A presentation that will help clinicians attain the basic diagnostic skills required to effectively manage patients.

1. SURGERY
OBSTRUCTIVE JAUNDICE
DR. CHONGO SHAPI (BSc. HB, MBChB)

2. OBSTRUCTIVE JAUNDICE/
SURGICAL JAUNDICE
Definition
Jaundice amenable to surgical treatment –usually due to
extra hepatic obstruction in the flow of bile.
Common causes include:
1.Cholelithiasis/choledocholithiasis
2.Pancreatic head carcinoma
3.Common bile duct strictures mostly iatrogenic-ERCP
and cholecytectomy.
4.Cholangiocarcinoma
5.Choledochocele ,Choledochal cysts and congenital
atresia
6.Infections
- Parasitic-Clonorchis sinesnsis and Ascaris
Lumbricoides
- Opportunistic infections in HIV-Cryptosporidium,
CMV, Microsporidia, TB adenitis
7.Other Tumours- Hepatoma, lymphomas, stomach
cancer ,Colorectal cancer, Ampullary cancer of
Duodenum, Gallbladder Adenocarcinoma
8. Pancreatic pseudo- cysts
CHOLELITHIASIS
-Cholelithiasis is the presence of gallstones in the
gallbladder. The spectrum of gallbladder disease in
cholelithiasis ranges:
1) Asymptomatic gallstones-Up to 90%
2) gallbladder colic/biliary colic.
3) Cholecystitis
4) Choledocholithiasis
5) Cholangitis
-Gallbladder colic is pain caused by a stone temporarily
obstructing the cystic duct or common bile duct (CBD)
-Cholecystitis is inflammation of the gallbladder from
obstruction of the cystic duct or CBD
(choledocholithiasis or common bile duct stone)
-Cholangitis is infection of the biliary tree.
Pathophysiology:
Three types of gallstones exist.
(1) Cholesterol (most common)
(2) Pigment-calcium bilirubinate-15%
(3) Mixed stones
-Impaired gallbladder motility, bile stasis and bile
content alteration predispose people to the formation of
gallstones
-An increase in the cholesterol concentration or a
decrease in the bile salt concentration results in
supersaturation of bile with cholesterol, and the
formation of a liquid crystalline phase of cholesterol.
-Normally, bile salts (ursodeoxychilic and cheno
deoxycholic), lecithin, and phospholipids help to
maintain cholesterol as a solute in the bile.
-When bile is supersaturated with cholesterol, it
crystallizes and forms a nidus for stone formation.
Cholesterol stones are the most common type of stone
Calcium and pigment also may be incorporated in the
stone. Pigment stones, which comprise 15% of
gallstones, are formed by the crystallization of calcium
bilirubinate. Diseases that lead to increased destruction
of red blood cells (hemolysis), abnormal metabolism of
hemoglobin (cirrhosis), or infections (including
parasitic) predispose people to pigment stones.
Black stones are found in people with hemolytic
disorders. Brown stones are found in the intrahepatic or
extrahepatic duct and are associated with infection in
the gallbladder.
-Usually mild jaundice, deep jaundice suggestive of
choledocholithiais
-Itchiness of the body
-Dark urine and pale stool
Crohn's disease, terminal ileal resection, and jejunoileal
bypass
Clinical presentation
Biliary colic
-Due to impaction of a stone in the neck of the
gallbladder. The severe pain starts abruptly in the
epigastrium, often after a heavy meal, and lasts for
several hours. Pain is usually intense for 1 to 4 hours
and then resolves slowly, leaving vague residual ache
or soreness. (stone drops back into the fundus of the
gallbladder or migrates out of the common duct into
the duodenum)
-It usually constant and is associated with restlessness,
vomiting, and sweating.
-The pain may radiate through to the back rarely to
radiate to the shoulder, as in acute cholecystitis.
-General examination may disclose a patient in obvious
severe pain(writhing in bed), with a mild tachycardia
and normal temperature.
-Abdominal examination shows only mild tenderness
in the epigastrium. In contrast to acute cholecystitis,
tenderness over the gallbladder is absent.
Acute cholecystitis
-It is usually due to persistent impaction of a stone in
the neck of the gallbladder.
-The result is initially a chemical inflammation of the
gallbladder wall perhaps due to the mucosal toxin
lysolecithin, produced by the action of phospholipase
on biliary lecithin.
-This is soon followed by bacterial infection
-Because of cystic duct occlusion the inflammatory
process is particularly aggressive and the gallbladder
becomes acutely distended, with accompanying
lymphatic and venous obstruction.
