Obstructive jaundice

1. Imaging Of
Obstructive
Jaundice
Presented by:
Dr. Bahaa Ahmad

2. introduction
• Jaundice manifests as yellow discolouration of the skin,
mucous membranes and sclerae.
• It is a clinical sign of hyperbilirubinemia (>2.5 mg/dl).
• It has many causes which can be largely divided into two
types:
 non-obstructive, i.e. pre-hepatic and hepatic causes
 obstructive, i.e. post-hepatic causes
• Imaging has a major role in detecting the obstructive causes.

3. Causes of obstructive jaundice
• Make Effective Presentations
• Using Awesome Backgrounds
• Engage your Audience
• Capture Audience Attention

4. Causes of Obstructive Jaundice
• Intraluminal causes:
 Gall stones
 Tumor.
 Ascariasis & Schitosomiasis
• Mural causes:
 Malignant stricture-cholangiocarcinoma
 Benign stricture- Scelerosing cholangitis
• Extrinsic Causes:
 Ca Head of Pancreas
 Periampullary Carcinoma,
 Portal LN
 Cholodochal cyst
 Mirizi syndrom.

5. Imaging Modalities:
A. Direct study :
1. Plain abdomen radiography .
2. U/S.
3. C.T., MRI.
4. ERCP .
5. Direct contrast study : operative cholangiogrophy,
P.T.C and post-operative - T-tube cholangiography.
6. Indirect contrast study : oral cholangiography is
contra-indicated in obstructive jaundice. iv
cholandiography.
7. fine needle biopsy.
B. Indirect study Ba. meal I.V.P.

6. Plain Abdominal X-ray
 Usually of little value.
 It can visualise the pathology which causes the obstruction :
a. Stones  radio-opaque stone in G.B. or hartmann’s pouch :
b. Calcification 
Calcified bladder wall  porcelain G.B  potentially malignant
(consequent to chronic inflammatory change).
Calcification in the pancreas  Chronic pancreatitis.
c. Gas in biliary tree  gall stone ileus/ post ERCP or
sphenctrotomy.
d. Paralytic ileus  acute pancreatitis and acute cholecysitis.
e. Bone  erosion, 2ries,  malignancy.

7. Gall bladder stones

8. Porcelain Gall Bladder

9. Gas in Biliary Tree (aerobilia)

10. Gas in Biliary Tree (aerobilia)

11. Ultrasound
Value 
1. Demonstration of dilated ducts.
2. Level of the obstruction.
3. Nature of the obstructed segment.
4. Deposits and Ascites.

12. Ultrasound
a. Gall stones :
b. Chronic cholecystitis :
- Gall stones.
- Wall thickening > 4 mm.
- - Contracted G.B. with no lumen.
c. Bile duct stones : visualize the stone and the dilated
C.B.D > 9mm
d. Pancreatic lesions: Acute pancreatitis  Chronic
pancreatitis  Benign tumour pancreatic carcinoma.

13. Gall bladder stones

14. CBD stone & dilatation/ IHBRD

15. Sclerosing cholangitis

16. Pancreatic Mass

17. Kaltaskin tumor (Hilar cholangiocarcinoma)

18. C.T. in obstructive jaundice
1. It is of value in distinguishing between extra or intra-hepatic cholestasis.
2. Dilated bile ducts  lower attenuation  linear or circular structures which
don’t enhance with contrast.
3.Dilated CBD  dilated tubular structure in porta-hepatis or pancreatic head.
4. In acute pancreatitis.
5. In chronic pancreatitis.
6. In pancreatic carcinoma.
7. Lymph node in the porta-hepatis  can be diagnosed early by C.T.

19. CT in biliary Obstruction

20. CT in biliary Obstruction

21. MRI & MRCP in obstructive jaundice
• MRI and MRCP are now routinely being used as the primary imaging modalities of the
hepatobiliary system .
• Excellent non-invasive and accurate imaging technique without the use of ionising radiation
and in many cases without the need for IV contrast.
• MRCP has been shown to have an overall 96–100% accuracy for the level of obstruction and
90% accuracy for the cause of obstruction .
• The main limitations of MRI:
 patients with claustrophobia
 patients with pacemakers
 the limited ability to offer therapeutic intervention.

22. MRI & MRCP in obstructive jaundice
Normal MRCP Biliary obstruction

23. MRI & MRCP in obstructive jaundice

24. MRI & MRCP in obstructive jaundice
Distal obstruction Sclerosing cholangitis

25. ERCP
Value:
• visualize both the biliary and pancreatic duct systems.
• obstruction relieve by the removal of stones, sphincterotomy and placement of stents and
drains.
• The addition of cholangioscopy to the ERCP allows for biopsies and brushings within the ducts.
Limitations:
• limited capacity to image the biliary tree proximal to the site of obstruction.
• cannot be performed if altered anatomy prevents endoscopic access to the ampulla .
Complications:
• Pancreatitis
• Perforation,
Biliary Peritonitis, Sepsis,
• Hemorrhage
• Adverse Effects From The Dye And The Drug Used To Relax The Duodenum

26. ERCP in obstructive jaundice

27. ERCP in obstructive jaundice

28. ERCP in obstructive jaundice

29. Percutaneous Transhepatic Cholangiopancreatography (PTC)
Value:
• useful for lesions proximal to the common hepatic duct.
• Biliary obstruction relief.
Limitations:
• The technique is not easy and requires considerable experience
Complications:
• Cholangitis.
• Peritonitis, Sepsis.
• Hemorrhage.
• Subphrenic abscess, and lung collapse
• Adverse Effects From The Dye .

30. Percutaneous Transhepatic Cholangiopancreatography (PTC)

31. Endoscopic US
Value:
• combines endoscopy and US to provide remarkably detailed images of
the pancreas and biliary tree.
• overcomes the limitation of evaluation of distal CBD by transabdominal
sonography.
• It is very accurate in diagnosing CBD calculi.
• It also picks up small resectable pancreatobilary mass with high
sensitivity (93-100%).
• allows diagnostic tissue sampling via EUS-guided fine-needle aspiration
.
Limitations:
• lack of expertise, availability of echoendoscopes, need for conscious
sedation

32. Indirect studies (Ba. meal)
a. Tumour in the pancreatic body and head may cause obstruction in the
pyloric antrum  duodenal loop  extrinsic invasion or compression.
b. cancer head---- Widening of the C. loop.
d. f. Lymphoma of the stomach  LN at portahepatis  Jaundice.

33. THANK
YOU