Approach to a case of Obstructive jaundice

approach to a case of obstructive jaundice
and the rationale of doing these investigations
a simplified approach

1. SPEAKER DR SUPREET KUMAR JUNIOR RESIDENT 1 ST YEAR GUIDE : DR J N MISHRA INVESTIGATIONS AND THEIR RATIONALE IN OBSTRUCTIVE JAUNDICE

2. INTRODUCTION Jaundice, or icterus, is a yellowish discoloration of tissue resulting from the deposition of bilirubin. Tissue deposition of bilirubin occurs only in the presence of serum hyperbilirubinemia and is a sign of either liver disease or, less often, a hemolytic disorder

3.    I. INDIRECT HYPERBILIRUBINEMIA      A. Hemolytic disorders      1. Inherited     a. Spherocytosis, elliptocytosis     Glucose-6-phosphate dehydrogenase and pyruvate kinase deficiencies     b. Sickle cell anemia     2. Acquired     a. Microangiopathic hemolytic anemias     b. Paroxysmal nocturnal hemoglobinuria     c. Spur cell anemia     d. Immune hemolytic      B. Ineffective erythropoiesis     1. Cobalamin, folate, thalassemia, and severe iron deficiencies     C. Drugs     1. Rifampicin, probenecid, ribavirin     D. Inherited conditions     1. Crigler-Najjar types I and II 2. Gilbert's syndrome      II. DIRECT HYPERBILIRUBINEMIA     A. Inherited conditions B. Acquired conditions C. Extra hepatic obstrn     1. Dubin-Johnson syndrome 2. Rotor's syndrome

4. CAUSES Intrahepatic extrahepatic intraductal extraductal Cirrhosis Hepatitis Drugs Neoplasm Stone disease Biliary stricture Parasites PSC Aids related cholangiopathy Biliary TB Secondary to neoplasm Pancreatitis Cystic duct stones

5. drugs cholestasis gallstone Acute cholestatic injury Hepatocellular necrosis Anabolic steroids chlorpromazine Thiazide diuretics amoxyclav Acetaminophen isoniazid Typically, drug-induced jaundice appears early with associated pruritus, but the patient's well-being shows little alteration. Generally, symptoms subside promptly when the offending drug is removed

6. Clinical classification Of Obstructive Jaundice (Benjamin Classification )

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

8. 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

9. 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 Stenosis of the Sphincter of Oddi

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

11. INVESTIGATIONS IN OBSTRUCTIVE JAUNDICE LABORATORY INVESTIGATIONS RADIOLOGICAL INVESTIGATIONS

12. Cause of obstruction

13. ROUTINE INVESTIGATIONS 1. HB 2. TLC 3. DLC 4. RFT ( serum urea, serum creatinine, serum sodium, serum potassium ) 5.BLOOD SUGAR

14. TESTS FOR ASSESSMENT OF LIVER FUNCTION

15. Tests for liver functioning Based on detoxification & excretory function Enzymes indicating liver injury Measure biosynthetic function Damage to hepatocytes cholestasis Serum bilirubin Urine bilirubin Blood ammonia Aspartate aminotransferase Alanine aminotransferase Alkaline phosphatase 5 nucleotidase GGT Serum albumin Serum globulin Coagulation factors

16. Bilirubin Rise by 25-43 micromol/ litre /day Mechanism of hyperbilirubinemia --- Biliary venous & biliary regurgitation of conjugated bilirubin due to disruption of tight intracellular junction --- Trans hepatocytic regurgitation due to reversal of the secretory polarity of hepatocytes --- Rupture of dilated canaliculi in to sinusoids due to necrosis of hepatocytes

17. BILIRUBIN METABOLISM

18. SGOT AND SGPT LEVELS SGOT (AST)/ ASPARTATE TRANSAMINASE * Marker for hepatocellular toxicity * Along with ALT is considered biomarker for liver health * Non specific * 2 isoenzymes * Normal Values…. MALES 8-40 IU/L FEMALES 6-34 IU/L

19. SGPT ( ALT ) / ALANINE AMINOTRANSFERASE * Better predictor of hepatic injury than SGOT alone * Significant elevations in HEPATITIS INFECTIOUS MONONUCLEOSIS CHF * NORMAL VALUES IN MALES < 50 IU/L FEMALES < 32 IU/L

