Obstructive jaundice

OBSTRUCTIVE JAUNDICE
BY
DR. FARRUKH IQBAL KHWAJA
( POST-GRADUATE TRAINEE )
( SURGICAL UNIT – I )
( LGH )

ANATOMY
GALL BLADDER
• pear-shaped sac, about 7–10 cm long.
• lying on the visceral surface of the right lobe of the liver in a fossa
between the right and quadrate lobe.
Divided into three anatomic areas : –
• fundus
• the corpus (body)
• the neck .

Gall Bladder Anatomy
• Blood supply : – cystic artery .
• usually a branch of the right hepatic artery
(>90% of the time).
• always found within the hepato-cystic triangle
(triangle of Calot).

Calot’s triangle :
Between inferior surface of liver,
Cystic duct & CHD
Contents:-
Cystic artery, RHA, Cystic lymph
node

Gall Bladder Anatomy
Venous drainage: – either through
(1) small veins that enter directly into the liver
(2) large cystic vein that carries blood back to the portal vein (rarely)
Lymphatic drainage :-
Cystic lymph nodes of Lund ( The Sentinel lymph node)
Nerve supply: –
• Vagus
• sympathetic branches that pass through the celiac plexus

JAUNDICE
Jaundice (is a symptom, not a disease)
Jaundice is a yellow discoloration of the skin, mucus membranes, or
eyes .
(derived from French word ‘jaune’ for yellow)
Now, This yellow color is due to Increased amount
Of “Bilirubin” in the blood (hyperbilirubemia).

LABORATORY AND CLINICAL CO-RELATION
OF HYPERBILIRUBEMIA
Normal Total serum bilirubin = 0.2-1.2 mg/dl
Yellowing of sclera at 2.5-3 mg/dl
Yellowing of skin and mucous membrane at 6mg/dl

TYPES OF JAUNDICE
• PRE-HEPATIC ( HEMOLYTIC ) JAUNDICE
• INTRA-HEPATIC (HEPATOCELLULAR )
JAUNDICE
• POST-HEPATIC (OBSTRUCTIVE) JAUNDICE
(also known as Cholestatic Jaundice
OR EXTRA-HEPATIC OR Surgical jaundice)
BOTH CAN
CAUSE
OBSTRUCTIVE
JAUNDICE

OBSTRUCTIVE (CHOLESTATIC) JAUNDICE
It is caused by a Pathology that block the normal flow of bile from the
liver into the intestine.(cholestasis)
PATHOLOGY causing OBSTRUCTION =OBSTRUCTION causing CHOLESTASIS
BILE PATHOLOGY
FORM INTESTINE
LIVER

SURGICAL JAUNDICE
DEFINITION :-
ALL THOSE JAUNDICE THAT CAN BE TREATED OR
CONTROLLED THROUGH SURGERY .

( Classification according to site )
OBSTRUCTION CAN BE IN TWO PLACES:-
1. INTRAHEPATIC - LIVER CELL DAMAGE/
BLOCAKAGE OF BILE CANALICULI/
COMPRESSION OF THE INTRAHEPAIC PORTION OF
THE BILIARY TREE
2. EXTRAHEPATIC - OBSTRUCTION OF
BILE DUCTS
ONLY INCLUDES INSIDE OF BLUE LINE
(INTRAHEPAIC PORTION OF THE BILIARY TREE)

Classification according to site
INTRAHEPATIC Causes Of Cholestatic Jaundice :-
• Viral / Alcohol Hepatitis
• Primary Biliary / Sclerosing Cirrhosis
• Drugs (e.g. Alcohol , amoxiclav etc. ) and toxins
• Infiltrative disease (e.g. T.B , lymphoma )
• Infection (e.g. Malaria , Leptospirosis )
• Cholestasis of pregnancy
• Total Parenteral Nutrition (TPN)
• Genetic disorders
THEREFORE, not all Obstructive Jaundice is Surgical Jaundice (e.g. hepatitis )
and not all Surgical Jaundice is due to Obstruction (e.g. Hereditary
Spherocytosis whose treatment is Splenectomy)

