugs and toxins ; Thalassemia ;
Hemoglobinopathies ; Gilbert’s
Syndrome ; crigler Najjar
Syndrome
HEPATIC OR HEPATOCELLULAR Viral hepatitis ; toxic hepatitis ;
intrahepatic cholestasis
POST-HEPATIC Extrahepatic cholestasis ;
gallstones ; tumors of bile duct ,
carcinoma of pancreas , lymph
node enlargement in porta
hepatis

5. Failure of normal amount of bile
to reach intestine due to
mechanical obstruction
of the extra hepatic biliary tree
or within the porta hepatis

6. SYMPTOMS
• Yellowish discolouration
• Clay coloured stools
• Tea coloured urine
• Pain abdomen
• Fever pruritis

7. SIGNS
• Scratch skin
• Hepatomegaly
• Dilated abdominal veins
• Edema

8. PHYSIOLOGICAL FACTS
• Total bile flow --- 600ml / day (500-1000ml/day)
• Hepatocyte component is ---400ml/day
• Can be bile salt dependent due to biliary Glutathione and Ductular
bicarbonate secretion cholangiocyte component---150ml/day
• It depends on secretin stimulation
• Total serum bilirubin is 0.3-1.2mg/dl
• With conjugated bilirubin < 15%
• 1mg/dl of bilirubin = 17mmol/L

9. PHYSIOLOGY OF OBSTRUCTION
• Normal secretory pressure of bile is 15-25cm of water
• At 35cm of water there is suppression of bile flow
• High pressure leads to cholangiovenous and cholangiolymphatic
reflux of bile
• Dilation of bile duct and intrahepatic biliary radicals
• IHBR dilatation may be absent there is secondary hepatic fibrosis or
cirrhosis

10. PATHOPHYSIOLOGY
• Increase in biliary pressure leads to
• Disruption of tight junctions between hepatocytes and bile duct cells with
increased permeability
• Reflux of bile contents in liver sinusoids
• Neutrophil infiltration , increased fibrinogenesis and deposition of
reticulin fibres in portal triad
• Reticulin fibres get converted into TYPE 1 Collagen
• Laying down of Collagen fibres leads to hepatic fibrosis obstruction of
sinusoids and secondary biliary cirrhosis and portal hypertension
• Fibrosis can also lead to atrophy of obstructed liver

12. CHANGES IN LIVER BLOOD FLOW
• Acute obstruction Increase in hepatic arterial blood flow
NO changes in portal venous blood flow
• Chronic obstruction Decrease in total liver blood flow , dilatation of
sinusoids and elevation portal pressure

13. CARDIOVASCULAR EFFECTS
• Decreased cardiac contractability
• Reduced left ventricular pressure
• Impaired response to beta agonist drugs
• Decreased peripheral vascular resistance
• Bradycardia due to direct effect of bile salts on SA Node
NET RESULT Hypotensive patient
Exaggerated Hypotensive response to bleeding
More prone to post operative shock

14. RENAL FAILURE
• 10% incidence with 70% mortality
• Factors responsible are Decreased cardiac function
Increased levels of ANP resulting hypovolemia
Decreased effect of bile salts on kidney mediated by
increased PG E2
Endotoxemia
• Resulting in
• Renal vasoconstriction shunting of blood from cortex
• Activation of complement system peritubular and glomerular fibrin deposition leading to cortical and tubular
necrosis

15. IMMUNE SYSTEM
• Defects in cellular immunity
• Impaired T cell proliferation
• Decreased neutrophil chemotaxis
• Defective bacterial phagocytosis
• Depressed function of RE system i.e. kupffer cells

16. WOUND HEALING
• Delayed wound healing
• High incidence of wound dehiscence
• Decreased activity of enzyme propyl hydroxylase in the skin
• This helps in incorporation of proline in collagen
• Defective synthesis of collagen

