This document describes a case of obstructive jaundice in an 82-year-old male presenting with progressive jaundice, itching, weight loss, and pale stools. Examination found jaundice, scratch marks, and a palpable gallbladder. Investigations showed elevated bilirubin and alkaline phosphatase consistent with obstructive jaundice. Imaging found a solid mass in the distal common bile duct. The causes, pathophysiology, investigations, and management of obstructive jaundice are then reviewed, focusing on endoscopic or surgical interventions depending on the underlying cause such as gallstones, pancreatic cancer, cholangiocarcinoma. Prognosis depends on factors like type of obstruction and patient

2. OBSTRUCTIVEJAUNDICE
Dr Fazal Hussain Khalil
Post Graduate Trainee
SBW KTH

3. OBJECTIVES
• clinical presentation of surgical Jaundice
• Review the Causes of Jaundice
• Pathophysiology of obstructive jaundice
• Important Investigations
• Management

4. Case Scenario
• 82 yr old male patient presents with
progressive jaundice, itching, loss of weight .

5. History of presenting illness
• Gradually progressive jaundice
• Recurrent episodes of itching
• White stools for last 2 months
• Dark yellow urine
• Generalized weakness & fatigability- 6 months
• Weight loss in last 1 year
• Reduced appetite
• No fever

6. H/o past illness
• No h/o DM, HT, TB, Chest pain
• No previous surgery(no history of cholelethiasis)
Personal History
• Decreased appetite with pale stools
• Normal bladder habits but deep yellowish
• Smoker – 25 yrs
• Non-alcoholic

7. Examination
General Physical Examination:
– Pulse 88/min,BP 110/70
– anemia +, Jaundice ++
– No Lymphadenopathy
– Scratch marks
Per abdomen
– Soft non-tender
– Gall bladder palpable
– No free fluid

8. Routine Investigations
• Hgb: 11.7
• Hct: 35
• WBC: 6000;
• normal differential count
• Platelet: 350,000
• Serum Crea: 1.2 mg
• Total bil: 20 mg;
B1(unconj): 2 mg
B2 (conj): 18 mg
• Alkaline phosphatase: 990 U/L
• CA 19-9: 350 units/ml
• Total protein: 6.5 grams;
• USG-Abd: solid mass in distal CBD, dilated CBD, Intrahepatic Biliary
distension and distended GB

9. • Ct abdomen
Ct abdomen show grossly dilated
intra and extrahepatic biliary channels
With distended gall bladder
And possibilty of periampullary mass
ADVISE ERCP

10. Causes of obstructive jaundice

11. Causes of Obstructive Jaundice
Obstructive jaundice is caused by conditions that block the normal
flow of bile from the liver into the intestines including:
• Cholelithiasis (gallstones)
• Cholangiocarcinoma
• Carcinoma pancreas
• Biliary stricture (mainly iatrogenic)
• Cholangitis (inflammation of the common bile duct)
• Congenital structural defects
• Choledochal cysts(Cysts of the bile duct)
• Lymph node enlargement
• Pancreatitis
• Parasitic infection
• Trauma, including surgical complications

12. Most common cause of obstructive
jaundice in our set up

13. Clinical classification Of Obstructive
Jaundice
(Benjamin Classification)

14. Type I : Complete obstruction
Classical symptoms with biochemical changes
Tumors : Ca. head of Pancreas
Ligation of the CBD
Cholangio carcinoma
Parenchymal Liver diseases

15. Type II : Intermittent obstruction
• Symptoms and typical biochemical changes
• But jaundice may or may not be present
 Choledocholithiasis
 Periampullary tumor
 Duodenal diverticula
 Choledochal Cyst
 Papillomas of the bile duct
 Intra biliary parasites
 Hemobilia

16. TYPE III : Chronic incomplete obstruction
With or without classical symptoms but pathological
changes are present in bile duct and liver
 Strictures of the CBD
Congenital
Traumatic
Sclerosing cholangitis
Post radiotherapy
 Stenosed biliary enteric anastamosis
 Cystic fibrosis
 Chronic pancreatitis ERCP showing distal common bile duct stricture
 Stenosis of the Sphincter of Oddi

17. TYPE IV : Segmental Obstruction
one or more segment of intrahepatic biliary tract is obstructed
 Traumatic
 Sclerosing cholangitis
 Intra hepatic stones
 Cholangio carcinoma

