Causes of obstructive jaundice in surgical patients

This presentation is about surgical obstructive jaundice.

1. OBSTRUCTIVE JAUNDICE By Getachew D.(HPB & Laparascopic Surgeon) June 20,2024 Gc .

2. Jaundice (also termed icterus ) is a condition of yellow discoloration of the skin, conjunctivae, and mucous membranes,resulting from widespread tissue deposition of the pigmented metabolite bilirubin

3. Medical Vs Surgical Jaundice

4. Obstructive Jaundice Benign Biliary Stricture Postoperative (80%) Cholecystectomy Choledochotomy Gastrectomy Inflammatory (20%) Stones Cholangitis Parasitic Pancreatitis Sclerosing cholangitis Radiotherapy Malignant Biliary Stricture/obstruction Intraluminal Bile duct cancer Ampullary carcinoma Extrinsic compression Pancreatic cancer Gallbladder cancer Hepatocellular cancer Congenital Idiopathic Choledocholithiasis

5. Obstructive Jaundice Approach Hx Rapidity of onset & course of jaundice Age and sex Symptoms Change in the color of urine and stool Presence of pruritus Abdominal pain Digestive symptoms Constitutional and other accompanying symptoms

6. Obstructive Jaundice Approach With careful Hx taking, P/E and blood tests overall accuracy of clinical assessmentranges from 87% to 97% a clinical approach alone does not accurately identify the level of biliary obstruction in a patient with post hepatic jaundice Multidisciplinary team approach Developing specific logical algorithms

7. Obstructive Jaundice Approach Hx of exposure any chemical or medication Occupational exposure to hepatotoxins to people with jaundice Sexual activity HIV status Blood contamination to possibly contaminated foods Alcohol consumption Recent travel history

8. Obstructive Jaundice Approach Previous history symptoms goes with gall stone and its complications Joundice,liver disease, Surgery Family Hx Hx of inherited disorders including liver diseases hemolytic disorder

9. Obstructive Jaundice Investigations LAB. TESTS CBC, U/A Hemolysis elevated serum lactate dehydrogenase (LDH) level, a decreased serum haptoglobin level, and evidence of hemolysis on microscopic examination of the blood smear LFT= Tests of liver secretion– Bilirubin, AP cell synthesis-- plasma Alb, prthrombin inflammation– Transaminase levels Helpful in differentiating b/n hepatocellular process and a cholestatic process, a critical step in determining what additional workup is indicated

10. 6/20/2024 Obstructive Jaundice Approach Physical exam:-  Nutritional status  Scleral icterus  virchow 's nodes  The abdominal exam should focus on :- Size and consistency of liver  Large, tender liver with rounded edge --- viral/alcoholic hepatitis  Grossly enlarged nodular liver/abdominal mass--- malignancy  Bruit heard over the liver ---- hepatoma Stigmas of CLD , Ascites ,splenomegaly, Murphy's sign --- A. cholecystitis Courvoisier's gall bladder---malignant obstruction Blood on DRE---malignancy

11. Obstructive Jaundice Investigations isolated hyperbilirubinaemia conjugated >> unconjugated cojugated hyperbilirubinaemia with other biochemical liver test abnormalities  hepatocellular conditions  cholestatic conditions intrahepatic extrahepatic

12. Obstructive Jaundice Charactersic lab findings in jaundice pt

13. Obstructive Jaundice

14. Obstructive Jaundice imaging goals (1) to confirm the presence of an extrahepatic obstruction verify that the jaundice is indeed posthepatic rather than hepatic), (2) to determine the level of the obstruction, the gold standard for defining the level of a biliary obstruction is direct cholangiography , endoscopic retrograde cholangiopancreatography (ERCP) percutaneous transhepatic cholangiography (PTC). (3) to identify the specific cause of the obstruction, and (4) to provide complementary information relating to the underlying diagnosis (e.g., staging information in cases of malignancy).

15. Obstructive Jaundice imaging Ultrasonography differentiating hepatic Vs post hepatic causes of jaundice, suggesting the level of obstruction. identify the presence of extrahepatic ductal obstruction with a high degree of reliability Operator dependant ,Difficalt to see distal cbd/gas shadow may fail to detect a post hepatic cause of jaundice very early in the course of an obstructive process/ HIDA Nondisanable duct secondary to fibrosis/extern compression extensive hepatic fibrosis, cirrhosis, sclerosing cholangitis, and liver transplantation Intermittant obstruction=cholidochololitiasis point to a specific hepatic cause of jaundice (e.g., cirrhosis or infiltration of the liver by tumor).