-The serosa may be covered by a fibrinous exudate and
subserosal haemorrhage gives the appearance of patchy
gangrene. The gallbladder wall itself is grossly
thickened and oedematous and the underlying mucosa
may show hyperaemia or patchy necrosis.
-Three grades of inflammation are recognized: acute
cholecystitis, acute suppurative cholecystitis, and acute
gangrenous cholecystitis.
- Rarely an abscess or empyema develops within the
gallbladder, while perforation of an ischaemic area
leads to a pericholecystic abscess, bile peritonitis, or a
cholecystoenteric fistula.
Clinical Presentation
-RUQ Pain becomes severe, constant localizing to the
right upper quadrant, often radiating to the tip right
scapula and hyperalgesia on medial border of
scapula(boas sign)and shoulder
-Pain is worsened by movement especially respiratory
movements.
-Murphy's sign -Patient asked to expire then Palpation
at intersection of 9th
intercostals space and mid
clavicular line patient then inspires, there is inspiratory
arrest during subcostal palpation. Is widely regarded as
pathognomonic of cholecystitis. However, positive in
chronic cholecystitis, acute hepatitis, and a localized
abscess around a perforated duodenal ulcer
-Gallbladder becomes palpable in  50% of cases due
to distension -Nausea and vomiting are usual
-Mild-moderate fever and tachycardia
NB The combination of jaundice; fever, usually with
rigors; and upper quadrant abdominal pain.
Charcots triad.Occurs as a result of cholangitis.
When the presentation also also includes hypotension
and mental status changes, it is known as Reynolds'
pentad

3. DDx of acute cholecystitis
-Acute pancreatitis, Pancreatic cancer
-Perforation of a peptic ulcer, duodenal cancer
-Biliary colic.
-Cholangitis
-Cholangiocarcinoma
-Hepatocellular carcinoma
-Acute appendicitis
-Acute pyelonephritis
A raised white cell count and serum amylase level may
occur in several of these conditions
In the majority of patients with cholecystitis, as with
recurrent biliary colic, the treatment of choice is early
surgery. In most cases, cholecystectomy done after
initial stabilization in 1st
24 hrs.-72 hrs
1. IV Fluids 2. NG tube for decompression. 3.IV
antibiotics 4. Prepare for surgery 5.Analgesia
Risk factors for cholelithiasis
(Fair, fat, fertile, female of forty)
-Female sex
-Dietary influence-fatty diet
-Hypercholesterolemia
-Increased risk in pregnancy
-Oral contraceptive-high estrogen content
- Estrogen replacement therapy
-Obesity
- Rapid weight loss
-Increased hemolysis -sickle cell, thalasemia
-Chronic alcoholism with liver cirrhosis
-Formation of stones increases with age
-Infections (including parasitic)-pigment stones
-Terminal ileal resection, and jejunoileal bypass
-Other illnesses predispose people to gallstone
formation.
Burns, Total parenteral nutrition, Paralysis, ICU care
and
Major trauma
Investigations Cholelithiasis
Imaging
1.Abdominal x-ray-show radioopaque stones if present
2.Abdominal ultrasound
3.MRCP(magnetic resonance
cholangiopancreatography)
Rarely ERCP-diagnostic and therapeutic.
4.CT-scan, tumors are better shown
5.PTC-Percutaneous trans hepatic cholangiography
6.MR Angiograpy
Laboratory
1.FHG-WBC and differential
2.LFT-Alkaline phosphatase and GGT,AST and ALT
Bilirubin –Total and Direct
3.Coagulation screen-, PTI, INR
(INR acceptable for surgery 1-1.5). Patients need to be
given vitamin k prophylaxis 10 mg IM
Complications of cholelithasis
1. cholecystitis(chronic or acute)
2. Acute pancreatitis
3..Acute cholangitis
4.Choledocholithiasis
5. Obstructive jaundice
6.Gallstone ileus
7.Cholangiocarcinoma
8.Liver abscess
9.Biliary-enteric fistula
10.Peritonitis
11.Gallbladder Adenocarcinoma
Management of Cholelithiasis
1.Medical therapy
2.Lithotripsy
3.ERCP and sphincterotomy
3.Cholecystectomy –open or laparascopic
5.Close follow up
1.MEDICAL TREATMENT:
-Gallstone dissolution therapy.
-Cholesterol gallstones can be dissolved by decreasing
the cholesterol saturation of bile.
-The naturally occurring bile salt chenodeoxycholic
acid and the synthetic ursodeoxycholic acid when
given by mouth achieve this.
M.O.A - reducing the hepatic synthesis of cholesterol
rather than by expanding the bile acid pool.