17. COAGULATION FACTOR DEFECTS
• Prolongation of prothrombin time
• Loss of calcium
• Endotoxin induced damage to factor XI , XII , PLATELETS
• Low grade DIC with increased FDP
• Thrombocytopenia from hypersplenism
• Decreased absorption of fat soluble vitamins A,D ,E,K

18. ITCHING
• Retained bile salts
• Levels doesn’t correlate well
• Itching disappears in terminal liver failure but bile salt level still
increased
• Other theory
• Due to endogenous opiate peptides
• Inducing opioid receptor mediated scratching activity of
central origin

19. BIOCHEMICAL EFFECTS
• Bilirubin
• Rise by 25 – 43 micromole /litre /day
• Mechanism of hyperbilirubinemia
• Biliary venous and biliary regurgitation of conjugated
bilirubin due to disruption of tight intercellular junction
• Trans hepatocytic regurgitation due to reversal of the
secretory polarity of hepatocytes
• Rupture of dilated canaliculi into sinusoids due to necrosis
of hepatocytes

20. ALKALINE PHOSPHATASE
• Most sensitive indicator
• Factor responsible are
• Biliary component regurgitation
• Increase in hepatic synthesis

22. TYPES OF BILIARY OBSTRUCTION
• COMPLETE OBSTRUCTION
• INTERMITTENT OBSTRUCTION
• CHRONIC INCOMPLETE
• SEGMENTAL OBSTRUCTION

23. INTERMITTENT OBSTRUCTION
• Symptoms and typical biochemical changes
• Clinically jaundice may or may not be present
• CAUSES
• CBD stones
• Periampullary tumours
• Duodenal diverticulum
• Choledochal cyst
• Biliary parasites
• Haemobilia

24. CHRONIC INCOMPLETE OBSTRUCTION
• With or without classical symptoms of biochemical changes
• Pathological changes in bile ducts or liver
• CAUSES
• Strictures of CBD
• Stenosis of biliary enteric anastomosis
• Chronic pancreatitis
• Cystic fibrosis
• Sphincter of oddi stenosis

25. SEGMENTAL OBSTUCTION
• One or more segment of intrahepatic biliary tract obstructed
• CAUSES
• Traumatic
• Intrahepatic stones
• Sclerosing cholangitis
• Cholangiocarcinoma

26. BILIARY OBSTRUCTION
INTRINSIC
Ductal calculi
• Primary ------------- develop de novo in bile ducts
• Secondary--------- migrates from gall bladder
Acute cholangitis
Biliary strictures
Sclerosing cholangitis
Parasites
Haemobilia
Cholangiocarcinoma
Periampullary tumours

27. BILIARY OBSTRUCTION
EXTRINSIC
Mirizzi syndrome
Pancreatitis
Pancreatic pseudo cyst
Carcinoma of gall bladder
Carcinoma of pancreas
HCC
Metastatic carcinoma

28. BILIARY OBSTRUCTION
CONGENITAL AND GENETIC DISORDERS
• Biliary atresia
• Choledocal cyst
• Caroli’s disease
• Progressive familial intrahepatic cholestasis
• Primary biliary cirrhosis
• Alpha 1 anti trypsin deficiency
• Tyrosinemia
• Neonatal hepatitis
• Wilson disease
• Dyskinesia of sphincter of oddi

29. MANAGEMENT
OBJECTIVES To establish the cause
To plan appropriate treatment
To prevent complications
To prevent recurrence

31. BIOCHEMICAL TEST
• To detect the presence of liver disease
• Distinguish between various types of liver disorders
• Gauge the extent of liver damage
• Follow the response to the treatment
SHORT COMINGS
• Normal in a patient with serious liver disease
• Abnormal in a patient with no liver disease
• Rarely suggest diagnosis
• Measure only a limited number of liver functions
• Thus no single test enables the clinician to accurately assess the liver’s total
functional capacity

