OBSTRUCTIVE JAUNDICE

Dr. Srinivas
Dr. B Srinivas
Dept of Surgery
MNR Medical College

Obstructive jaundice
Definition :
Is a condition
characterized by
Yellow discoloration
of the skin , sclera
& mucous
membrane as a result
of an elevated Sr.
Bilirubin conc. due to
an obstructive cause.

Classification of obstructive
jaundice
Type I : complete obstruction
Tumors : Ca. head of Pancreas
Ligation of the CBD
Cholangio carcinoma
Parenchymal Liver diseases

Type II : Intermittent obstruction

Choledocholithiasis
Periampullary

tumor
Duodenal diverticula
Choledochal Cyst
Papillomas of the bile duct
Intra biliary parasites
Hemobilia

TYPE III : Chronic incomplete obstruction

Strictures of the CBD

Congenital
Traumatic
Sclerosing cholangitis
Post radiotherapy

Stenosed biliary
enteric anastamosis
Cystic fibrosis
Chronic pancreatitis
Stenosis of the
Sphincter of Oddi

ERCP showing distal common bile

duct stricture with proximal
dilation

TYPE IV : Segmental Obstruction

Traumatic
Hepatodocholithiasis
Sclerosing

cholangitis

Cholangio

carcinoma

PATHOPHYSIOLOGY OF OBSTRUCTION

Alterations in
Systemic and renal hemodynamics
Hepatic function

Protein synthesis,
Reticulo-endothelial function
Hepatic metabolism

Hemostatic mechanism
Gastrointestinal barrier
Immune function
Wound healing

Coagulation system

Prolonged bile duct obstruction leads to

significant defects in clotting factors

Before surgery these defects should be

corrected by Fresh frozen plasma and Vitamin K

Even if there is no measurable coagulation

dysfunction Vitamin K should be given to all
patients with obstructive jaundice

Blood

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AlkP AlkP AlkP AlkP AlkP

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Bile

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AlkP AlkP AlkP AlkP AlkP

Blood

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AlkP AlkP AlkPAlkP AlkPAlkPAlkPAlkP

X
Bile

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AlkPAlkPAlkPAlkP

Abnormal LFTs
Obstruction

Hepatitis

Cirrhosis

Bilirubin
Alk phos
ALT/AST
gGT
PT (INR)

What are reliable signs & symptoms (more

than 90% certainty) that a patient with
obstructive jaundice need urgent intervention
?
Fever, persistent
(90%)
Abdominal pain (70%)
Jaundice (60%)
Tea-colored
urine/pale stools
Altered mental status
(10-20%)
Hypotension (30%)
RUQ tenderness

Goal of Treatment

Obstructive Jaundice
Relief of Obstruction
Prevent Complication
Prevent Recurrence

The role of Radiology

Are the ducts dilated
What is the level of obstruction
What is the cause
What is the best therapeutic approach

JAUNDICE

J a u n d ic e
AXR
U lt r a s o u n d

D ila te d d u c ts
S u r g ic a l
G a ll s t o n e s
P a n c r e a tic c a n c e r

U n d ila t e d d u c ts
M e d ic a l
H e p a t it is

Investigations
Non-invasive
AXR
US
CT
HIDA Scintigram
MRI/MRCP

Invasive
ERCP
PTC
Operative
cholangiogram
T-tube cholangiogram
Angiogram
Biopsy

Obstructive Jaundice
CBD stones (Choledocholithiasis) vs. tumor
Clinical

Age < 45
Biliary colic
Fever
Transient spike in AST or amylase

Clinical

features favoring CBD stones:

features favoring cancer:

Painless jaundice
Weight loss
Palpable gallbladder
Bilirubin > 10

Unconjugated vs.
Conjugated
Unconjugated

production exceeds
ability of liver to
conjugate
Ex. Hemolytic
anemia's,
hemoglobinopathies,
in-born errors of
metab., transfusion
rxn.

Conjugated
Can

produce but
not excrete
Intra- or extra
hepatic
obstruction
Metabolic defect

Choledocholithiasis
Defined as stones in the CBD
Patho physiology : intermittent obstruction
of CBD
Often asymptomatic
Symptoms are indistinguishable from other
causes of Biliary pain
Predisposes to Cholangitis & Acute Pancreatitis
Elevated sr. bilirubin & Alk. Phos.

Evaluation
ERCP
Primary

diagnostic
and therapeutic
modality
Sphincterotomy and
stone extraction
Placement of stent if
stone extraction
unsuccessful
Mortality rate 1.5%

Open CBD Exploration

Indications

Presence of multiple stones (more than 5)

Stones > 1 cm

Multiple intra hepatic stones

Distal bile duct strictures

Failure of ERCP
Recurrence of CBD stones after
sphincterotomy

CBD Exploration - SurgicalOptions

Common bile duct exploration with T-tube

decompression

Choledochoduodenostomy

Transduodenal sphincterotomy and

sphincterplasty

Roux-en-Y Choledocho jejunostomy

CHOLEDOCHAL CYSTS
Congenital anomalies of the biliary tract that
manifest as cystic dilatation of the extra
hepatic and intra hepatic bile ducts
Females are most commonly affected

ETIOLOGY :
Congenital weakness of the bile duct wall
Congenital obstruction of the bile ducts
Reo virus association is seen in 78% of patients
40% of anomalies are seen at the junction of
pancreatic and common bile ducts

CLASSIFICATION OF CHOLEDOCHAL
CYST

Proposed by Todani & colleagues

TYPE I : accounts for 80 90 % of cases

exhibit segmental or diffuse fusiform dilatation of the
CBD.

