obstructive jaundice

1. Obstructive jaundice
Dr Suhas U

2. • Jaundice occuring secondary to blockade of
any duct that carries bile from liver to
gallbladder or from gallbladder to small
intestine.

3. TYPES
A PREHEPATIC
HEPATIC
POSTHEPATIC
HAEMOLYSIS
OBSTRUCTIVE OR
SURGICAL

4. ANATOMY

5. Bile (exocrine secretion of liver )
50% drain
into
duodenum
50% into GB

6. Causes
• Causes in lumen
• Causes in wall
• Causes from outside
• Benign
• Malignant

7. In the lumen
• CBD Stones (m/c)
• Stones in pancreatic
duct
• Biliary atresia
• Hydatid cyst of biliary
tree
• Ova / cysts
In the wall
• Periampullary carcinoma
• Choledochal cyst
• Stenosis at papilla
• Cholangiocarcinma
• Klatkin’s tumour
• Stricture bile duct

8. From outside
• Ca head pancreas
• Chronic pancreatitis
• Lymph nodes

9. 1. Congenital:Biliary atresia, choledochal cyst.
2. Inflammatory:Ascending cholangitis, sclerosing cholangitis.
3. Obstructive:CBD stones, biliary stricture, parasitic infestation.
4. Neoplastic:Carcinoma of head or periampullary region of
pancreas, cholangiocarcinomas, Klatskintumour.
5. Extrinsic compressionof CBD by lymph nodes or tumours.

10. • Benign

11. Symptoms
• PAIN
• YELLOW DISCOLOURATION SKIN &M.M.
• DARK URINE [TEA COLOUR]
• CLAY COLOUR STOOL
• ITCHING
• FEVER IF CHOLANGITIS SUPERVENE
• LOSS OF APPETITE
• LOSS OF WEIGHT IN MALIGNACY

12. Signs
• LOSS OF Wt. IN MALIGNANCY
• TOXIC IN CHOLANGITIS,
[CHARCOT`S TRIAD,;PAIN, FEVER ,JAUNDICE,
REYNALD’S PENTAD -SHOCK & CONFUSION ]
• YELLOW DISCOLOURATION OF SKIN,M.M.
• TROISIER`S SIGN. VIRCHOW`S NODE
• TENDER R.U.Q.[IN CHOLANGITIS]
• COURVOISIER` LAW[IN CA.HEAD OF PAN.]
• ABDOMINAL MASS
• ASCITES[IN MALIGNANCY]

14. Investigations
• Blood investigations - CBC , LFT, RFT, serology
, prothrombin time , anitmicrobial antibody,
tumour markers
• Urine for bilirubin
• Imaging – invasive / non invasive

15. LFT
• Increased conjugated
bilirubin
AST/SGOT
• Intracellular
• Type 2 specific
• Less specific
ALT/SGPT
• Specific to liver
• Intracellular
• Mild elevation –
obstructive jaundice
• Severe elevation –
cholangitis

16. Alkaline phosphotase
• Membrane bound enzyme
• Apical part of hepatocytes
• Osteoblasts , kidney, salivary glands,
• Hepatic origin – increased GGT , 5’-
nucleotidase

17. GGT
• Liver , biliary tract,
pancreas diseases with
duct obstruction
• Extreme sensitivity
limits its use
Serology
• To rule out hepatitis

18. Prothromin time ratio (INR)
• Factors I,II,V,VII,VIII,IX,X,XIII – liver
• Factors II,VII,IX,X- vitamin K dependent
Obstructive jaundice with
increased INR
Parenteral Vit K
INR not improve, then liver
disease

19. Imaging – non ivasive
USG abdomen
• 1st modality of investigation
• IHB diameter – 2mm
• CHD - <4mm
• CBD - <5-7mm
• Differentiate extrahepatic from intrahepatic
causes
• Limitations – specific cause and exact level, CBD
stones , obese

20. CT abdomen with contrast
• More accurate and specific cause and level
• Limited value in CBD stones , radiation
exposure, expensive

21. MRCP/ MRI
• Sensitive non invasive test biliary , pancreatic
stones ,strictures, dilatation
• Extent of disease
• No need of contrast
• Less risk compared to ERCP
• Limitations – contraindications to MRI