16. 6/20/2024 19 Obstructive Jaundice imaging Endoscopic Retrograde Cholangiography (ERCP ) distal obstruction Therapeutic interventions: Removal of stones Sphincterectomy Stenting : Dilatation of strictures Placement of biliary drainage Percutaneous Transhepatic Cholangiography(PTC) Proximal obstruction Drainage of intrahepatic ducts

17. 6/20/2024 20

18. ERCP demonstrates extrinsic compression of the common hepatic duct by a stone in Hartmann's pouch. A biliary stent has been inserted for drainage Jaundice has occurred after laparoscopic cholecystectomy as a result of bile leakage from a distal biliary tributary. A stent has been inserted to decrease bile duct luminal pressure and foster spontaneous resolution.

19. ERCP (a) and corresponding MRCP (b) demonstrate presence of a stone in the distal CBD.

20. Obstructive Jaundice imaging Second line tests important considerations=local expertise and cost-effectiveness MRCP and endoscopic ultrasonography (EUS) both appear to be excellent at diagnosing biliary obstruction and establishing its location and nature . MRCP exhibits more modest detection rates when diagnosing small CBD stones. Preferred EUS for periampullary pathologic conditions and MRI with MRCP for more proximal diseases of the biliary tree Spiral (helical) CT scanning useful in diagnosing biliary obstruction and determining its cause , concomitant oral or I.V. cholangiography is required to detect choledocholithias spiral CT, EUS, and MRCP in combination with abdominal MRI are very useful in diagnosing and staging biliopancreatic tumors. Cytology specimens are readily obtained via (FNA) during CT or EUS.

21. Obstructive Jaundice imaging Workup and Management of Post hepatic Jaundice Once US has confirmed that ducal obstruction is present, there are three possible clinical scenarios: 1.suspected cholangitis , ERCP /PTC is indicated for Dx and Rx after appropriate resuscitation , correction of any coagulopathies present, and administration of antibiotics , 2. suspected choledocholithiasis without cholangitis=based on local expert LC with either preoperative ERCP, IO cholangiography/ US preoperative ERCP in this setting of jaundice it allows confirmation of the diagnosis preoperatively it is capable of clearing the CBD of stones in 95% of cases 3.a suspected lesion other than choledocholithiasis. before the decision is made to proceed to cholangiography or operation another imaging modality besides the US should be considered assessment of resectability and operability

22. ERCP demonstrates missing liver segments .PTC of segment VI reveals excluded liver ductal system . MRCP shows the excluded liver segments, as well as the biliary system, which still communicates with the common hepatic duct.

23. Mx of Choledocholithiasis ERCP with distal common bile duct stone prior to cholecystectomy

24. Mx of Choledocholithiasis ERCP and common bile duct stone extraction.

25. Obstructive Jaundice … Choledocholithiasis Complications of CBD stone Obstructive Jaundice Cholangitis Fever, RUQ pain, jaundice = > Charcot’s triad Charcot’s triad + Altered mental status + Shock = > Reynolds’s pentad Other Complications Supportive cholangitis=> liver abscess Impaired LF => Biliary cirrhosis

26. Obstructive Jaundice … Choledocholithiasis in 6% to 12% of patients with gallbladder stones. Classification : 1 o stones -- originate in the CBD 2 o stones -- originate in the gallbladder Most CBD stones are 2 o stones. Other definitions of CBD stones: Retained -- discovered within 2yrs of cholecystectomy Recurrent -- detected >2yrs of cholecystectomy

27. Obstructive Jaundice Intraoperatively, palpation is a reliable method of detecting common duct stones. The use of routine operative cholangiography can detect unsuspected stones. Once the common bile duct is opened, choledochoscopy —either flexible or rigid

28. A: Operative cholangiography demonstrating good flow of contrast into the duodenum. No filling defects are present. There is opacification of both right and left hepatic ducts. B: Ultrasonography is an acceptable substitute for operative cholangiography.

29. Obstructive Jaundice Mx of Choledocholithiasis Indications for Intraoperative Cholangiogram    Elevated preoperative liver enzymes ( ALP, bilirubin)   Jaundice   Dilated common bile duct on preoperative imaging    Unsuccessful preoperative ERCP for choledocholithiasis Gallstone pancreatitis without endoscopic clearance of CBD ?Large CBD /CD and small stones   Unclear anatomy during laparoscopic dissection     Suspicion of intraoperative injury to biliary tract       

30. Obstructive Jaundice Mx of Choledocholithiasis Summary of Objective and Intra-Operative Criteria for Possible Presence of CBD Stones Clinical    Jaundice (present, recent, recurrent)   Acholic stools ,Dark urine (bilirubin)    Fever Laboratory values    Serum bilirubin >1.2 mg/dL    Serum alkaline phosphatase >250 U/L Radiologic studies   Multiple small stones  CBD diameter >6 mm  ,CBD calculi Intraoperative findings    Multiple small stones  CBD diameter >10 mm    Cystic duct diameter 0.5 mm

