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Obstructive jaundice management
This document provides an overview of the management of obstructive jaundice. It begins with definitions and classifications of jaundice. Obstructive jaundice can be intrahepatic or extrahepatic in origin. Common causes of intrahepatic cholestasis include viral hepatitis, alcoholic hepatitis, and drug toxicity. Extrahepatic obstructions are often due to choledocholithiasis (gallstones in the common bile duct), tumors, or strictures. Diagnostic imaging includes ultrasound, MRCP, ERCP, and intraoperative cholangiography. Treatment depends on whether the obstruction is pre-operative or discovered during cholecystectomy, and may involve ERCP, laparoscopic or open CBD exploration, or
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Obstructive jaundice management
- 1. Management of Obstructive Jaundice Dr.Al-Mumtin, Ahmed
- 2. Introduction • Definition ofJaundice. • Jaundice vs Hyperbilirubinaemia. • Systemic Approach. • Based on Billirubin metabolism classification.
- 3. • Pre-hepatic, hepaticand post-hepatic. • Differentials. • Conjugated, and Unconjugated Hyperbilirubinaemia.
- 4. Obstructive Jaundice • Intrahepatic. •Extrahepatic.
- 5. Principally • Conjugated hyperbilirubinaemiadue to : • Impaired bile formation (hepatocytes) • Impaired bile flow (bile ducts/ductules)
- 7. Intrahepatic Cholestasis ✴Viral Hepatitis: •Fibrosing cholestatic hepatitis. • Hep. B &C Hep.A, EBV, CMV ✴Alcoholic Hepatitis ✴Drug toxicity • Pure cholestasis- Anabolic & contraceptive steroids • Cholestatic hepatitis- chlorpromazine, erythromycin, Amoxiclav • Chronic cholestasis- chlorpromazine & prochloperazine ✴Primary Biliary cirrhosis ✴Primary Sclerosing cholangitis ✴Vanishing Bile duct Syndrome • Chronic rejection of liver transplant • Sarcoidosis • Drugs ✴ Non hepatobiliary Sepsis ✴ Benign post-operative cholestasis ✴ Para neoplastic Syndrome ✴ Veno-occlusive disease ✴ GVHD ✴ Inherited • Progressive familial intrahepatic cholestasis • Benign recurrent cholestasis ✴ Cholestasis of pregnancy ✴ Total Parenteral Nutrition ✴ Infiltrative diseases • TB • Lymphoma • Amyloidosis ✴ Infections • Malaria • Leptospirosis
- 8.
- 10. Benjamin Classification of ObstructiveJaundice 1983 • Type 1: complete obstruction. • Tumours. • Ligation/clipping of CBD • Cholangiocarcinoma • type 2: Intermittant obstruction. • Choledocholithiasis • periampullary carcinoma • duodenal diverticulae • papillomas of bile duct • choledochal cyst. • Type 3: chronic incomplete obstruction. • Strictures (congenital, iatrogenic, sclerosing, post- radiotherapy) • stenosed biliary-enteric anastomosis • chronic pancreatitis • CF • Stenosis of sphincter of oddi. • Type 4: segmental Obstruction. • Traumatic or iatrogenic • sclerosing cholangitis • cholangiocarcinoma
- 12. • Clinically- • Pruritus, •Fatigue, • Xanthomas, • Hepatic Osteodystrophy: back pain from osteoporosis, • Pale stools, or steatorrhea • Evidence of fat-soluble vitamin deficiency. • Enlarged liver with a firm smooth non-tender edge. • Histologically- • Bile plugs (bilirubinostasis), • Feathery degeneration of hepatocytes (cholate stasis), • Small-bile-duct destruction, • Peri cholangitis, • Portal edema, • Bile lakes and infarcts (typically with extrahepatic obstruction), • Finally , biliary cirrhosis.
- 14.
- 15. Choledocholithiasis • Definition. • 5to 20 percent of patients have choledocholithiasis at the time of cholecystectomy. • Primary vs secondary cholidocholithiasis.
- 16. Clinically • Biliary pain. •Cholestatic Jaundice. • Uncomplicated cholidocholithiasis. • Asymptomatic • RUQ pain. • Nausea and vomiting.
- 17. Clinically • Physical exam: •RUQ, Epigastric tenderness. • Jaundice. • Courvoisier’s sign.
- 18. Laboratory Tests • ALT,AST elevation, 64% sensitive. • Increased Bilirubin; 69% sensitive, 88% specific. • ALP is 57% sensitive, 86% specific. • GGT elevation 84% sensitive. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. AU Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV SO Gastrointest Endosc. 1996;44(4):450.