22. Imaging – invasive
ERCP
• Lesions distal to bifurcations of hepatic ducts
• With cholangioscopy to biopsy
• Therapeutic intervention can be planned
• Limitations – proximal to obstruction , altered
anatomy
• Complications -

23. PTC
• Lesions proximal to CHD
• Fluoroscopic guidance , iodine based contrast
• Liver is punctured to enter pheripheral IHB
• Complications – allergic reaction ,
peritonitis,sepsis, cholangitis, subhrenic abscess ,
• Accuracy – 90%,
• Reserved for use if ERCP failed / altered anatomy
precludes access to ampulla..
• Drainage

24. Treatment
• Stabilisation
• Surgery

25. Preoperative management
• Prevention of renal failure
• Correction of coagulation status
• Prevention of cholangitis
• Preoperative biliary drainage

26. Renal failure
Causes
• Vomiting
• Inadquate oral intake
• Bile salt induced
diuresis
• Fasting for
investigations
Prevention
• Adequate IV hydration
• Bile salts administration
• Dopamine / diuretics
• Biliary drainage

27. Coagulation failure
• Malabsorption of vit K and hence its
dependent factors
• Parenteral Vit K administration and reasses
• Abnormal INR – CLD- freeze dried plasma
(clotting factors)

28. Cholangitis
• m/c in stones
• Instrumentation
• Gut failure
• Bacterial translocation
• Decreaed Kupffer cell activity
• Monomicrobial vs polymicrobial
• Gram negatives – E.coli , klebsiella, proteus
• Antibiotics – III gen cephalosporins with anaerobic coverage

29. Jaundice
• Level of jaundice – risk factor
• External or internal drainage
• Normal physiology restored with internal.
• Complications of bacterial colonisation with
both precludes its use.

30. Treatment

31. Stones
CBD stones
• ERCP with removal
m/c method
Failures – large , intrahepatic, multiple stones, altered
anatomy , impacted stones
• CBD exploration + darinage – laparoscopic / open
Laparoscopic – transcystic / trsnsductal
Open CBD exploration

32. Stones
Intrahepatic stones
• Percutaneous stone extraction with roux en Y
hepaticojejunostomy
Pancreatic duct stones
• ERCP+sphicterotomy +stone removal + stents

33. Acute cholangitis
• Adequate hydration
• IV antibiotics
• Endoscopic / percutaneous stone removal
unsuccessful
• Open CBD exploration with T tube drainage

34. Primary sclerosing cholangitis
• Choleretic agents – UDCA
• Immunosuppressive therapy
• Symptomatic – balloon dilatation of dominant
strictures
• Orthotopic liver transplantation

35. Biliary strictures
• ERCP+ sphincterotomy +
baloon dilatation + stent
placement
unsuccessful
• Roux en Y proximal biliary to
jejunal anastomosis

36. Choledochal Cysts
• Type I – simple excision +
cholecystectomy+
Roux en Y HJ
• Type II – simple excision
Abnormal ABPJ – roux en Y HJ
• Type III- transduodenal excision
• Type IV – extrahepatic – type I
intrahepatic – partial hepatectomy
• Type V – partial hepatectomy / liver transplantation

37. Gallbladder cancer
Polyps >1cm – open cholecystectomy
Cancer detected following cholecystectomy
T1a – sufficient
T1b/T2 – radical cholecystectomy
GB carcinoma preoperatively
Advanced locoregional disease
Diagnostic laparoscopy with proceed
Advanced disease at presentation
Palliation for jaundice , pain , intestinal obstruction

38. Cholangiocarcinoma
• Distal –
pancreaticoduodenectomy
• Proximal –
en bloc resection of CBD + hepatic parenchyma + regional nodal
tissue
Bismuth collaret classification
I and II – CBD resection + cholecystectomy + Roux en Y
II – partial hepatic resection
III and IV – complex resection , reconstruction of portal vein, hepatic
artery
Palliation – unresectable / uncurable disease

39. • IV fluids and antibiotics
• ERCP with stent placement
• Pancreaticoduodenectomy/ whipple’s
When malignancy cannot be ruled out
Chronic pancreatitis

40. WHIPPLE`S OPERATION
Pancreatico-duodenoctomy
Ca head pancreas/ Periampellulary Ca

42. BENJAMIN CLASSIFICATION