Approach to a case of obstructive Jaundice Dr. J.V.Hardikar

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Approach to a case of obstructive Jaundice
Dr. J.V.Hardikar Professor Head Dept.of
Surgery K.E.M. Hospital Mumbai 400012
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Management of Obstructive Jaundice
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Is there a jaundice?
Is it Obstructive in nature?
Is it intrahepatic or extrahepatic Obstruction?
If extra hepatic ,then What is the site of
Obstruction?
What is the cause of Obstruction?
Is it remedial?
Can the condition be Cured?
How best can you Palliate?
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Is there a Jaundice?
ßCarotenemia, Muddy sclera, Mepacrine toxicity
Is it obstructive in nature?
History Physical Examination Investigations
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Physical examination

• General signs of liver cell failure
• Spider naevi, palmer erythema,scanty axillary
  and pubic hair foetor hepaticus ,neurological
  changes supraclavicular swelling(Virchows sign)
  scratch marks
• Ascitis (associated ALD, Malignant)
• Hepatosplenomegaly Splenomegaly may be due to
  splenic vein thrombosis secondary to pancreatic
  malignancy
• Palpable Gall bladder ,Abdominal lump

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Jaundice with distended palpable Gall bladder
Periampullary/Ca head of pancreas Cholangiocarcino
ma of lower CBD Carcinoma Gallbladder
Jaundice without palpable gall bladder Choledoc
holithiasis (shrunken Gall bladder) Hilar
cholangiocarcinoma Nodes at porta hepatis
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Courvoisiers Law

• If in a jaundiced patient,the gall bladder is
  palpable,
• the case is not of stone impacted in CBD for
  previous cholecystitis existed when stone was in
  the gall bladder rendered gall bladder fibrotic
  and incapable of dilatation

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Exceptions to Courvoisiers law

• Double impaction
• Oriental Cholangiohepatitis
• Earlier Cholecystectomy
• Malignant nodes at Porta hepatis

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Choledocholithiasis Clinical Features
Cholangitis Pain,Fever Jaundice,Shock Cloudy
Sensorium (Reynolds Pentad)
Backache due to pancreatitis acholic stools
pruritus ,high colored urine malnutrition and
weight loss
Alkaline Phosphatase,raised liver Enzymes
in Cholangitis Leukocytosis
Real-Time Mode Ultrasound is the single most
important Investigation
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Aetiology of obstructive jaundice

• Benign strictures
• Iatrogenic, trauma
• Recurrent cholangitis
• Mirrizi's syndrome
• Sclerosing cholangitis
• Cholangiocarcinoma
• Biliary atresia
• Choledochal cysts

• Common
• Common bile duct
• stones
• Carcinoma of the head of pancreas
• Malignant porta
• hepatis lymph nodes
• Ampullary
• carcinoma
• Pancreatitis ,pseudocysts

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Round Worm
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CBD Stone
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Investigations
Liver Function Tests Alk.Phos. Direct
Hyperbilirubinemia Serum Proteins Normal Enzymes
Absent Urobilinogen in urine Prolonged
P.T.which returns to normal after Vit.K
admin. Tumor markers like CA 19-9
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Intra/Extra? Ultrasound Examination C.T.
MRCP/ERCP Site USG ERCP MRCP EUS

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• USG remains the first line of investigation in
  
• biliary-pancreatic disease
• Availability, Cost
• Versatility
• Portability
• Interventional procedures are easily carried out
• However It is operator dependent
• Good for G.B.calculi but poor for detection of
  CBD stones
• Result is affected by bowel gas and Obesity.

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Exact site of Obstruction Hepatic duct,
CBD , Periampullary ca head Nature of
Obstruction Benign or Malignant Resectibility
of the lesion Involvement of vessels and
adjacent structures Presence of secondaries In
unresectable case, How palliation is done?
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Spiral CT Scan
Contrast-enhanced triple phase helical abdominal
CT scan. This should be carried out with thin
cuts to provide arterial (3mm cuts) and venous
phase (3 or 5mm cuts) cross sectional imaging

• Hypodense lesion ,Dilated CBD and PD with or
  without pancreatic mass
• Accurate assessment of spread,involvement of
  vessels
• Hepatic mets free fluid
• False ve (10)focal pancreatitis ,sarcoidosis
• Tuberculosis, lymphoma secondary tumors.

MRI does not score over CT. Hypointense T1
weighted images,and Hyper intense T2 images. It
detects vascular encasement. MRCP is can image
the CBD and PD without cannulation and injection
of contrast
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ERCP vs MRCP

• Routine ERCP may not be required if diagnosis is
  certain on CT scan
• ERCP can provide direct visualization of
  ampullary tumor and biopsy can be taken
• Preop biliary drainage is required as a
  therapeutic measure under following circumstances
• Severe cholangitis
• Patients whose surgery is delayed due to sepsis
  ,abnormal coaglation or malnutrition
• a mode of palliation for obstructive jaundice.
• MRCP gives information about site of obstruction
  without injection of contrast
• No therapeutic potential, no tissue diagnosis is
  possible

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Endoscopic Ultrasound
Much Superior to Conventional CT comparable
with Latest Generation spiral CT Can
differentiate small stone from tumor in
periampullary region Biopsies are possible
Highly Operator dependent,costly Echoendoscope
is bigger hence uncomfortable for the patient It
is mainly useful for pancreatic imaging and
biopsies assessment of nodal involvement
Vascular encasement Prior to endoscopic treatment
of pseudocysts.
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Biopsy not possible
Biopsy Possible
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Choledocholithiasis known before Surgery
Therapeutic Options
History Pre-op. Investigations
Clear the common bile duct with an initial
Endoscopic papillotomy followed by laparoscopic
cholecystectomy.
Open Cholecystectomy with common bile duct
exploration.
Lap. Chole with Lap CBD Exploration
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Choledocholithiasis Identified during
Cholecystectomy.
Lap.U.S. Cholangiogram Transcystic Choledochoscopy
Therapeutic Options

• Conversion to an open operation with
• Common bile duct exploration,

(2) Laparoscopic common bile duct exploration,
(3) completion of the laparoscopic
cholecystectomy with postoperative endoscopic
sphincterotomy and stone extraction
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Choledocholithiasis Identified After
Cholecystectomy.
Therapeutic Options
Theses patients are best managed with
endoscopic sphincterotomy and stone extraction.
If a T tube is still present from a recent common
bile duct exploration radiologic extraction of
the stone via the T tube tract is usually
possible
Open Surgery is usually avoided
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Interventional Radiology For retrieving the stone
from CBD by balloon Catheter
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Choledochoduodenostomy
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• Thank you Dr. Jamkar , Dr. Shere and the members
  of organising committee of CME for inviting me