- 19. • Complicated cholidocholithiasis. •Two major complications: • Pancreatitis. • Nausea, vomiting, high levels of amylase and lipase. • Acute Cholangitis • Charcot’s triad, Renauld’s pentad. • Long standing complications
- 20. Imaging • Transabdominal U/S. •Sensitivity is 20-90%. • Dilated CBD is suggestive of choledocholithiasis. • A “Cutoff” 6 mm may miss cases. A transverse ultrasound in the region of the porta hepatis shows multiple shadowing stones (arrows) within a dilated distal common bile duct.
- 21. Imaging • EUS andMRCP • EUS vs ERCP • MRCP vs ERCP • MRCP vs EUS. • EUS for stones < 6 mm and sludge not detected by MRCP.
- 22.
- 23. Imaging • Intraoperative cholangiogram: •59-100 % sensitive, 93-100% • Operator dependant. • Proponents and Opponents. • Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. AU Gurusamy KS, Giljaca V, Takwoingi Y, Higgie D, Poropat G,Štimac D, Davidson BR SO Cochrane Database Syst Rev. 2015;2:CD010339.
- 24. Imaging • Computed Tomography: •93% sensitive, 100% specific.
- 25. ERCP • Diagnostic andtherapeutic. • High sensitivity and specificity. • Invasive. • Technical expertise is needed. • Prone to complications
- 26. Sclerosing cholangitisMultiple CBDStones Ascariasis in CBD
- 27. Bile duct obstruction fromchronic pancreatitis Biliary stricture, secondary to Cholangiocarcinoma
- 28. PTC • Percutaneous transhepatic cholangiography. •Abnormal anatomy not accessible to ERCP • Failed ERCP • Diagnostic and therapeutic.
- 30. Risk stratification • BarkunAN, Barkun JS, Fried GM, et al. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. Ann Surg 1994;220:32-9
- 31. Diagnosis Tse F, BarkunJS, Barkun AN. The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystec- tomy. Gastrointest Endosc 2004;60:437-48.
- 32. Next In management •The mainstay; Remove the stones. • Early identifications of complications. • Approach begins by the times choledocholithiasis is identified. • Before or After cholecystectomy, ERCP. • Intraoperatively; intra-op ERCP or CBD exploration (laparoscopic or open), or post-op ERCP.
- 33. • Hospital staywas significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004 • No difference in morbidity and success of CBD clearance between the 2 groups • Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02 • Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.
- 34. CBD Exploration • Traditionally;Diagnosed by intraoperative cholangiography and treated by open CBD exploration. • Advances in pre-op imaging and development of less invasive measures improved earlier diagnosis, and treatment. • Potantial existence of CBD stones should be considered for all patients with symptomatic cholelithiasis.
- 35. Indication of CBDexploration • Should be performed in all patients with confirmed CBD stones who are surgical candidates and have failed, or are not candidates for endoscopic therapy. • PTC, electrohydraulic lithotripsy, and laser lithotripsy maybe useful in a small number of selected patients who are not candidates for surgery or endoscopic therapy.
- 36. Surgical Approach • Ifidentified on IOC: • Laparoscopic exploration. • Open exploration. • Post-op ERCP.
- 37. Open vs EndoscopicExploration • SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013). • Conclusion: • Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. • No significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. • No significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. TI Surgical versus endoscopic treatment of bile duct stones. AU Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA SO Cochrane Database Syst Rev. 2013;9:CD003327
- 38. Laparoscopic Exploration • Laparoscopictranscystic exploration • The preferred technique for Laparoscopic exploration. • Provided: • CBD diameter <6 mm • Stone location distal to the cystic duct/CBD junction • Cystic duct diameter >4 mm • Fewer than 6 to 8 stones within the CBD • Stones smaller than 10 mm
- 39. Laparoscopic Exploration • Laparoscopiccholedochotomy: • More difficult technically. • Indication: Failed laparoscopic transcystic exploration or for patients who are not candidates for the transcystic approach. • Indications: • Failed laparoscopic transcystic exploration or preoperative endoscopic stone extraction • Narrow/tortuous cystic duct • Dilated CBD (6 to 10 mm) • Large stones (>10 mm) • Multiple stones • Stone location proximal to the cystic duct/CBD junction.
- 40. • Primary closureof the choledochotomy with interrupted fine monofilament absorbable suture is safer than closure around a T-tube. • Decreased operating time, • Decreased postoperative and biliary complications, shorter time until return to work • Decreased hospital costs. TI Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. AU Gurusamy KS, Samraj K SO Cochrane Database Syst Rev. 2007;
- 41. When to dothe Cholecystectomy?