18. Pathophysiology of obstructive
jaundice

19. PATHOPHYSIOLOGY OF
OBSTRUCTIVE JAUNDICE
Obstructive jaundice is a condition in which there is blockage of the flow of bile
out of the liver. This results in an overflow of bile and its by-products into the
blood, and bile excretion from the body is incomplete
Hepatic functions
Protein synthesis,
Reticulo-endothelial function
Hepatic metabolism
Coagulation defect..increased prothrombin time(Decreased absroption of fat solube vitamins A,D,E,K(decreased factor
XI ,XII ,platelets)
Renal functions
Renal vasoconstriction
Activation of complement system causing peritubular and glomerular fibrin deposition leading to
tubular and cortical necrosis
Cardiovascular effects
Decreased peripheral vascular resistance
Bradycardia due to direct effect of bile salts on SA node
Decreased cardiac contractability
Delayed wound healing due to defective synthesis of
collagen

20. Investigations

21. ROUTINE
• Haemoglobin usually decreased in case of malignancy
• Rfts are usually derranged

22. BIOCHEMICAL PROFILE
1.Conjugated bilirubin> increased
2.Urine bilirubin +
3.Urobilinogen will be absent
4.S.ALK PHOSPH RAISED (most sensitive, levels are elevated in nearly 100 % of patients with extra
hepatic obstruction except in some cases of intermittent obstruction.Values usually greater than 3 times
the upper limit of reference range, and in most typical cases, they exceed 5 times the upper limit)
5. GAMMA –GLUTAMYL TRANSPEPTIDASE(GGT) is a sensitive marker of
biliary tract disease is raised
6.5’nucleotidase is raised and its more specific
7.ALT AST may rise
8.Albumin decreased
9.PT prolonged clotting factor decreased
10.RFTs are usually impaired

23. Radiology
• IMAGING GOALS
 To confirm the presence of an extrahepatic obstruction
 To determine the level of the obstruction, to identify the specific
cause of the obstruction
 To provide complementary information relating to the underlying
diagnosis (eg., Staging information in cases of malignancy).
 What is the best therapeutic approach

24. Ultrasound abdomen
– More sensitive than CT for gallbladder
stones and other pathology of gall bladder
– Sensitive for dilated ducts (Dilation of the
extrahepatic (>10 mm) or intrahepatic
(>4 mm) bile ducts suggests biliary
obstruction.)
– Liver parenchymal mass and mets
– Portable, cheap, no radiation,
– But it is operator dependant

26. ENDOSCOPIC ULTRASOUND (EUS)
• EUS has been reported to have up to a 98%
diagnostic accuracy in patients with obstructive
jaundice
• it allows diagnostic tissue sampling via EUS
guided fine-needle aspiration (EUS-FNA)
• The sensitivity of EUS for the identification of
focal mass lesions in pancreas has been reported
to be superior to that of CT scanning, both
traditional and spiral, particularly for tumors
smaller than 3 cm in diameter.
• Compared to MRCP for the diagnosis of biliary
stricture, EUS has been reported to be more
specific (100% vs 76%)

27. Ct scan
• Main role in malignant conditions
mainly for localization of primary
tumors and mets
• Best for Pancreatic
Carcinoma(Highly sensitive for lesion
>1mm)
•Mainly done when ultrasound fail or
when there is ductal dilation on
ultrasound
•also to find level and cause of
obstruction
•and in malignant conditions

28. MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
• Noninvasive test to visualize the hepato biliary
tree
• Entire biliary tree and pancreatic duct can be
seen
• Best for Intra Hepatic stones and
CHOLEDOCHAL CYST
• SINGLE BEST FOR CHOLANGIOCARCINOMA
• MRCP is better to determine the extent and
type of tumor as compared to ERCP

29. Endoscopic retrograde cholangiogram
(ERCP
• Its an invasive procedure and
has therapeutic potential.
• Allows biopsy or brush cytology
• Stone extraction or stenting
COMPLICATIONS
 Pancreatitis
 Cholangitis
 Hemorrhage
 Sepsis
CONTRAINDICATIONS
 Unfav anatomy
 Pseudocyst
 Rec a/c pancreatitis

30. Percutaneous Transhepatic
Cholangiogram (PTC)
• PTC is indicated when
percutaneous intervention is
needed and ERCP either is
inappropriate or has failed.
• Can be used to drain biliary
obstructions.

