1. Obstructive jaundice results from obstruction of bile flow from the liver to the duodenum, causing bilirubin levels to rise above 2.5mg/dL and resulting in jaundice. 2. The top 3 causes of obstructive jaundice are choledocholithiasis, strictures, and pancreatic cancer. 3. Evaluation involves clinical examination, blood tests of liver function and markers, ultrasound of the bile ducts, and CT or ERCP to visualize the biliary tree and determine the level and cause of obstruction.

1. Obstructive JaundiceObstructive Jaundice
Dr. Bwanga A.Dr. Bwanga A.

2. What is it?What is it?
 Obstructive jaundice results fromObstructive jaundice results from
obstruction of bile flow to theobstruction of bile flow to the
duodenum.duodenum.
 Jaundice occurs when bilirubin levelsJaundice occurs when bilirubin levels
are greater than 2.5mg/dLare greater than 2.5mg/dL

4. Hyperbilirubinemia: TwoHyperbilirubinemia: Two
Major CategoriesMajor Categories
 Plasma elevation of predominantlyPlasma elevation of predominantly
unconjugated bilirubin due to theunconjugated bilirubin due to the
overproduction of bilirubin, impaired bilirubinoverproduction of bilirubin, impaired bilirubin
uptake by the liver, or abnormalities ofuptake by the liver, or abnormalities of
bilirubin conjugationbilirubin conjugation
 Plasma elevation of both unconjugated andPlasma elevation of both unconjugated and
conjugated bilirubin due to hepatocellularconjugated bilirubin due to hepatocellular
diseases, impaired canalicular excretion,diseases, impaired canalicular excretion,
and biliary obstructionand biliary obstruction

5. EvaluationEvaluation
 The first question to be resolved is
whether the cholestasis results from
intrahepatic or extrahepatic disease
process

6. ExtrahepaticExtrahepatic
 Clinically important clues to
extrahepatic obstructions include:
– abdominal pain
– a palpable gallbladder or upper
abdominal mass
– evidence of cholangitis
– history of previous biliary surgery.

7. IntrahepaticIntrahepatic
 Clinical clues to intrahepatic
cholestasis include:
– Pruritus
– Risk factors (alcohol, medications, sexual
contact, drug hx, needle punctures, travel
history)
– Onset and associated symptoms.

8. Differential Diagnosis ofDifferential Diagnosis of
Bile Duct ObstructionBile Duct Obstruction
 Proximal ObstructionProximal Obstruction
– CholangiocarcinomaCholangiocarcinoma
– LymphadenopathyLymphadenopathy
– Metastatic tumorMetastatic tumor
– Gallbladder carcinomaGallbladder carcinoma
– Sclerosing cholangitisSclerosing cholangitis
– GallstonesGallstones
– ParasitesParasites
– Postsurgical stricturePostsurgical stricture
– HepatomaHepatoma
– Benign bile duct tumorBenign bile duct tumor
 DistalDistal
– CholedocolithiasisCholedocolithiasis
– Pancreatic carcinomaPancreatic carcinoma
– PancreatitisPancreatitis
– Ampullary carcinomaAmpullary carcinoma
– LymphadenopathyLymphadenopathy
– PseudocystPseudocyst
– Postsurgical stricturePostsurgical stricture
– Ampulla of VaterAmpulla of Vater
dysfunctiondysfunction
– ParasitesParasites

10. Top 3 DifferentialTop 3 Differential
 Top 3 Causes are:Top 3 Causes are:
– CholedocholithiasisCholedocholithiasis
– StrictureStricture
– Pancreatic CancerPancreatic Cancer

11. Presenting SymptomsPresenting Symptoms
 Jaundice, dark urine, pale stools, andJaundice, dark urine, pale stools, and
generalized pruritus are the clinicalgeneralized pruritus are the clinical
hallmarks of obstructive jaundice.hallmarks of obstructive jaundice.
 Abdominal pain, systemic symptomsAbdominal pain, systemic symptoms
(eg, anorexia, vomiting, fever), or(eg, anorexia, vomiting, fever), or
additional physical signs reflect theadditional physical signs reflect the
underlying cause.underlying cause.