- 43. Take Home • Obstructivejaundice is a huge spectrum of differentials. • Cause directed management is the key. • Choledocholithiasis is the major entity in the surgical jaundice. • Endoscopy and gastrointestinal specialised personnel is the cornerstone in management. • Narrow window of surgery in the management.
- 44. Controversy Still Exists •Shall we still admit patients with Choledocholithiasis in Surgical wards under Surgical specialties?
- 46. References • Harrison’s Principlesof Internal Medicine, 19th edition. • Goldman-Cecil Medicine, 24th edition • UpToDate (R) • Schwartz principles of surgery • Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632. • Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239:28. • Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg 1992; 163:53. • Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003; 17:1705. • Neuhaus H, Feussner H, Ungeheuer A, et al. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy 1992; 24:745. • Houdart R, Perniceni T, Darne B, et al. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am J Surg 1995; 170:38. • O'Neill CJ, Gillies DM, Gani JS. Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically. ANZ J Surg 2008; 78:487.
- 47. References • Prat F,Meduri B, Ducot B, et al. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999; 229:362. • Fitzgerald JE, White MJ, Lobo DN. Courvoisier's gallbladder: law or sign? World J Surg 2009; 33:886. • Abboud PA, Malet PF, Berlin JA, et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996; 44:450.11 Yang MH, Chen TH, Wang SE, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2008; 22:1620. • Sox HC, Blatt MA, Higgins, MC, et al. Medical decision making, Butterworths, Boston 1988. p.67. • ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1. • Iranmanesh P, Frossard JL, Mugnier-Konrad B, et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial. JAMA 2014; 312:137. • Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012; 5:CD009779. • Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354.
- 48.
Editor's Notes
- #3 Over 20 million Americans are estimated to have gallbladder disease (defined as the presence of gallstones on transabdominal ultrasound or a history of cholecystectomy). Among those with gallbladder disease, the exact incidence and prevalence of choledocholithiasis are not known, but it has been estimated that 5 to 20 percent of patients have choledocholithiasis at the time of cholecystectomy, with the incidence increasing with age Every year 1-3% of people develop gallstones and about 1-3% of people become symptomatic Each year, in the United States, approximately 500,000 people develop symptoms or complications of gallstones requiring cholecystectomy. Gallstone disease is responsible for about 10,000 deaths per year in the United States. About 7000 deaths are attributable to acute gallstone complications, such as acute pancreatitis incidence of gallstones in women is 2-3 times that in men. The difference appears to be attributable mainly to estrogen, which increases biliary cholesterol secretion. Among individuals undergoing cholecystectomy for symptomatic cholelithiasis, 8-15% of patients younger than 60 years have common bile duct stones, compared with 15-60% of patients older than 60 years.
- #13 After 3–5 yrs of jaundice , liver cell failure indicated by deep jaundice, ascites, edema and a lowered serum albumin develops. Pruritus lessens and the bleeding is not controlled by vitamin K. Hepatic encephalopathy is terminal.
- #16 Choledocholithiasis refers to the presence of gallstones within the common bile ductie, formation of stones within the common bile duct) is less common. Primary choledocholithiasis typically occurs in the setting of bile stasis (eg, patients with cystic fibrosis), resulting in a higher propensity for intraductal stone formation. Older adults with large bile ducts and periampullary diverticular are at elevated risk for the formation of primary bile duct stones. Patients with recurrent or persistent infection involving the biliary system are also at risk, a phenomenon seen most commonly in populations from East Asia
- #17 The pain is often more prolonged than is seen with typical biliary colic (which typically resolves within six hours)
- #18 The pain is often more prolonged than is seen with typical biliary colic (which typically resolves within six hours) Abstract BACKGROUND: Variously described as Courvoisier's law, sign, or even gallbladder, this eponymous "law" has been taught to medical students since the publication of Courvoisier's treatise in 1890. METHODS: We reviewed Courvoisier's original "law," the modern misconceptions surrounding it, and the contemporary evidence supporting and explaining his observations. RESULTS: Courvoisier never stated a "law" in the context of a jaundiced patient with a palpable gallbladder. He described 187 cases of common bile duct obstruction, observing that gallbladder dilatation seldom occurred with stone obstruction of the bile duct. The classic explanation for Courvoisier's finding is based on the underlying pathologic process. With the presence of gallstones come repeated episodes of infection and subsequent fibrosis of the gallbladder. In the event that a gallstone causes the obstruction, the gallbladder is shrunken owing to fibrosis and is unlikely to be distensible and, hence, palpable. With other causes of obstruction, the gallbladder distends as a result of the back-pressure from obstructed bile flow. However, recent experiments show that gallbladders are equally distensible in vitro, irrespective of the pathology, suggesting that chronicity of the obstruction is the key. Chronically elevated intraductal pressures are more likely to develop with malignant obstruction owing to the progressive nature of the disease. Gallstones cause obstruction in an intermittent fashion, which is generally not consistent enough to produce such a chronic rise in pressure. CONCLUSION: We hope that reminding clinicians of Courvoisier's actual observations will reestablish the usefulness of this clinical sign in the way he intended.