31. Other investigations
• Oral Cholecystography (OCG)>>> useful when patient has symptoms of cholelithiasis,
but a negative ultrasound.
• also is useful for counting the number of stones present.
• HIDA SCAN- useful in a/c cholecystitis,
• DIAGNOSTIC LAPAROSCOPY-
• ANGIOGRAPHY- abnormal vasc.anatomy
• Tumor markers- CA19-9 , CEA

32. Management of Obstructive
Jaundice

33. Management
Perioperative management of obstructive
jaundice
• Preoperative biliary decompression improves postoperative morbidity
(usually cause increased hemorrhage & infections and is mainly Indicated in severe jaundice
or when there are signs of impending liver failure.Endoscopic internal drainage preferred
over per-cutaneous external drainage
• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or
loop diuretics to prevent renal failure(12 to 24 hours prior to surgery)
• catheterization to monitor output
• Broad spectrum antibiotic prophylaxis
• Parenteral vitamin K +/- fresh frozen plasma
• Need careful post operative fluid balance to correct dehydration
• Correction of hypokalemia
• Cholestyramine and antihistamine for symptomatic relief of pruritis

34. Treatment of Obstructive Jaundice is
based on the cause
1) Cholelithiasis (gallstones)
Ideally ERCP follwed by laproscopic
Cholecystectomy
Or open cholecystectomy with
CBD exploaration

35. 2) Ca Head of Pancreas / Periampullary Carcinoma/malignancy
of lower 3rd of CBD
a) Whipple resection (pancreaticoduodenectomy) is mainly done which
involves removal of
head & neck of pancreas, duodenum, distal 40% of stomach, lower CBD, GB,
upper 10 cm of jejunum, regional L.Ns
and reconstruction through gastrojejunostomy,choledochojejunostmy and
pancreaticojejunostomy
b) If not operable then we go for Endoscopic sphincterotomy + stenting with
Percutaneous transhepatic biliary drainage

36. 3) Ca gall bladder
a) if involving cbd then whipple resection is done
b) And in case of inoperable cases Endoscopic / Radiological stenting is done
4) Choledochal cyst
 Surgical excision of the cyst with Reconstruction of the
extra hepatic biliary tree
 Biliary drainage is accomplished by Choledocho–jejunostomy
with a Roux – en – Y anastamosis
 Long term follow up is necessary because of complications
like cholangitis , lithiasis , anastomotic stricture

37. 5) Cholanchiocarcinoma
Surgery depends on the stage of tumor and may involve
• Removal of the bile ducts
If the tumor is at a very early stage (Stage 1), just the bile ducts containing
the cancer are removed. The remaining ducts in the liver are then joined
to the small bowel, allowing the bile to flow again.
• Partial liver resection
If the tumor has begun to spread into the liver, the affected part of the
liver is removed, along with the bile ducts.
• Whipple procedure
If the tumor is larger and has spread into nearby structures, the bile ducts,
part of the stomach, part of the small bowel (duodenum), the pancreas,
gall bladder and the surrounding lymph nodes are all removed
• If surgery to remove the tumour is not possible, it may be possible to
relieve the blockage through stents through ERCP or PTC

38. 6)Choledocholithiasis (stones in the CBD)
a)Treatment of choice is stone extraction through ERCP
b) Mechanical lithotripsy – through modified dormia basket
c)Through shock waves laser technology
d)Open exploration of common bile duct is indicated in
 Presence of multiple stones (more than 5) and Stones > 1 cm
 Multiple intra hepatic stones
 Distal bile duct strictures
 Failure of ERCP
 Recurrence of CBD stones

39. 7)Strictures are usually treated by endoscopic stenting
which is comparable to that of surgery, with similar
recurrence rates. Therefore, surgery should probably be
reserved for those patients with complete ductal obstruction
or for those in whom endoscopic therapy has failed. Surgery
with Roux-en-Y choledochojejunostomy or
hepaticojejunostomy is the standard of care with good or
excellent results in 80 to 90% of patients.
8) Stenosis of the Sphincter of Oddi endoscopic or
operative sphincterotomy will yield good results

40. Prognostic factors
( Pitt’s score)
Parameters
• Type of
obstruction(malignant or
benign)
• Age > 60 yrs
• S.Alb< 3gm/dl
• S.Bil > 10mg%
• S.Alk P > 100 IU
• S.Creatinine >1.3mg%
• TLC >10000/mm3
• Hematocrit < 30%
Factors Mortality
Upto 2 0%
3 4%
4 7%
5 44%
6 67%
8 100%

41. Thank You