Obstructive jaundice

1. OBSTRUCTIVE JAUNDICE Dr Fazal Hussain Khalil Post Graduate Trainee SBW KTH

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

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

4. 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

5. 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

6. 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

7. 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

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

9. Causes of obstructive jaundice

10. 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

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

12. Clinical classification Of Obstructive Jaundice ( Benjamin Classification)

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

14. 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

15. 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

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

17. Pathophysiology of obstructive jaundice

18. 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

19. Investigations

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

21. 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

22. 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

23. Ultrasound abdomen More sensitive than CT for gallbladder stones and other pathology of gall bladder S ensitive 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 radiati on, But it is operator dependant

24. 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%)

25. 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

26. 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

27. 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

28. 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.

29. 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

30. Management of Obstructive Jaundice

31. 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

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

33. 2) Ca Head of Pancreas / Periampullary Carcinoma/malignancy of lower 3 rd of CBD 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

34. 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

35. 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

36. 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

37. 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

38. 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/mm 3 Hematocrit < 30% Factors Mortality Upto 2 0% 3 4% 4 7% 5 44% 6 67% 8 100%

39. Thank You