INVESTIGATIONS OF A PATIENT WITH OBSTRUCTIVE JAUNDICE -LETS GO

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1. INVESTIGATIONS FOR DIAGNOSIS OF THE CAUSE OF OBSTRUCTIVE JAUNDICE

2. Routine hematological investigations Liver Function Tests Urine Analysis Imaging

3. What do we want to know???? Are the biochemical tests suggestive of cholestasis ? Is the biliary tree dilated? Is there suspicion for either choledocholithiasis or malignancy? Is the patient a suitable surgical candidate? When would endoscopic ultrasound/ MRCP be useful?

4. ROUTINE HEMATOLOGICAL TESTS : Hb %- low in malignancy Total L eucocyte Count and Differential Leucocyte Count- increased in infections like acute cholangitis PT- normal is 12-16secs a rise of >4 from control or >1.5 times of control is significant

5. LIVER FUNCTION TESTS : Serum bilirubin : (Normal value<1.0mg%...>3mg% is indicative) Both conjugated & unconjugated fractions are assessed conjugated fraction is raised in obstructive jaundice

6. Serum Aspartate aminotransferase(SGOT) & Alanine aminotransferase(SGPT) : mildly raised Serum alkaline phosphatase(ALP) : grossly elevated Gamma glutamyl transpeptidase (GGT) : raised

7. URINE ANALYSIS : For presence of bilirubin & urobilinogen Bilirubin + Urobilinogen Normally it is present in traces. absent in obstructive jaundice

8. IMAGING Ultrasonography abdomen : most useful, reliable , non-invasive and quick investigation for diagnosis of obstructive jaundice Dilated biliary radicles, stones in biliary tree, mass or lesion in GB head can be demonstrated Multiple secondaries in liver can be detected,favouring diagnosis of malignancy

9. Endoscopic Retrograde Cholangio-pancreatography (ERCP ): It has both diagnostic and therapeutic role in obstructive jaundice Prophylactic antibiotics are given before the procedure as severe infection of the biliary tree (cholangitis) and acute pancreatitis can occur in 1-2% of patients

10. DISEASE Choledocholithiasis Choledochal cyst Biliary stricture Cholangiocarcinoma DIAGNOSTIC USE CBD stone can be detected as filling defects in CBD or CHD demonstrates Cystic dilatation, stones,pancreato -biliary maljunction & excludes complete obstruction of bile duct Delineate the level of stricture Assess distal tumors Brush biopsy can be taken THERAPEUTIC USE Endoscopic sphincterotomy & stone extraction stenting stenting

11. DISEASE Acute pancreatitis Chronic pancreatitis Ca head of pancreas and peri-ampullary carcinoma DIAGNOSTIC USE Acute biliary pancreatitis with biliary obstruction/cholangitis Gold standard test :shows dilated duct and stones in it(chain of lakes appearance) Long,irregular stricture in a pancreatic duct THERAPEUTIC USE ERCP & papillotomy Palliative stenting

12. Magnetic Resonance Cholangio-Pancreatography (MRCP ): non-invasive technique that delineates bile ducts very well,hence investigation of choice in obstructive jaundice 96% sensitive and 99% specific

13. Contrast enhanced computed tomography(CECT) scan of abdomen : Identifies nature and extent of a mass( stone,cholangiocarcinoma,pancreatic carcinoma) & assess their operability

14. Endoscopy : To diagnose pancreatic carcinoma(seen as ulcerative lesion in 2 nd part of duodenum) & take biopsy

15. Endoscopic ultrasonogram (EUS) : Endoscopy aided ultrasonography Detect stones in common bile duct,pancreatic head mass. Endosonoguided FNAC can be done

16. Ba meal follow through : In CA pancreas—distortion of medial border of duodenum (inverted 3 sign) In CA head of pancreas—widening of C-loop of duodenum .

17. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY : Done in case of severe obstructive jaundice whe r e the lesion is suspected to be in the proximal part of the biliary tree , under the cover of antibiotics and after control of any bleeding tendency INDICATIONS : Failure of ERCP High biliary strictures Klatskin tumor Catheter drainage in high blocks