Ursodeoxycholic acid is more efficient at reducing the
cholesterol saturation of bile.
-Unexplained benefit is that some patients experience
relief of their symptoms without much change in the
size of the stones.
-Dissolution therapy can only be used for non-calcified
stones within a functioning gallbladder
-Less than 20 per cent of patients are suitable
candidates
-Unsuitable for patients with acute symptoms and are
less effective in obese patients and in stones >15 mm
-Chenodeoxycholic acid (10-15 mg/kg/day)
ursodeoxycholic acid (8-12 mg/kg/day) and up to( 15
mg/kg/day in obese patients)
-Liver function is carefully monitored and the stones
are measured at 6 months.
-If there has been no reduction in size there is no point
in continuing with treatment. Eighty per cent of small
stones dissolve in 6 months, but larger stones require
up to 2 years treatment.
-Recurence common.
-Useful in patients who are poor anaesthetic risks or
who refuse surgery.
2.EXTRA-CORPOREAL SHOCK WAVE
LITHOTRIPSY
Fragmentation of both gallbladder and common bile
duct stones using high energy sound.
Munich criteria for lithotripsy
1-Functioning gallbladder >50% emptying
2-Stones must be radiolucent
3-Stones should be less than 30 mm in diameter or
40ml in volume
4-Should not be more than three (ideally only one)..
These criteria restrict the use of extracorporeal shock
wave lithotripsy to between 5 per cent and 10 per cent
of patients.
Contraindications
-Pregnancy
-Cholecystitis
-Cholangitis
-Pancreatitis
-Gastroduodenal ulcers

4. Patients are partly immersed in a water bath or placed in
contact with a water cushion. An electromagnetic
impulse, a piezoelectric generator or a high-voltage
spark from an underwater electrode produces a shock
wave that is transmitted through water. The acoustic
impedance of most body tissue is similar to that of
water, while stones have different impedance.
The wave, guided by ultrasound or fluoroscopy to focus
directly at the stone, penetrates the body with only
slight attenuation. When the wave reaches the stone,
tear and shear forces develop, disintegrating it.
Patients generally take an oral gallstone-dissolving drug
such as ursodiol -for one week before lithotripsy and
continue it for at least three months after disappearance
of stone fragments.
3.ERCP and SPHICTEROTOMY
Endoscopic retrograde cholangiopancreatography and
endoscopic sphincterotomy offer effective minimally
invasive effective procedure as the procedure of choice.
4.CHOLECYSTECTOMY-OPEN OR
LAPARASCOPIC
Open cholecystectomy
-Dissecting the Calots triangle is the first step in
cholecystectomy
-Borders of calots triangle are cystic duct laterally, CBD
medially and the inferior aspect of the liver superiorly
-The cystic artery crosses the triangle from left to right,
running behind the bile duct and arising from the right
hepatic artery.
-Once the cystic duct and artery have been definitely
identified, the cystic artery is ligated in continuity and
divided between ligatures.
-The cystic duct is dissected as far as is necessary to
expose a sufficient length for easy cannulation for
operative cholangiography. Any stones in the cystic
duct are milked back into the gallbladder and the cystic
duct is ligated close to the gallbladder.
The dissection of the gallbladder from the liver can
begin either at the fundus or in the region of the cystic
duct.
Complication
Sudden hemorrhage is usually from the cystic artery.
If this cant be controlled by clamping then occluding the
hepatic artery with the fingers and thumb of the left
hand placed across the entrance of the lesser sac
(Pringle's manoeuvre).
Laparascopic cholecystectomy
Laparoscopic cholecystectomy is rapidly replacing open
cholecystectomy
PANCREATIC HEAD CANCER
Pancreatic cancer is the second most common
gastrointestinal malignancy after colorectal cancer,
which affects five times more people.
However, it’s the malignancy with the lowest 5-year
survival.
Age
Malignant neoplasms of the pancreas can occur at any
age, but they are rare before the age of 40: the mean age
of diagnosis is 64 years, after which the incidence
increases rapidly.
Risk factors
1.Cigarete smoking-most consistent risk factor
2.Diet-Fatty diet
3.Assoction with Diabetis mellitus
4.Chronic pancreatitis
5.Exposure to several chemical agents, including
naphthylamine, benzidine, and petrol has also been
linked to pancreatic cancer.
6. Prior surgery in the alimentary tract has also been
implicated as a causative factor. Patients with a history
of gastrectomy have at least a X3 risk
7.Genetic predisposition
Sites
About 75% are in the head and 25% in the body and
tail of the organ.