32. TESTS COMMONLY USED ARE
1. Bilirubin---- Urinary bilirubin , Urobilinogen , Serum bilirubin(total ,
direct)
2. Alkaline phosphatase
• ALP levels are elevated in nearly 100% of patients with extra
hepatic obstruction except in some cases of intermittent
obstruction
• Values usually greater than 3 times the upper limit of reference
range ,
and in most typical cases , they exceed 5 times the upper limit
• An elevation less than 3 times the upper limit is evidence against
the complete extra hepatic obstruction

33. AST and ALT
• Serum enzymes that provide evidence of hepatocellular
damage. ALT found primarily in liver , where as AST also
found in heart , kidney , skeletal muscles and brain
• AST is less specific for liver function . The levels of AST
and ALT should be done simultaneously since ALT can
confirm the hepatic origin of the less specific but more
sensitive AST
• In extra hepatic obstruction usually AST levels are not
elevated (<10 times the upper reference limit)

34. GAMMA -GLUTAMYL- TRANSPEPTIDASE(GGTP)
• Correlates with ALP level
• Most sensitive indicator of biliary tract disease
• Better indicator of obstruction in children – levels are independent of
age
• Helpful in the diagnosis of acute biliary tract obstruction in contrast
ALP because ALP requires synthesis of fresh ALP and hence lags
behind the onset of obstruction

35. 5-NUCLEOTIDASE
• The principle value is to confirm the hepatic origin of an elevated ALP
• This is particularly helpful in children , pregnant women and patients
who may have bone disease resulting in rise of ALP
• It is more useful than ALT / GGTP in detecting hepatic metastasis

36. OTHER LAB INVESTINGATIONS
• Prothrombin time
• Serum albumin
• Stool for occult blood
• Presence of occult blood in the stools of a patient with
jaundice must raise the suspicion of malignancy
[THOMAS SIGN]

37. OBSTRUCTIVE JAUNDICE MEDICAL JAUNDICE
Serum bilirubin
 Conjugated
 unconjugated
+++
+
+
+++
Urobilinogen ↓ ↑
Urinary bilirubin + 0
Urinary bile salts + 0
Serum ALP ↑ No change
Serum GGTP ↑ No change
Serum 5-Nucleotidase ↑ No change
Transaminases Mildly raised Markedly raised

38. BILIARY IMAGING
• To confirm the presence of extra hepatic obstruction
• To determine the level of obstruction
• To identify specific cause of obstruction
• To provide complimentary information relating to the underlying
diagnosis(eg staging information in case of malignancy)

39. TRANSABDOMINAL ULTRASONOGRAPHY
• Ultrasound of abdomen is an extremely useful and accurate method for identifying gall stones and
pathologic changes in gall bladder consistent with acute cholecystitis .
• Abdominal ultrasound ,if performed by an experienced operator , should be part of the routine
evaluation of patients suspected of having gall stone disease , given the high specificity ( > 98 %) and
sensitivity ( >95%) of this test for the diagnosis of cholelithiasis .
• In addition to identifying gall stones , ultrasound can also detail signs of cholecystitis such as thickening
of gall bladder wall , pericholecystic fluid , and impacted stone in the neck of gall bladder .
• It is often the initial screening test for patients with suspected extrahepatic biliary obstruction
• Dilation of extrahepatic ( >10mm) or intrahepatic ( >4mm) bile ducts suggests biliary obstruction
• Intraoperative ultrasound is now used frequently to further evaluate intrahepatic lesions , assess
resectability , and determine involvement of vascular structures

41. COMPUTED TOMOGRAPHY
• Integral part in diagnosis of obstructive jaundice
• Sensitivity of CT in detection of CBD stones is about 22 %
• Investigation of choice
• Suspected malignancy of gallbladder ,
extrahepatic biliary system , or near by organs ,
in particular , the head of pancreas
CHOLELITHIASIS

42. CT CHOLANGIOGRAPHY
• Involves IV contrast agents excreted preferentially by the liver
• Excretion and subsequent passage of a contrast
agent , provides a functional dimension not obtained
with conventional magnetic resonance
cholangiography
• Demonstration of bile leaks , biliary communication
with cysts and segmental obstruction

43. MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
• Non invasive
• Investigation of choice for detecting biliary pathology
• No intravenous contrast
• Purely diagnostic
• MRCP uses T2 –weighted imaging with parameters designed to afford best view of bile duct
• Bile has long T2- relaxation time and hence a high signal intensity , so that bile ducts are
easily distinguished from vessels on heavily T2 – weighted images
• Fast , effective , non invasive way to image biliary tract
• demonstrates ductal dilatation and strictures with 95 % sensitivity
• Sensitivity for stone visualization – 75 – 95 % , better than CT or US
• CONTRAINDICATIONS – Pt with pacemaker , cerebral aneurism clips , other metal implants .
• MRCP in a case of PSC showing a long stricture .

44. NORMAL MRCP ANATOMY

45. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
• Provides dynamic information during contrast medium introduction and drainage
• CBD stones
• Sensitivity 90-95 %
• Specificity 92 -98 %
• Offers option of intervention
• Stone extraction
• Sphincterotomy
• Placement of biliary stent

46. ADVANTAGES OF ERCP
• Diagnostic and therapeutic
• Find out obstruction especially in lower part of biliary passage
• Opportunity to take tissue sample
DISADVANTAGES OF ERCP
• Invasive
• Bleeding , pancreatitis , cholangitis, perforation ( 10 %)

47. ERCP showing multiple calculi
( filling defects ) within cystic
and common bile ducts
ERCP following endoscopy papillotomy
Shows a wire basket being used to
fragment , snare and extract biliary calculi

48. ENDOSCOPIC ULTRASOUND
• Detailed imaging of organs in close proximity to the digestive tract
• SENSITIVITY (94 %) and specificity( 95%) --------dx of choledocholithiasis
• Tissue sampling by EUS – guided fine needle aspiration ( EUS –FNA )

49. • EUS and EUS- FNA are sensitive (overall 73%)- cholangiocarcinoma and very specific(97%)in
predicting unresectability
• High detection rates (96 -100%) and staging accuracy of EUS with respect to duodenal or CBD
wall involvement , invasion of the pancreas and portal vein , and spread to regional lymph
nodes
• more accurate than CT and MRI in tumor staging of ampullary neoplasms (EUS 78% , CT 24%
MRI 46%)

50. INTRAOPERATIVE CHOLANGIOGRAPHY
• Mirrizi described the procedure in 1937
• Most commonly used during elective cholecystectomy
• Assess retained stones and to provide clarification of the biliary anatomy
• Diagnosis ---- choledocholithiasis , biliary injury (earlier recognition and correction of biliary
injury)

51. TREATMENT
CONSERVATIVE TREATMENT :
1. FLUID AND ELECTROLYTE THERAPY AND URINE OUTPIT MONITERING
• Dehydration occurs in obstructive jaundice
• Recurrent vomiting
• Decreased intake
• Fever
• Prevention of dehydration , liberal fluid therapy with correction of electrolytes
2. CORRECTION OF COAGULATION DEFECTS
• Decreased absorption of vitamin K
• Liver injury
• Assessment of PT/INR
• Inj vitamin K 10mg OD x 3 days
• Transfuse FFP in emergency situation
3. PREVENTION OF INFECTIONS
• Cholangitis and sepsis
• Gram negative organisms (E.coli , K. Pneumonia)
• Anaerobes
• Cephalosporins , Fluoroquinolones , Metronidazole

52. WORKUP AND MANAGEMENT OF POST HEPATIC JAUNDICE
DUCTAL OBSTRUCTION
SUSPECTED CHOLANGITIS
SUSPECTED
CHOLEDOCHOLITHIASIS
WITH OUT CHOLANGITIS
SUSPECTED LESION OTHER
THAN
CHOLEDOCHOLITHIASIS

