Obstructive Jaundice

discuss etiology causes, and treatment of patients having obstructive jaundice.

1. OBSTRUCTIVE JAUNDICE

2. Obstructive jaundice Definition : Conjugated hyperbilirubinemia 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 .

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

4. Type II : Intermittent obstruction Choledocholithiasis Periampullary tumor Duodenal diverticula Choledochal Cyst Papillomas of the bile duct Intra biliary parasites Hemobilia

5. 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

6. TYPE IV : Segmental Obstruction Traumatic Hepatodocholithiasis Sclerosing cholangitis Cholangio carcinoma

7. PATHOPHYSIOLOGY OF OBSTRUCTION Alterations in – Systemic and renal hemodynamics – Hepatic function – Hemostatic mechanism – Gastrointestinal barrier – Immune function – Wound healing • Protein synthesis, • Reticulo-endothelial function • Hepatic metabolism

8. 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

9. ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile

10. ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile X

11. Abnormal LFTs Obstruction Hepatitis Cirrhosis Bilirubin    Alk phos   /   /  ALT/AST  /    /  gGT    /  PT (INR)   

12. • Fever, persistent (90%) Abdominal pain (70%) • Jaundice (60%) • Tea-colored urine/pale stools • Altered mental status (10-20%) • Hypotension (30%) • RUQ tenderness reliable signs & symptoms 90% certainty ) a patient need urgent intervention ?

13. Obstructive Jaundice • Relief of Obstruction • Prevent Complication • Prevent Recurrence Goal of Treatment

14. Are the ducts dilated What is the level of obstruction What is the cause What is the best therapeutic approach The role of Radiology

15. JAUNDICE

16. Investigations Non-invasive AXR US CT HIDA Scintigram MRI/MRCP Invasive ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy

17. Obstructive Jaundice CBD stones (Choledocholithiasis) vs. tumor Clinical features favoring CBD stones: Age < 45 Biliary colic Fever Transient spike in AST or amylase Clinical features favoring cancer: Painless jaundice Weight loss Palpable gallbladder Bilirubin > 10

18. 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

19. 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.

20. Evaluation ERCP Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5%

21. 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

22. CBD Exploration – Surgical Options Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy

23. 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

24. 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

25. 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.

26. 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

27. Cholangiocarcinoma 90% are extra-hepatic 60’s and 70’s Highest incidence in Japan, Israel, and Native Americans Increased 3 fold in the last 30yrs in the USA M/F=3/2

28. Cholangiocarcinoma Etiology Ulcerative Colitis Thorotrast Exposure Sclerosing Cholangitis Typhoid Carrier Choledochal Cysts Adult Polycystic Kidney Disease Hepatolithiasis Liver Flukes Papillomatosis of Bile Ducts

29. Cholangiocarcinoma Extra-hepatic: Distribution Right or left hepatic duct = 10% Bifurcation = 20% Proximal CBD = 30% Distal CBD = 30%

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

31. 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.

32. 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.

33. MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation Klatskin tumor

34. ERCP: Distal CBD Cancer

35. Ca of CBD Bifurcation

36. Periampullary Carcinoma and The Whipple

37. Endoscopic View

38. Pathology Adeno carcinoma accounts for 95% Arises from 4 different tissues of origin Head of pancreas Distal Bile duct Ampullary of Vater Periampullary duodenum

39. Pathology Prognosis for each of these are different. Five 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.

40. 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).

41. 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.

42. 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

43. 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.

44. Whipple Procedure Five basic techniques are used to resect pancreatic cancers Standard pancreaticoduodenectomy Pylorus preserving pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson)

45. Kocherizing the Duodenum

46. SMA Involved?

47. SMV Identification

48. Dividing the Neck

49. The End Result

50. 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 it’s a radio sensitizer, so it improves response to chemo.

51. Thank you