20. ALKALINE PHOSPHATSE *Most sensitive indicator Of EXTRA HEPATIC BILIARY OBSTRUCTION * Factor responsible are Biliary component regurgitation Increase in hepatic synthesis * Biliary component is secreted by BILIARY DUCTULAR ENDOTHELIUM * Normal range 20-140 IU/L * May remain elevated for a long time even after the obstruction is relieved

21. GAMMA GLUTAMYL TRANSFERASE & 5’NUCLEOTIDASE GGT * Predominantly used as a marker for liver diseases * enhanced sensitivity for detection of BILIARY OBSTRUCTION if correlated with ALKALINE PHOSPHATASE * NORMAL VALUE 0-51 IU/L 5’ NUCLEOTIDASE * An enzyme synthesized in liver * Values if grossly elevated is indicative of biliary obstruction * NORMAL VALUE 2-17 UNITS/L

22. Measure biosynthetic function serum albumin normal value 3.5 – 5.5 gm /dl prothrombin time normal value 12 – 14 sec

23. URINE ANALYSIS 1 Bile salts 2 Bile pigments 3 Urobilinogen STOOL EXAMINATION 1 Occult blood

24. RADIOLOGICAL EVALUATION OF BILIARY TRACT INTRA OP METHODS PRE OPERATIVE METHODS PLAIN ABDOMINAL X RAY ABDOMINAL USG ENDOSCOPIC USG CT M R C P ERCP PTC BILIARY SCINTILLOGRAPHY PER OP CHOLANGIOGRAPHY INTRA OP BILIARY ENDOSCOPY LAPROSCOPIC USG

25. 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

26. PLAIN X RAY * Cholelithiasis in 10-20 % of patients with radio opaque stones * Radiolucent gas in a BI and TRI RADIATE FISSURE, in centre of stone * May sometimes show rare cases of calcification of GB (PORCELAIN GB ) * Gas in wall of GB ( EMPHYSEMATOUS CHOLECYSTITIS) * SPECKLED CALCIFICATION in the head of pancreas suggestive of CHRONIC PANCREATITIS * DUCT DILATATION WILL NOT BE REVEALED IN PLAIN FILMS

27. RADIO OPAQUE STONES IN GALL BALDDER

28. PORCELAIN GALL BLADDER

29. GAS IN GALL BLADDER AND ITS WALLS

30. ABDOMINAL ULTRASONOGRAPHY * Is the initial imaging modality of choice as - it is accurate - readily available - quick to perform - inexpensive OPERATOR DEPENDANT AND MAY GIVE SUBOPTIMAL RESULTS DUE TO EXCESSIVE BODY FAT AND BOWEL GAS * Biliary obstruction is characterized by BILIARY DILATATION THIS DILATATION MAY BE CONSPICUOUSLY ABSENT IN 15 % OF PATIENTS * Prospective evaluation of USG suggests that level of obstruction can be defined in 90 % of the cases

31. * COLOR FLOW DOPPLER SONOGRAPHY may assist in distinguishing dilated ducts from Portal venous and Hepatic arterial branches * Provides useful information about the nature and etiology of BILIARY OBSTRUCTION * Mass lesion visualization is possible THE RELIABILITY WITH WHICH A BENIGN DISEASE MAY BE DISTINGUISHED FROM A MALIGNANT PROCESS REMAINS UNCLEAR * Upper limits of normal diameter of CBD-8mm CHD-6mm

32. ENDOSCOPIC ULTRASOUND (EUS) Combines Endoscopy and US Higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs. 20 MHz) and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA). EUS has been reported to have up to a 98% diagnostic accuracy in patients with obstructive jaundice 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%) and to have a much greater positive predictive value (100% vs. 25%), although the two have equal sensitivity (67%). The positive yield of eus-fna for cytology in patients with malignant obstruction has been reported to be as high as 96%.

33. Endoscopic ultrasonography. CBD, common bile duct; PD, pancreatic duct.

34. COMPUTED TOMOGRAPHY * Unlike USG CT is less affected by body habitus and is less operator dependant * It allows visualisation of the liver, bile ducts, gall bladder and pancreas and is particularly useful in detecting hepatic and pancreatic lesions and is the modality of choice in the staging of cancers of the liver, gall bladder, bile ducts and pancreas. * It can identify the extent of the primary tumour and defines its relationship to other organs and blood vessels * Improvements in CT technology, such as multidetector scanners, which allow for three-dimensional reconstruction of the biliary tree have led to greater diagnostic accuracy and have increased the accuracy of CT in assessing benign disease.