53. SUSPECTED CHOLANGITIS
• A clinical picture compatible with acute suppurative cholangitis(Charcot's triad
Or Reynaud’s pentad) is most likely diagnosis of choledocholithiasis
• Appropriate resuscitation , correction of any coagulopathies if present , and administration of
antibiotics
• ERCP is indicated for diagnosis and treatment
• If ERCP is unavailable or is not feasible (because of previous Roux-en-Y reconstruction )
transhepatic drainage or surgery ,may be necessary
• Mainstay of treatment of severe cholangitis is not just administration of antibiotics but rather
the establishment of adequate drainage

54. SUSPECTED CHOLEDOCHOLITHIASIS WITHOUT CHOLANGITIS
• Choledocholithiasis is the most common cause of biliary obstruction
• Strongly suspected if the jaundice is episodic or painful or if USG has shown presence of
Gallstones or Bile duct stones
• Patient with suspected with CBD stones should be referred for LAP cholecystectomy with
either pre-operative ERCP , intra-operative cholangiography
• Preoperative ERCP in this setting of jaundice is preferred
• Diagnostic yield is high
• Therapeutic clearing the CBD of stones in 95% of cases

55. SUSPECTED LESION OTHER THAN CHOLEDOCHOLITHIASIS
• No gallstones are seen
• Clinical presentation is less acute (eg constant abdominal or back pain)
• Associated constitutional symptoms (eg weight loss , fatigue , long standing anorexia )
• Possible causes may be classified into 3 categories depending in the location of obstructing
lesion
• Upper third of biliary tree
• Middle third
• Lower third

56. ETIOLOGY:
UPPER THIRD
OBSTRUCTION
• Polycystic liver
disease
• Caroli's disease
• HCC
• OCH
• Haemobilia
• Cholangiocarcinoma(
klatskin’s tumor)
• Sclerosing
cholangitis
• Papilloma's of bile
duct
MID THIRD
OBSTRUCTION
• Cholangiocarcinoma
• Sclerosing
cholangitis
• Gallbladder cancer
• Choledochal cyst
• Mirrizi syndrome
• Extrinsic nodal
compression
• Iatrogenic bile duct
injury
• Cystic fibrosis
LOWER THIRD
OBSTRUCTION
• Cholangiocarcinoma
• Pancreatic tumours
• Ampullary tumours
• Chronic pancreatitis
• Sphincter of Oddi
dysfunction
• Papillary stenosis
• Duodenal diverticula
• Retro duodenal
adenopathy(lympho
ma , carcinoid)

57. DIAGNOSIS AND ASSESSMENT OF RESECTABILITY
• Involvement of SUPERIOR MESENTERIC VEIN , PORTAL VEIN , THE SUPERIOR MESENTRIC
ARTERY and THE PORTA HEPATIS and on whether there is evidence of significant local
adenopathy or extra pancreatic extension of tumor indicates UNRESECTABILITY
• The majority of lesions will be clearly unresectable ,either because of the presence of hepatic
or peritoneal Metastases .

58. NON OPERATIVE MANAGEMENT
DRAINAGE PROCEDURES

59. • In the majority of patients with malignant obstructions ,
treatment is palliative rather than curative
• Cholangiogram and decompression of obstructed biliary
system
• In the absence of pre existing or concomitant hepatocellular
dysfunction , drainage of one half of the liver is generally
sufficient for resolution of jaundice

60. OPERATIVE MANAGEMENT AT
SPECIFIC SITES
BYPASS AND RESECTION

61. UPPER THIRD OBSTRUCTION
PALLIATION
• Because the left hepatic duct has a long extra hepatic segment
and is more accessible the preferred bypass is a left
hepatojejunostomy

62. RESECTION FOR CURE
• The hilar plate is taken down to lengthen the hepatic duct segment
available for subsequent anastomosis
• A formal hepatectomy is required to required to ensure an adequate
proximal margin of resection
• If the resection is carried out proximal to the hepatic duct bifurcation
,several cholangiojejunostomies have to be done to anastomose
individual hepatic biliary branches
• In cases of left hepatic involvement ,resection of the caudate lobe is
indicated as well