12. EvaluationEvaluation
 Clinical evaluation is quite sensitive,Clinical evaluation is quite sensitive,
but has a PPV of only about 75%.but has a PPV of only about 75%.
 If obstruction is suspected, then aIf obstruction is suspected, then a
more aggressive work-up ismore aggressive work-up is
appropriate.appropriate.

13. Work UpWork Up
 CBC with Diff, Urea, Creatinine,CBC with Diff, Urea, Creatinine,
electrolytes, LFT’selectrolytes, LFT’s
 Immunological markers,Immunological markers,
immunoglobulins, and serologicalimmunoglobulins, and serological
markers for viral hepatitis can bemarkers for viral hepatitis can be
helpful.helpful.
 Serum AFP, CEA, and CA 19.9Serum AFP, CEA, and CA 19.9

14. Lab ResultsLab Results
 BloodBlood
– Conjugated bilirubin >35 mmol/lConjugated bilirubin >35 mmol/l
– Increase in ALP / GGT >> AST / ALTIncrease in ALP / GGT >> AST / ALT
– Albumin may be reducedAlbumin may be reduced
– Prolonged PTTProlonged PTT

15. UltrasoundUltrasound
 Widely recommended as first-line imagingWidely recommended as first-line imaging
procedure in evaluation of cholestaticprocedure in evaluation of cholestatic
jaundice.jaundice.
 Normal CBD <8 mm diameterNormal CBD <8 mm diameter
 CBD diameter increase with age and afterCBD diameter increase with age and after
previous biliary surgeryprevious biliary surgery
 For obstructive jaundice ultrasound has aFor obstructive jaundice ultrasound has a
sensitivity 70 - 95% and specificity 80 -sensitivity 70 - 95% and specificity 80 -
100%100%
 Hindered by intestinal gas and obesity.Hindered by intestinal gas and obesity.

16. CTCT
 More likely than US to yield information re:More likely than US to yield information re:
level of obstruction.level of obstruction.
 Reasonable first line in pts. With lymphomaReasonable first line in pts. With lymphoma
or where retroperitoneal lymph nodeor where retroperitoneal lymph node
involvement is suspected.involvement is suspected.
 A negative US or CT is not an appropriateA negative US or CT is not an appropriate
stopping pt. in evaluation of a patient withstopping pt. in evaluation of a patient with
suspected obstruction.suspected obstruction.

17. ERCP vs. PTCERCP vs. PTC
 If obstruction is supported by CT or US,If obstruction is supported by CT or US,
direct visualization of the biliary tree withdirect visualization of the biliary tree with
PTC or ERCP is appropriate and necessary.PTC or ERCP is appropriate and necessary.
 PTC and ERCP both have 99% sensitivityPTC and ERCP both have 99% sensitivity
and specificity for the diagnosis of biliaryand specificity for the diagnosis of biliary
obstruction, and both are capable ofobstruction, and both are capable of
demonstrating the site and nature of thedemonstrating the site and nature of the
obstruction in more than 90% of patients.obstruction in more than 90% of patients.

18. ERCP vs. PTCERCP vs. PTC
 ERCP is the procedure of choice inERCP is the procedure of choice in
suspected ampullary or duodenal lesions insuspected ampullary or duodenal lesions in
pancreatic carcinoma and inpancreatic carcinoma and in
choledocholithiasis.choledocholithiasis.
 PTC is preferred when an obstruction lesionPTC is preferred when an obstruction lesion
high in the biliary tree is anticipated.high in the biliary tree is anticipated.
 A negative study obtained by ERCP or PTCA negative study obtained by ERCP or PTC
represents a reasonable endpoint to therepresents a reasonable endpoint to the
work-up of obstruction in the jaundiced pt.work-up of obstruction in the jaundiced pt.