TYPE II : consists of a true Choledochal diverticulum

TYPE III : consists of dilatation of the intra duodenal portion

of the CBD.

TYPE IV : multiple intra hepatic & extra hepatic cysts

TYPE V or CAROLIS disease : consists of single or multiple

dilatation of the intra hepatic ductal system

Clinical features :

Disease often appears during first months of life

80% of pts. have cholestatic jaundice & acholic
stools
Vomiting , irritability & failure to thrive may occur
Spontaneous perforation of a Choledochal cysts
may occur
Progressive hepatic injury due to biliary obstruction

DIAGNOSIS :

BEST established by USG Abdomen

In Older children PTC or ERCP may help define the
anatomy of the cyst.

TREATMENT

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

Cholangiocarcinoma

90% are extra-hepatic

60s and 70s

Highest incidence in Japan, Israel, and Native

Americans

Increased 3 fold in the last 30yrs in the USA

M/F=3/2

Cholangiocarcinoma
Etiology

Ulcerative Colitis

Thorotrast Exposure

Sclerosing
Cholangitis

Typhoid Carrier

Choledochal Cysts

Adult Polycystic
Kidney Disease

Hepatolithiasis
Liver Flukes
Papillomatosis of Bile
Ducts

Cholangiocarcinoma
Extra-hepatic: Distribution
Right

or left hepatic duct = 10%

Bifurcation
Proximal
Distal

= 20%

CBD = 30%

CBD = 30%

Cholangiocarcinoma
Diagnosis and Initial Workup
Jaundice
Wt

loss, anorexia, abdominal pain, fever

US

then CT (CTA?) Followed by ERCP, PTC or

MRCP

CEA

and CA 19-9 can be elevated

Cholangiocarcinoma
Intra-hepatic Disease

Suspicious mass on CT. Quadruple phase CT

with 0.5 cm cuts through the liver and portal
hepatitis. Consider CTA reconstruction.

Treatment

If adenoncarcinoma: look for primary with a

chest CT and upper/lower endoscopy.

Colon, pancreas, and stomach are common

primary sites.

Cholangiocarcinoma
Intra-hepatic Disease-Surgery/Ablation

Extent of surgical therapy is determined by the

location, hepatic function, and underlying cirrhosis.

Anatomic resections have lowest recurrence rates.

However non anatomic resection increases
potential surgical candidates and improves survival

Hepatic devascularization prior to resection is

preferred

Ablative therapy gives good local control.

MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation

Klatskin tumor

ERCP: Distal CBD Cancer

Ca of CBD Bifurcation

Periampullary Carcinoma
and The Whipple

Endoscopic View

Pathology
Adeno

carcinoma accounts for 95%

Arises from 4 different tissues of origin

Head

of pancreas
Distal Bile duct
Ampullary of Vater
Periampullary duodenum

Pathology
Prognosis
Five

for each of these are different.

year survival for pancreas: 18%

Five year for ampulla: 36%
Five year for distal bile duct: 34%
Five year for duodenum: 33%
Determination of tissue origin is important
for prognosis, extent of resection.

Pathology
Determination

of tissue origin from FNA,

endoscopic biopsy.

Also

from thin section CT scan, ERCP

Determination

of k-Ras also helps (95% of

pancreatic cancer).

Spread

Loco regional spread results from lymphatic

invasion and direct tumor spread to
adjacent soft tissue.

Ampullary lesions spread to LN 33%,

typically to a single LN in the posterior
pancreatcoduodenal group.

Duodenal has intermediate spread.

Pancreas metastasizes 88% to multiple

sites.

Treatment

Standard Whipple
pancreaticoduodenectomy thought to
provide adequate tumor clearance in the
case of non-pancreatic ampullary tumor,
because tumor spread is localized.

Biopsy proven paraduodenal LN is thought

by most to preclude curative resection

Surgery and
Chemotherapy

Low risk patients had 5 year local control

and survival of 100% and 80% respectively.

High risk patients had 5 year local control

and survival of 50% and 38%, respectively.

Based on these findings, some have

proposed a course of preoperative
chemoradiation to improve local disease
control in these high risk patients.

Whipple Procedure
Five basic techniques are used to resect
pancreatic cancers
Standard

pancreaticoduodenectomy
Pylorus preserving
pancreaticoduodenectomy
Total pancreatectomy
Regional pancreatectomy
Extended resection (MD Anderson)

Kocherizing the Duodenum

SMA Involved?

SMV Identification

Dividing the Neck

The End Result

Adjuvant Therapy
Autopsy

series show that 85% of patients will

experience recurrence in operative field.

70%

have metastases to liver.

So

need to address local control (radiation)

and distant disease (chemotherapy).

Most

commonly used is 5 FU and this only

has a 15-28% response on its own, but its a
radio sensitizer, so it improves response to
chemo.

Thank you