Classification according to site
• EXTRAHEPATIC ( only main ) Causes Of Obstructive Jaundice :-
• CBD STONES
• CARCINOMA
• BILE DUCT STRICTURES
• BILE DUCT CYST (Choledochal cyst)
• PARASITIC INFESTATIONS
• POST OP. BILIARY STRICTURES
• LYMPH NODE COMPRESSION/MIRIZZI’S SYNDROME
Others : chronic pancreatitis
cystic fibrosis etc.

Classification according to Depth
(extra-hepatic)
1. INTRA-MURAL :-
CBD stones
Parasite (ascariasis)
2. TRANS-MURAL :-
Cholangiocarcinoma
Choledochal Cyst
Strictures
3. EXTRA-MURAL :-
Ca head of pancreas
Peri-ampullary Tumor
Lymph Node
Mirizzi’s Syndrome
Accidental Ligation Of CBD

Classification according to Level Of CBD
(extra-hepatic) ONLY MAIN CAUSES
1. UPPER ONE THIRD :- (Supra-duodenal)
IATROGENIC BLIARY DUCT INJURY
KLATSKIN TUMOR (Proximal Cholangiocarcinoma)
2. MIDDLE ONE THIRD :- (Retro-duodenal)
Gall Bladder Cancer
Mirizzi’s syndrome
Choledochal Cyst
3. LOWER ONE THIRD :- (Pancreatic)
Ca head of Pancreas
Ampullary Tumor
Chronic Pancreatitis
Sphincter Of Oddi Dysfunction
ALL THREE LEVELS :-
Sclerosing Cholangitis
papilloma's of CBD
Cholangiocarcinoma

PATHOLOGICAL CLASSIFICATION OF
CLASSIFICATION DESCRIPTION
• 1. CONGENITAL Biliary atresia
Choledochal cyst
• 2. INFLAMMATORY Ascending cholangitis
Sclerosing cholangitis
• 3. OBSTRUCTIVE CBD stone (most common cause)
biliary stricture(3rd M.C.C),
Parasitic infestation
• 4. NEOPLASTIC Carcinoma head of pancreas (2nd
most common)
Periampullary carcinoma
cholangiocarcinoma
Klatskin tumor
• 5. EXTRINSIC COMPRESSION Lymph node or tumor(Mirizzi’s
OF CBD syndrome)

CLINICAL (Benjamin) CLASSIFICATION
Its mean that A/C to symptoms + labs ,what could be the cause.
Type I
Type II
TYPE III
TYPE IV

Classical Symptoms Of Obstructive Jaundice
• Jaundice
• Itching
• RUQ pain
• Stool becomes white
• Urine becomes dark yellow
OTHER
• G.Weakness and fatigability
• Weight loss
• Loss of appetite
• Anemia
Differentiating Point of Surgical Jaundice from Medical Jaundice

Classical Biochemical (Labs) Changes in
Obstructive Jaundice
1. Conjugated bilirubin
2. Serum ALP
3. GAMMA –GLUTAMYL TRANSPEPTIDASE (GGT)
4. Urine bilirubin +++
5. Urobilinogen will be absent
Blood
Urine

• Type I : Complete obstruction
Classical symptoms + biochemical changes
Causes :
• Tumors : Carcinoma head of Pancreas
• Ligation of the CBD
• Cholangiocarcinoma
• Parenchymal Liver diseases

• Type II : Intermittent obstruction
Symptoms + typical biochemical changes But jaundice may or may not be present
Causes:
• Choledocholithiasis (CBD Stone)
• Periampullary tumor
• Duodenal diverticula
• Choledochal Cyst
• Papillomas of the bile duct
• Intra-biliary parasites
• Hemobilia (refers to bleeding from and/or into the biliary tract)