31. Obstructive Jaundice Mx of Choledocholithiasis Non surgical Endoscopic sphincterotomy or balloon dilation + Extraction of CBD stones. Surgical CBD exploration = Laparoscopic/Open surgical Alternatives – if all above are not successful: - Choledochoduodenostomy - Roux-en-Y Choledochojejunostomy

32. Obstructive Jaundice BILIARY DUCT STONE REMOVAL choledochotomy Methods used to clear stones from the bile ducts. Stone forceps ,a biliary Fogarty catheter, scoops , Irrigation a choledochoscope , retrieval instruments =baskets, balloons, forceps, and a mechanical lithotriptor. impacted stone, fragmentation may be successful electrohydraulic lithotriptor , garnet laser , or a tunable dye laser. If these techniques for fragmentation are not successful or not available, a duodenotomy and sphincterotomy may be necessary to extract the stone

33. BILIARY DUCT STONE REMOVAL Stone forced through ampulla with saline flush. IV glucagon administration may also be used as an adjunct to flushing. Flushing may be accomplished with the cholangiocatheter or a red rubber catheter inserted via the cystic duct or common duct (if a choledochotomy has been made). Stone retrieval using a balloon catheter inserted via the cystic or common bile duct. The diameter of the inflated balloon should not be larger than the diameter of the CBD.

34. Open common bile duct exploration. (a) After common bile duct exploration, a T tube is fashioned and is placed into the duct. (b) Interrupted 4-0 absorbable sutures are used to close the choledochotomy snug around the tube. A completion cholangiogram may then be performed. The tube is brought out through the right abdominal wall, through a separate stab incision, and secured to the skin.

35. Management of common bile duct (CBD) stones with laparoscopic cholecystectomy.

36. Pancreatic Head Tumor Periampullary tumors .HOP Tumors .Distal CBD CCA . Ampullary Tumors .Duodenal tumors Ddx CBD Stones Mx ……Best surgical

37. Other causes of OJ Stricture CCAs PSC,PBC GB Ca Pancreatic,gastric ,Duodenal tumors Chronic pancreatitis etc

38. Ascending Cholangitis Definition Diagnosis Grading…..TG 18 Mx

39. Thank u.

40. Obstructive Jaundice post operative biliary duct injury

41. Obstructive Jaundice

42. Intraoperative cholangiogram obtained during laparoscopic cholecystectomy. Cholangiogram demonstrates an injury to the common bile duct (which is clipped such that contrast does not fill the proximal biliary tree). Contrast fills the normal distal bile duct and duodenum

43. Obstructive Jaundice Management of post operativ biliary duct injury Approach dependes on the time of detection Intra operative detection suspects an injury or variant anatomy, clearly defined biliary anatomy using intraoperative cholangiography / careful dissection,,then Options Immediate Surgical Repair if experienced surgeon is available Refer to the better center Post operative detection Establish diagnosis & define biliary anatomy to control the bile leak with percutaneous stents Proximal biliary decompression Correct derengements - F & E,coagulation , nutrition

44. CT scan demonstrating biloma associated with biliary leak after bile duct injury. Diagnostic MRCP demonstrating biliary anatomy associated with a cystic duct leak after laparoscopic cholecystectomy. There is an intact biliary system with extravasation of contrast in the subhepatic space

45. Endoscopic retrograde cholangiopancreatogram demonstrating cystic duct leak. B. Endoscopic retrograde cholangiopancreatogram with multiple clips across the common bile duct without visualization of the proximal biliary tree in a patient with total transection of the common bile duct during laparoscopic cholecystectomy.

46. Obstructive Jaundice Primary sclerosing cholangities PSC is predominantly a disease of young men. PSC can occur with multifocal fibrosclerosis syndromes, retroperitoneal, mediastinal, and/or periureteral fibrosis, Riedel's thyroiditis, or pseudotumor of the orbit. The typical presentation includes either an asymptomatic with abnormal liver function tests or an individual with intermittent jaundice. Imaging multifocal strictures and dilatations, " beading ," of the intrahepatic and extrahepatic ducts , brushings for cytology should be obtained to help distinguish between benign and malignant strictures.

47. Obstructive Jaundice An endoscopic retrograde cholangiopancreatographic image of a patient with primary sclerosing cholangitis that shows the classic features of primary sclerosing cholangitis, includingdiffuse multifocal strictures involving both the intrahepatic and extrahepatic bile ducts. B: A percutaneous transhepatic cholangiopancreatographic image of a similar patient.

48. Obstructive Jaundice The management algorithm for a patient with primary sclerosing cholangitis (PSC).