This document provides an overview of the approach to surgical jaundice. It defines obstructive jaundice as a failure of bile to reach the intestine due to a mechanical obstruction. The causes of obstructive jaundice include gallstones, tumors, strictures, and pancreatitis. A thorough history, physical exam, and lab and imaging tests are needed to determine the cause and guide treatment, which may include procedures like ERCP or surgery to relieve the obstruction.

1. Approach to Surgical
Jaundice
SUPERVISOR: DR MOHAMAD ZUFAR
PRESENTER: NUR AINA IZZATI BINTI ZAKARIAH
AHMAD ARIFUDDIN BIN AHMAD ADAM

2. DEFINITION
PATHOPHYSIOLOGY
CAUSES
CLINICAL FEATURES
INVESTIGATIONS
TREATMENT

3. DEFINITION
 Jaundice is yellowish discoloration of skin, sclera and mucous membrane
because of increased level of bilirubin in blood (> 3mmol/L)
 OBSTRUCTIVE JAUNDICE is a failure of normal amount of bile to reach
intestine due to mechanical obstruction of the extrahepatic biliary tree or
within the porta hepatis

5. PATHOPHYSIOLOGY
 Impaired excretion of bilirubin
 Impaired delivery of bilirubin into intestine
“surgically relevant jaundice” or obstructive jaundice
“Cholestasis” refers to the latter two, impaired excretion and obstructive
jaundice

6. CAUSES OF
JAUNDICE

7. CAUSES OF OBSTRUCTIVE JAUNDICE

8. HISTORY & CLINICAL FEATURES
 Yellowish discoloration of sclera
 Pain in RHC
 Fever, rigors and chills – symptoms of cholangitis
 Tea-colored urine
 Pale stool
 Anorexia, nausea, vomiting
 Pruritis – result of bile salt retention
 Any history suggestive of gall stones
 Any H/O blood transfusions, hospital admissions, previous operation, travel
history, needle prick, sexual contact – to exclude risk factors of viral hepatitis

9. PHYSICAL EXAMINATION
 Vitals: Is patient haemodynamically stable? Any fever?
 General inspection: Jaundice. Pallor? Any abdominal distension, leg swelling?
 Peripheries: Stigmata of chronic liver disease? Scratch marks? Conjunctival pallor?
 Abdomen - Any scars of abdominal surgery? - Generalised distension? Ascites could be due to:
• 1. malnutrition (low albumin)
• 2. peritoneal malignancy
• 3. obstruction of portal vein by cancer
 - Hepatomegaly? (Could be due to metastatic disease, or primary liver pathology)
 Enlarged gallbladder? (Courvoisier’s law – if the gallbladder is palpable with painless
obstructive jaundice, cause is unlikely stones)
 Splenomegaly? (Portal hypertension – think prehepatic, hepatic, posthepatic)
 DRE: Pale stools?
 Cervical and supraclavicular lymph nodes
 Bony tenderness
 Respiratory examination

10. INVESTIGATIONS
1. Bloods
 LFT - bilirubin raised (+/- direct>indirect; Normal 3:7) + raised ALP and GGT
(only order when diagnosis is ambiguous)
 FBC – any infection, anaemia (to be corrected before ERCP)
 RP – dehydration, Cr level for suitability of CT imaging
 Amylase - concomitant pancreatitis
 PT/PTT – any prolonged PT from vitamin K malabsorption, liver dysfunction
(to be CORRECTED before procedures like ERCP)
 Tumour markers – CA 19-9, CEA ( Cholangiocarcinoma and Pancreatic CA)
 Blood c/s if febrile and jaundiced (TRO HBS sepsis)
 GXM – in case of op (eg. cholecystectomy)

11. 2. Imaging (Ultrasound versus CT - Both useful in demonstrating dilated biliary system
as well as site & cause of obstruction)
 U/S HBS: Best for imaging stones
• US findings:
i. Choledocholithiasis: Duct dilation>8mm (impt to identify dilated INTRAhepatic
ducts as it indicates that (a) obstruction is more severe (b) PTC is a possible
option if ERCP fails)
ii. Gallstone disease / Cholecystitis: GB stones or sludge, thickened GB wall,
pericholecystic fluid, fat stranding
iii. Complications of gallstones:
iv. Liver consistency (fatty or cirrhotic)
Disadvantages:
i. Unable to detect malignancy well
ii. Unable to detect distal CBD stones well
iii. Sensitivity reduced with fat patient habitus
iv. Operator dependent

12.  CTAP:
• Indications
i. Suspected perforated GB
ii. Rule out malignant etiology
• Advantages:
i. Preferred if there is a suspicion of malignancy (Ca pancreas or periampulary
cancer)  define the tumour (T) better & stage at the same time (N & M)
ii. Logistics (can be done earlier esp cholangitis patient to plan for early
intervention)
 CXR
• ARDS in cholangitis
• Pleural effusion