• TYPE III : Chronic incomplete obstruction
With or without classical symptoms but
pathological changes are present in
bile duct and liver
Causes:
• Strictures of the CBD
1. Congenital
2. Traumatic
3. Sclerosing cholangitis
4. Post radiotherapy
• Stenosed biliary enteric anastamosis
• Cystic fibrosis
• Chronic pancreatitis

• TYPE IV : Segmental Obstruction
one or more segment of intrahepatic biliary tract is obstructed
CAUSES:-
• Traumatic
• Sclerosing cholangitis
• Intra hepatic stones
• Cholangiocarcinoma

Courvoisier's law
Courvoisier's law states that in the presence of a palpable
enlarged gallbladder which is non-tender and accompanied with
mild painless jaundice, the cause is unlikely to be gallstones

Stone Vs Cancer
Classification
(excluding Weight loss Hx)STONE
PAINFULL JAUNDICE
1. NON-PALPABLE = GALLBLADDER
Or CBD SONE
2. NON-PALPABLE =CBD STONE
(On & Off Jaundice)
3. PALPABLE = CBD + CYSTIC
DUCT STONE
(Double impaction)
CANCER
PAINLESS JAUNDICE
1. NON-PALPABLE = KLATSKIN TUMOR
(Prox. Cholangiocarcinoma)
2. PALPABLE = AMPULLARY CANCER
(On & Off Jaundice) (Distal. Cholangiocarcinoma)
3. PALPABLE = CARCINOMA OF HEAD
(Progressive Jaundice) OF PANCEREAS.

OBSTRUCTION + INFECTION
(ACUTE CHOLECYSTITIS VS CHOLANGITIS)
• CHOLECYSTITIS = inflammation of gall bladder
• CHOLEANGITIS = inflammation of bile duct
1. Painful (RUQ) + fever = Acute Cholecystitis
(no Jaundice )
2. Painful (RUQ) + fever + Jaundice = Acute (Ascending) cholangitis
(Charcot’s Triad)
3. Painful (RUQ) + fever + Jaundice = Acute (Ascending) cholangitis
+ Hypotension + Mental status (Reynold’s Pentad)
Change (Shock)

Tokyo Guideline for Acute Cholecystitis
• RUQ Pain/tenderness/Mass
• Murphy’s Sign(RUQ tenderness during inspiration by
examiner’s right subcostal palpation)
• Fever
• WBCs Count
• CRP
• Finding Characteristic of Acute Cholecystitis .
• A
(Local Sign)
• B
(systemic sign)
• C
(Imaging studies)
Suggestive Dx = ONE item in A + ONE item in B
Definite Dx = ONE item in A + ONE item in B + C

INVESTIGATIONS IN OBSTRUCTIVE JAUNDICE
LABORATORY RADIOLOGICAL
INVESTIGATIONS INVESTIGATIONS

GOALS OF INVESTIGATIONS
• Severity of jaundice
• Determine level of obstruction
• Ductal dilatation
• Cause of obstruction

Hepatocellular
Injury
SEVERITY OF JAUNDICE (disease)

SEVERITY OF JAUNDICE (disease)
• BASIC :-
CBC , UCE , RBS
• LIVER FUNCTION TEST (LFTs) :-
Serum bilirubin -----------------------------(Conjugated Bilirubin >> Unconjugated Bilirubin)
Alkaline phosphatase ----------------------(Most sensitive indicator Of EXTRA HEPATIC BILIARY OBSTRUCTION / CHOLESTASIS)
GAMMA-GT ----------------------------------(marker for liver diseases, enhanced sensitivity for detection of BILIARY OBSTRUCTION ,
if correlated with ALKALINE PHOSPHATASE )
Aspartate aminotransferase -------------(Marker for hepatocellular toxicity)
Alanine aminotransferase ----------------(Better predictor of hepatic injury than AST alone)
OTHER TEST :-
Urine bilirubin (URINALYSIS)
Serum albumin -----------------------------(Assess Severity / chronicity )
Serum globulin
Coagulation factors ------------------------( prothrombin time for Assessment of Severity )
Blood ammonia
5-nucleotidase. (Same as GGT)