Pathology
Malignant tumours of the pancreas can occur in either
the exocrine parenchyma or in the endocrine cells of
the islets of Langerhans
Exocrine neoplasms are far more common. Adeno-
carcinoma accounts for around 80 per cent of
pancreatic neoplasms, and is thought to be of ductal
origin.
At time of diagnosis more than 85 per cent of these
tumours have extended beyond the limits of the organ.
Perineural invasion within and beyond the gland is
particularly prominent in this type of cancer, although
lymphatic spread also leads to early metastasis to
adjacent and distant lymph nodes.
The most common sites of extralymphatic
involvement are the liver and peritoneum.
The lungs are the most frequently affected of the extra-
abdominal organs.
Some rare types of cancers with relatively favorable
diagnosis include:
Mucinous cystadenoma-cystadenocarcinoma and the
papillary-cystic tumor mostly occur in women.
Lymphomas constitute up to 5% of pancreatic cancers
are of favorable outcome.
Clinical presentation
1. Epigastric or left upper quadrant of the abdomen
pain ; it has a dull, aching nature and can radiate to the
back.
The patient may experience some relief when lying or
sitting in a flexed or curled position. The pain becomes
more severe as the disease advances.
2. Jaundice-Usually insidious in onset, progressive
deep jaundice associated with severe pruritus. It is
painless in a third of cases.
3. Weight loss, night sweats and generalized fatigue.
Anorexia and vomiting may occur in duodenal
obstruction.
4. Psychiatric disturbances, particularly depression,
which are seen in up to 75 per cent of patients.
5. Gastrointestinal bleeding may also occur; this is
most commonly secondary to gastric or duodenal
invasion by the tumor.
6.Migratory thrombophlebitis

5. Physical exam
In the early stages of pancreatic cancer
1. Jaundice.
2. Evidence of weight loss.
3. Hepatomegaly, which reflects bile duct obstruction.
4. A non-tender gallbladder can be palpated in 50 per
cent of jaundiced patients (Courvoisier's sign).
5. In advanced disease, ascites and a palpable mass are
indicative of an unresectable tumour.
Diagnosis
Imaging
1.Upper abdominal ultrasonography
Demonstrate pancreatic masses, dilation of the
pancreatic duct as well as of the bile duct and
gallbladder, hepatic metastasis.
Shows pancreatic tumours to be less echogenic than the
surrounding parenchyma, and accompanied by changes
in the contour of the gland.
Endoscopic ultrasonography, especially for tumours
located in the head of the pancreas.
2.CT-SCan
Important in delineating the tumour and its local spread
and staging of the tumour.
3. (ERCP)
is a valuable tool in the differential diagnosis of the
cause of obstructive jaundice when pancreatic or other
peri-ampullary cancer is suspected.
. Virtually all pancreatic cancers show abnormalities in
the pancreatogram, these consisting mainly of stenosis
or obstruction of the pancreatic duct.
Laboratory
1.FHG-Hb level
2.LFT-Alkaline phosphatase and GGT, AST and ALT
Bilirubin –Total and Direct.
3.Coagulation screen- PTI, INR.
4.An elevated carcinoembryonic antigen (CEA) has
been noted in over 70% of patients with confirmed
pancreatic neoplasm.
5.The CA19-9 antigen correlate with the degree of
differentiation of the tumor and with advancing stages
of the disease.
6.Percutaneous fine-needle aspiration of the tumour for
cytological examination is invaluable, particularly for
patients with advanced stage pancreatic cancer, who
otherwise would require surgical exploration. The
procedure is usually performed under direct guidance by
ultrasonography or CT.
Management
Pancreatoduodenectomy has been the standard
operation for carcinoma of the pancreatic head since its
demonstration by Whipple in 1935(Whipple surgey)
Variations on this procedure include total, subtotal, and
radical pancreatectomy, as well as the pylorus-
preserving pancreatoduodenectomy
In unresectable tumors palliative surgery involves by
pass surgery. A triple or Double by-pass my be
performed
1.Cholecystojejunostomy-By-pass bile
2. Gastrojenunostomy –tumour head of pancrease
causes obstruction at duodenum and this to by-pass
gastric contents.
3. Jejunojejonostomy-To prevent reflux of bile into the
stomach.
Chemotherapy
Single-agent chemotherapy does not provide
substantive palliation and improvement in survival for
patients with non-resectable pancreatic cancer
The mean survival time after the administration of 5-
fluorouracil (5-FU) is less than 20 weeks, with a
response rate of only 10-15%. Mitomycin,
streptozotocin, ifosfamide, and doxorubicin likewise
provide only a 10-25% response rate without
improvement in long-term survival.