20. ComplicationsComplications
 Ascending cholangitisAscending cholangitis
– Charcot's triad is classical clinical pictureCharcot's triad is classical clinical picture
– Hepatic abscessesHepatic abscesses
 Clotting disordersClotting disorders
– Vitamin K required for gamma-carboxylation of Factors II,Vitamin K required for gamma-carboxylation of Factors II,
VII, IX, XIVII, IX, XI
 Hepato-renal syndromeHepato-renal syndrome
– Renal failure post interventionRenal failure post intervention
– Due to gram negative endotoxinaemia from gutDue to gram negative endotoxinaemia from gut
 Drug MetabolismDrug Metabolism
– Half life of some drugs prolonged. (e.g. morphine)Half life of some drugs prolonged. (e.g. morphine)
 Impaired wound healingImpaired wound healing

21. PerioperativePerioperative
ManagementManagement
 Preoperative biliary decompressionPreoperative biliary decompression
improves postoperative morbidityimproves postoperative morbidity
 Broad spectrum antibiotic prophylaxisBroad spectrum antibiotic prophylaxis
 Parenteral vitamin K +/- fresh frozen plasmaParenteral vitamin K +/- fresh frozen plasma
 IV access and catheterIV access and catheter
 Pre operative fluid expansionPre operative fluid expansion
 Need careful post operative fluid balance toNeed careful post operative fluid balance to
correct depleted ECF compartmentcorrect depleted ECF compartment

22. CholedocholithiasisCholedocholithiasis
 Patients present with jaundice, acholic stool,Patients present with jaundice, acholic stool,
RUQ pain, and bilirubinuria.RUQ pain, and bilirubinuria.
 LFT’s show elevation of total and directLFT’s show elevation of total and direct
bilirubin and alkaline phosphatasebilirubin and alkaline phosphatase
 RUQ US will reveal an enlarged commonRUQ US will reveal an enlarged common
bile ductbile duct
 Tx is cholecystectomy and common ductTx is cholecystectomy and common duct
exploration, T-tube placement, andT-tubeexploration, T-tube placement, andT-tube
cholangiogram.cholangiogram.
 Cholangitis is commonCholangitis is common

23. CholedocholithiasisCholedocholithiasis
 Accurate prediction of the presence ofAccurate prediction of the presence of
common bile duct stones can becommon bile duct stones can be
difficultdifficult
– If elevated bilirubin, ALP and CBD > 12If elevated bilirubin, ALP and CBD > 12
mm risk of CBD stones is 90%mm risk of CBD stones is 90%
– If normal bilirubin, ALP and CBD diameterIf normal bilirubin, ALP and CBD diameter
risk of CBD stones 0.2%risk of CBD stones 0.2%
 ERCP and endoscopic sphincterotomyERCP and endoscopic sphincterotomy
is investigation of choiceis investigation of choice

24. Bile Duct StricturesBile Duct Strictures
 Usually the consequence of iatrogenicUsually the consequence of iatrogenic
injury.injury.
 Can also be caused by chronicCan also be caused by chronic
pancreatitis, cholangitis, trauma ofpancreatitis, cholangitis, trauma of
passing stones, and duodenalpassing stones, and duodenal
penetrating ulcers.penetrating ulcers.
 Cholangitis is commonCholangitis is common

25. Pancreatic CancerPancreatic Cancer
 Most common periampulary tumor ofMost common periampulary tumor of
the pancreas is adenocarcinoma.the pancreas is adenocarcinoma.
 Classically presents as “painlessClassically presents as “painless
jaundice” although abdominal pain isjaundice” although abdominal pain is
often present (radiates to back alongoften present (radiates to back along
with loss of appetite and weight loss).with loss of appetite and weight loss).

26. Pancreatic CancerPancreatic Cancer
 Tumors producing complete obstruction ofTumors producing complete obstruction of
the common bile duct may be accompaniedthe common bile duct may be accompanied
by marked palpable dilation of theby marked palpable dilation of the
gallbladder (Courvoisier’s sign).gallbladder (Courvoisier’s sign).
 Ampullary tumors may produce intermittentAmpullary tumors may produce intermittent
jaundice because of sloughing of the tumorjaundice because of sloughing of the tumor
and partial relief of the block.and partial relief of the block.