- #19 Elevated liver enzymes has: Poor positive predictive value. high negative predictive value.
- #20 liver disease > rare secondary biliary cirrhosis. secondary biliary cirrhosis is reversible in chronic pancreatitis and choledochal cysts. but is unknown reversibility in cholidocholithiasis.
- #21 non-invasive, bed-side evaluation, low cost, can evaluate for cholithiasis, choledocholithiasis, and CBD dilation.. TAUS: sensitivity for choledocholithiasis 20-90%, and in a meta analysis of 5 studies, sensitivity for detecting CBD stones is 73% and specificity is 91%. TAUS : has poor sensitivity for stones in the distal common bile duct because the distal common bile duct is often obscured by bowel gas in the imaging field A cutoff of 6 mm is often used to classify a duct as being dilated. However, using a cutoff of 6 mm may miss stones. One study of 870 patients undergoing cholecystectomy found that stones were often detected in patients whose ducts would have been classified as "nondilated" using the 6 mm cutoff [27]. In addition, the probability of a stone in the common bile duct increased with increasing common bile duct diameter: 0 to 4 mm: 3.9 percent 4.1 to 6 mm: 9.4 percent 6.1 to 8 mm: 28 percent 8.1 to 10 mm: 32 percent >10 mm: 50 percent Conversely, because the diameter of the common bile duct increases with age, older adults may have a normal duct with a diameter that is >6 mm.
- #22 Magnetic resonance cholangiopancreatography (MRCP) showing large distally impacted bile duct stone in a patient post Roux-en-Y gastric bypass with jaundice. MRCP and EUS have largely replaced ERCP for the diagnosis of choledocholithiasis in patients at intermediate risk for choledocholithiasis. Both tests are highly sensitive and specific for choledocholithiasis. Deciding which test should be performed first depends on various factors such as ease of availability, cost, patient-related factors, and the suspicion for a small stone. A meta-analysis of 27 studies with 2673 patients found that EUS had a sensitivity of 94 percent and a specificity of 95 percent. A review of 13 studies found that MRCP had a median sensitivity of 93 percent and a median specificity of 94 percent. In a pooled analysis of 301 patients from five randomized trials that compared EUS with MRCP, there was no statistically significant difference in aggregated sensitivity (93 versus 85 percent) or specificity (96 versus 93 percent)
- #23 Small bile duct stone missed by magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP), but shown by endoscopic ultrasound (EUS). This demonstrates the superior sensitivity of EUS for small bile duct stones. A) MRCP showing dilated bile duct with no apparent stone, incidental pancreas divisum. B) EUS in same patient showing very small bile duct stone (<5 mm) (arrow). C) ERCP in same patient showing dilated common bile duct without apparent stone. D) Endoscopic view of extracted stone after biliary sphincterotomy (arrow).
- #24 Proponents of routine intraoperative cholangiography argue that it: permits delineation of biliary anatomy, reduces and identifies bile duct injuries, and identifies asymptomatic choledocholithiasis. Opponents argue that: adds to procedure time and expense. that asymptomatic common bile duct stones may pass spontaneously and/or have a low potential for causing complications, such that their identification may lead to unnecessary common bile duct exploration and/or conversion to open surgery
- #26 The sensitivity of ERCP for choledocholithiasis is estimated to be 80 to 93 percent, with a specificity of 99 to 100 percent requires technical expertise, and is associated with complications such as pancreatitis, bleeding, and perforation
- #31 American Society for Gastrointestinal Endoscopy (ASGE) proposed the following approach to stratify patients based on their probability of having choledocholithiasis
- #32 - The aim of the diagnostic evaluation is to confirm or exclude the presence of common bile duct stones using the least invasive, most accurate, and most cost-effective imaging modality. symptomatic patient, clinically suspecting, labs are suggestive, begin with transabdominal ultrasound.
- #37 papillosphencterotomy
- #41 Absorbable sutures should be used in the bile duct since permanent suture is lithogenic