63. MIDDLE THIRD OF OBSTRUCTION
PALLIATIVE
• Surgical bypass of middle third lesions is technically simpler
• HEPATOJEJUNOSTOMY is done distal to the hepatic duct bifurcation
RESECTION FOR CURE .
• tumors in this part usually quite amenable to resection along with the lymphatic chains in the
porta hepatis
• Mirrizi syndrome ….extrinsic obstruction of the cbd , either by causing inflammation of gall
bladder or via direct impingment
• TREATMENT OF THIS SYNDROME HEPATOJEJUNOSTOMY

64. LOWER – THIRD OBSTRUCTION
PALLIATION
• The preferred bypass technique for lower – third lesions is a Roux-en-Y
choledochojejunostomy
• Cholecystojejunostomy carries a higher risk of complications and subsequent development of
jaundice
RESECTION FOR CURE
• Resection of a lower third lesion usually involves a pancreaticoduodenectomy though
transduodenal ampullary resection may be an acceptable alternative for a small adenoma of
the ampulla
• For optimal results , pancreaticoduodenectomy is best performed specialized center
• Postoperative adjuvant therapy may improve the prognosis after resection of a pancreatic
adenocarcinoma

65. PALLIATION IN PATIENTS WITH ADVANCED MALIGNANT DISEASE
• When a patient has advanced malignant disease , drainage of the biliary system for palliation
is not routinely indicated , because the risk of complications related to the procedure may
outweigh the potential benefit
• The best treatment for a patient with asymptomatic obstructive jaundice and liver metastases
may be supportive care alone
• Biliary decompression is indicated if cholangitis or severe pruritis interferes with quality of life
• Stent placed with ERCP to be the palliative modality of choice for advanced disease
• Upper-third lesions may be managed most easily through the initial placement of an
internal/external catheter at the time of ptc.

66. • Metal expandable stents remain patent longer than the large
conventional plastic stents
• RCTs suggest that surgical biliary bypass should be reserved for
patients who are expected to survive for 6 months are longer because
bypass is more palliation at the cost of greater initial morbidity
• When a pancreatic malignancy is present , intraoperative celiac
ganglion should be performed by either prophylactic or therapeutic
pain

68. SCENARIO 1
Choledocholithiasis
• ERCP + sphincterotomy + stone clearance + stenting
Followed by Laparoscopic cholecystectomy (after 4-6
weeks)
or
Choledocholithotomy with cholecystectomy in single
setting

69. ADVANCED LAPARASCOPIC
SURGEONS
LAP. CHOLECYSTECTOMY + LAP. CBD
EXPLORATION

70. TRANSCYSTIC APPROACH TRANSDUCTAL APPROACH
• If CBD stone < 1cm . Via Bile duct
• No need of T-Tube after surgery . Open vertically
• With the cholangioscope , can go upto hepatic ducts .T- Tube for 14 Days
• C/I : Large stone > 1cm , multiple (> 8 stones) . 8th day T- Tube cholangiogram

71. 8th day T-Tube cholangiogram Retained stone
• Heparinizing stone are methyl terbutylether
Burhene technique
• T-Tube x 6weeks ERCP + Sphincterotomy + stone removal
• Cholangioscope via
T-Tube tract
• Not used nowadays

72. IF CBD DIAMETER > 12 MM
1. CHOLEDOCHODUODENOSTOTMY
PROBLEM :- SUMP SYNDROME
2. HEPATOJEJUNOSTOMY
PROBLEM:- ERCP NOT POSSIBLE
ACCESS [HUDSON’S] LOOP CAN BE
DONE

73. SCENARIO 2
STONE IMPACTED AT AMPULLA
NON-DILATED DILATED BILIARY
BILIARY DUCT DUCT
TRANSDUODENAL CHOLEDOCHOENTEROSTOMY
SPHINCTEROPLASTY

74. SCENARIO 3
DISTAL CBD CANCER,PERIAMPULLARY
CANCER , HERAD OF PANCREAS
CANCER S CAUSING OBSTRUCTIVE
JAUNDICE
• WHIPPLES PROCEDURE -
PANCREATICODUODENECTOMY