35. Computed tomography scan demonstrating a gallstone within the gall bladder (arrowed).

36. Computed tomography scan demonstrating a hilar mass .

37. Intraductal stones appear as target sign on ct CT. 75-88% sensitive, 97%specific for Choledocholithiasis 79%sensitive, 100% specific for gallstones

38. . MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) Noninvasive test to visualize the hepato biliary tree No contrast Fluid found in the biliary tree is hyper intense on T2-weighted images. Surrounding structures do not enhance and can be suppressed during image analysis. Sensitive in detecting biliary and pancreatic duct stones, strictures, or dilatations within the biliary system. MRCP combined with conventional MR imaging of the abdomen can provide information about surrounding structures (eg, pseudocysts, masses). ERCP and MRCP similarly effective in detecting malignant hilar and perihilar obstruction MRCP is better able to determine the extent and type of tumor as compared to ERCP

39. Absolute contraindications cardiac pacemaker cerebral aneurysm clips ocular or cochlear implants Fluid stasis in the adjacent duodenum or ascitic fluid may produce image artifacts on MRCP, making it difficult to clearly visualize the biliary tree.

40. MRCP Showing Choledocholithiasis

41. MRCP is also highly accurate MRCP sensitivity 88-92%, specificity 91-98% in detecting Choledocholithiasis

42. Endoscopic retrograde cholangio pancreatography (ERCP ) Its an invasive procedure and has therapeutic potential . Allows biopsy or brush cytology Stone extraction or stenting COMPLICATIONS Pancreatitis Cholangitis Hemorrhage Sepsis CONTRAINDICATIONS Unfavorable anatomy Pseudo cyst Red a/c pancreatitis

43. ERCP film showing Choledocholithiasis

44. Endoscopic retrograde cholangiopancreatography: partial occlusion of the bile duct by a malignant stricture

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

46. Transhepatic cholangiogram showing a stricture of the common hepatic duct

47. Radioisotope scanning * Technetium-99m (99mTc)-labelled derivatives of iminodiacetic acid (HIDA, IODIDA) when injected intravenously are selectively taken up by the retroendothelial cells of the liver and excreted into the bile. * This allows for visualisation of the biliary tree and gall bladder. In 90 per cent of normal individuals the gall bladder is visualised within 30 minutes following injection with 100 per cent being seen within 1 hour * Non-visualisation of the gall bladder is suggestive of acute cholecystitis. If the patient has a contracted gall bladder as often seen in chronic cholecystitis, the gall bladder visualisation may be reduced or delayed. * Biliary scintigraphy may also be helpful in diagnosing bile leaks and iatrogenic biliary obstruction.

48. It can identify and quantitate the leak thus helping the surgeon determine whether or not an operative or conservative approach is warranted Dimethyl iminodiacetic acid (HIDA) scan.

49. INTRA OPERATIVE TECHNIQUES A. PER OPERATIVE CHOLANGIOGRAPHY * During open or laparoscopic cholecystectomy, a catheter can be placed in the cystic duct and contrast injected directly into the biliary tree. The technique defines the anatomy and in the main is used to exclude the presence of stones within the bile ducts *A single x-ray plate or image intensifier can be used to obtain and review the images intraoperatively *In addition, care should be taken when injecting contrast not to introduce air bubbles into the system as these may give the appearance of stones and lead to a false-positive result

50. Normal common bile duct: gentle The common bile duct is dilated infusion of contrast with multiple Stones which passes without hindrance into the duodenum.

51. Operative biliary endoscopy (choledochoscopy) * At operation, a flexible fibre optic endoscope can be passed via the cystic duct into the common bile duct enabling stone identification and removal under direct vision * The technique can be combined with an x-ray image intensifier to ensure complete clearance of the biliary tree. * After exploration of the bile duct, a tube can be left in the cystic duct remnant or in the common bile duct (a T-tube) and drainage of the biliary tree established *After 7–10 days, a track will be established. This track can be used for the passage of a choledochoscope to remove residual stones in the awake patient in an endoscopy suite.

52. LAPROSCOPIC ULTRASONOGRAPHY * At laparoscopy the use of laparoscopic probe can be used to image the extra hepatic biliary system * Useful in BILIARY & PANCREATIC tumor staging and identify the primary tumors and determine its relationship to the major vessels such as hepatic artery, superior mesenteric artery , portal vein and superior mesenteric vein