DETERMINE THE LEVEL OF OBSTRUCTION & CAUSE
(RADIOLOGICAL EVALUATION OF BILIARY TRACT)
PRE OPERATIVE METHODS
• PLAIN ABDOMINAL X RAY
• ABDOMINAL USG
• ENDOSCOPIC USG
• CT
• MRCP
• ERCP
• PTC
• BILIARY SCINTILLOGRAPHY
INTRA OPERATIVE METHODS:-
• PER OP CHOLANGIOGRAPHY
• INTRA OP BILIARY ENDOSCOPY
• LAPROSCOPIC USG

PLAIN X-RAY
• CHOLELITHIASIS :- in 10-20 % of patients with radio opaque stones
• RADIOLUCENT GAS:- in center of stone (Mercedes-Benz sign)
• PORCELAIN GB :- calcification of GB (rare cases)
• EMPHYSEMATOUS CHOLECYSTITIS:- Gas in wall of GB
• SPECKLED (Spotty) CALCIFICATION:- in the head of pancreas suggestive of
CHRONIC PANCREATITIS
DUCT DILATATION WILL NOT BE REVEALED IN PLAIN FILMS

CHOLELITHIASIS
(Radio-Opaque Stones)

SPECKLED (Spotty) CALCIFICATION

ABDOMINAL USG
• Is the initial imaging modality of choice .
• 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.)
So Dilation means Obstruction in USG)
Disadvantages:-
• May be conspicuously absent in 15 % of patients but Prospective
evaluation of USG suggests that level of obstruction can be defined in 90 %
of the cases.
• Operator dependent & may give suboptimal results due to EXCESSIVE
BODY FAT AND BOWEL GAS.

ABDOMINAL USG
• The portal triad in biliary ultrasound scans (Normally), with the portal
vein comprising Mickey's head and the common bile duct and hepatic
artery the ears. . (”Mickey Mouse" sign)
Mickey Mouse" sign (Normal) Mickey Mouse" sign Obliterated

ABDOMINAL USG
(CBD OBSTRUCTION)
DILATION OF CBD AT THE SAME LEVEL AS PORTAL VEIN (“DUBBLE-
BARREL” SIGN)

ABDOMINAL USG
CBD DILATION AND STONE

ABDOMINAL USG
GALLBLADDER STONE

CHOLANGIOCARCINOMA (BILE DUCT TUMOR)
ULTRASOUND

ABDOMINAL USG
CA HEAD OF PANCREAS

ENDOSCOPIC USG
• EUS has been reported to have up to a 98%
diagnostic accuracy in patients with
obstructive jaundice.
• Allows diagnostic tissue sampling via EUS-
guided fine-needle aspiration (EUS- FNA).
• The sensitivity of EUS for the identification
of focal mass lesions in pancreas has been
reported to be superior to that of CT
scanning 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%) and to
have a much greater positive predictive
value (100% vs. 25%), although the two
have equal sensitivity (67%).

ENDOSCOPIC USG
(CA OF HEAD OF PANCREAS)

COMPUTED TOMOGRAPHY ( CT-Scan )
• It allows visualization of the liver, bile ducts, gall bladder and
pancreas.
• It is the modality of choice in the staging of cancers of the liver, gall
bladder, bile ducts and pancreas.
• Improvements in CT technology, such as multi-detector scanners,
which allow for three-dimensional reconstruction of the biliary tree
have led to greater diagnostic accuracy and have increased the
accuracy of CT in assessing benign disease.

MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
MRI + contrast media = MRCP
• Noninvasive test to visualize the hepato-biliary tree (Only Diagnostic)
• Sensitive in detecting biliary and pancreatic duct stones, strictures, or dilatations within
the biliary system.
• MRCP combined with conventional MR imaging of the abdomen can provide information
about surrounding structures (eg, pseudocysts, masses).
• ERCP and MRCP similarly effective in detecting malignant hilar and perihilar obstruction
• MRCP is better able to determine the extent and type of tumor as compared to ERCP
ABSOLUTE CONTRA-INDICATIONS (CIx) :-
1. cardiac pacemaker
2. cerebral aneurysm clips
3. ocular or cochlear implants

MRCP
Klatskin tumor (Cholangiocarcinoma)

MRCP
Pancreatic cancer (Double Duct Sign)

MRCP
(Acute Acalculous Cholecystitis + Mirizzi’s Syndrome)
Acute Acalculous Cholecystitis complicated by extrinsic compression of the common hepatic/common bile duct
by the enlarged and inflamed gallbladder followed by jaundice. Its mechanism is very similar to that of Mirizzi’s
syndrome, when the bile duct is compressed from outside due to a stone impacted in the gallbladder neck or
cystic duct
5-Months later

MRCP
(Primary Sclerosing Cholangitis)

Endoscopic retrograde cholangio-pancreatography
(ERCP )
Endoscopy + Fluoroscopy (X-ray + contrast media) = ERCP
• Its an invasive procedure
• Has Diagnostic & therapeutic potential.
• Allows biopsy or brush cytology
• Stone extraction or stenting (for stricture)
CONTRAINDICATIONS (CIx):-
1. Unfavorable anatomy
2. Pseudo cyst
3. Acute pancreatitis (unless the etiology
of the pancreatitis is gallstone-related
and the therapeutic goal is to improve
the clinical course by means of
stone extraction)
4. Existing bowel perforation

Endoscopic retrograde cholangio-pancreatography
(ERCP )

ERCP in Patients With Sickle Cell Disease
CBD STONE
ERCP showing normal bile ducts with a stone in the lower CBD in one and multiple stones in the other.

ERCP (Bile Leak)
ERCP for two patients showing bile leak from the cystic duct (dotted arrow) and a stone in the bile ducts (solid arrow)
following laparoscopic cholecystectomy in one and dilated bile ducts with stones in the lower CBD in another.

ERCP
(Biliary Stricture Biopsy)

ERCP (Biliary Stricture)
Self-Expandable Metallic Stent (or SEMS)

ERCP
(Klatskin's Tumor)
Klatskin's tumor (in
hepatic duct
bifurcation) in patient
with Primary Sclerosing
Cholangitis

Percutaneous Trans-hepatic Cholangiography
(PTC)
• PTC is indicated when
Percutaneous intervention is
needed and ERCP either is
inappropriate or has failed.
• Can be used to drain biliary
obstructions.

Percutaneous Trans-hepatic
cholangiography is a
diagnostic imaging procedure
that involves the insertion of
sterile 21-gauge cannula or
smaller needle into periphery
biliary radicle with the use of
imaging guidance , followed
by contrast material injection
to delineate biliary anatomy.
The findings are documented
into Radiograph using
multiple projections.
Trans-hepatic cholangiogram
showing a stricture .

HEPATO-BILIARY SCINTILLOGRAPHY
(Radioisotope scanning)
• Technetium-99m (99mTc)-labelled
derivatives of imino-diacetic acid (HIDA,
IODIDA) when injected intravenously are
selectively taken up by the retro-
endothelial cells of the liver and excreted
into the bile
• This allows for visualization of the biliary
tree and gall bladder.
• In 90 per cent of normal individuals the
gall bladder is visualized within 30 minutes
following injection with 100 per cent being
seen within 1 hour
• Non-visualisation of the gall bladder is
suggestive of acute Cholecystitis. If the
patient has a contracted gall bladder as
often seen in chronic Cholecystitis, the gall
bladder visualization may be reduced or
delayed.
• Biliary scintigraphy may also be helpful in
diagnosing bile leaks and iatrogenic biliary
obstruction.

(Acute Cholecystitis)

(Biliary Leak)

INTRA-OPERATIVE
TECHNIQUES
PER-OPERATIVE CHOLANGIOGRAPHY• During open or laparoscopic
cholecystectomy, a catheter can be
placed in the cystic duct and contrast
injected directly into the biliary tree.
The technique defines the anatomy
and in the main is used to exclude the
presence of stones within the bile
ducts
• A single x-ray plate or image intensifier
can be used to obtain and review the
images intraoperatively
• In addition, care should be taken when
injecting contrast not to introduce air
bubbles into the system as these may
give the appearance of stones and lead
to a false-positive result

PER-OPERATIVE CHOLANGIOGRAPHY
CBD stenosis
Per-operative Cholangiography of the patient: A stenosis of the distal common bile duct with
well-arranged margins and regular thinning, revealing chronic pancreatitis.

Operative biliary endoscopy
(choledochoscopy)
• At operation, a flexible fibre optic
endoscope can be passed via the
cystic duct into the common bile duct
enabling stone identification and
removal under direct vision
• After exploration of the bile duct, a
tube can be left in the cystic duct
remnant or in the common bile duct
(a T-tube) and drainage of the biliary
tree established
• After 7–10 days, a track will be
established. This track can be used for
the passage of a choledochoscope to
remove residual stones in the awake
patient in an endoscopy suite.

LAPROSCOPIC ULTRASONOGRAPHY
• At laparoscopy, the use of
Laparoscopic Ultrasound
Transducer can be used to image
the extra hepatic biliary system
• Useful in BILIARY & PANCREATIC
tumor staging and identify the
primary tumors and determine its
relationship to the major vessels
such as hepatic artery, superior
mesenteric artery , portal vein
and superior mesenteric vein

(LapUS)

(LapUS)
(Pancreatic tumor)

Management of Obstructive Jaundice
Perioperative Measures :
• Preoperative biliary Drainage (PBD) improves postoperative morbidity
• Intravenous administration of 5% dextrose saline followed by 10%mannitol
or loop diuretics to prevent renal failure(12 to 24 hours prior to surgery)
• catheterization to monitor output
• Broad spectrum antibiotic prophylaxis
• Parenteral vitamin K +/- fresh frozen plasma
• Need careful post operative fluid balance to correct dehydration
• Correction of hypokalemia
• Cholestyramine and antihistamine for symptomatic relief of pruritis.

Preoperative biliary drainage (decompression)
• Preoperative biliary drainage (PBD) can be achieved by an internal or
external approach. Internal biliary drainage is achieved by
endoscopic placement of a biliary stent and endoscopic
sphincterotomy. External biliary drainage is performed via a fluoro-
guided percutaneous trans-hepatic approach.
• if the value of total bilirubin is more than 5 mg/dl, and the duration of
jaundice is more than 3 weeks. Preoperative biliary drainage improves
the liver function, so that major operations can be safely performed
without major complications.

Treatment of Obstructive Jaundice is based on the cause

Choledocholithiasis
(stones in the CBD)
a)Treatment of choice is stone
extraction through ERCP
b) Mechanical lithotripsy – through
modified dormia basket
c)Through shock waves laser
technology
d)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

Ca Head of Pancreas / Peri-ampullary
Carcinoma/malignancy of lower 3rd of CBD
• Whipple resection
(pancreaticoduodenectomy) is
mainly done which involves
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
Endoscopic sphincterotomy +
stenting with Percutaneous
trans-hepatic biliary drainage

Biliary Strictures
• Strictures are usually treated by
endoscopic stenting which is
comparable to that of surgery, with
similar recurrence rates. 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 with good or
excellent results in 80 to 90% of
patients.
• Stenosis of the Sphincter of Oddi,
endoscopic or operative
sphincterotomy will yield good
results

Obstructive jaundice

More Related Content

What's hot

Similar to Obstructive jaundice

More from Dr. Farrukh Iqbal Khwaja

Recently uploaded

Obstructive jaundice