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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
Management of Obstructive Jaundice
             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?
Is there a Jaundice?
  ßCarotenemia, Muddy sclera, Mepacrine toxicity


              Is it obstructive in
              nature?

       History
       Physical Examination
       Investigations
                           Bilirubin levels in different types of Jaundice

40



35           Haemolytic


             Hepatocellular
30

             Obstructive

25



20



15



10



5



0
     1   2   3         4         5         6        7        8         9     10   11
Haemolytic             Hepatocellular Obstructive
Long standing          Constitutional    Progressive
                       symptoms
Low bilirubin levels   Blood transfusion High bilirubin
                                         levels
Anaemia                Epidemic          Pruritus

hepatosplenomegaly     Exposure to       Wt. loss/malena
                       toxins
Ulcerations over legs Septicemia         Abdominal lump

Splenomegaly                             Colour of stools

                                         Previous biliary
                                         surgery
          Physical examination
• General : signs of liver cell failure
 Spider naevi, palmer erythema,scanty axillary
  and pubic hair foetor hepaticus ,neurological
  changes supraclavicular swelling(Virchow’s
  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
  Jaundice with distended palpable Gall bladder


  Periampullary/Ca head of pancreas
  Cholangiocarcinoma of lower CBD
  Carcinoma Gallbladder

Jaundice without palpable gall bladder



Choledocholithiasis (shrunken Gall bladder)
Hilar cholangiocarcinoma
Nodes at porta hepatis
Courvoisier’s 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
Exceptions to Courvoisier’s law
                • Double impaction
                • Oriental
                  Cholangiohepatitis
                • Earlier
                  Cholecystectomy
                • Malignant nodes at
                  Porta hepatis
              Choledocholithiasis
              Clinical Features

Cholangitis: Pain,Fever Jaundice,Shock
Cloudy Sensorium (Reynold’s 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
  Aetiology of obstructive jaundice

     Common              Benign strictures
Common bile duct        Iatrogenic, trauma
  stones
                         Recurrent cholangitis
Carcinoma of the
 head of pancreas        Mirrizi's syndrome
 Malignant porta
                         Sclerosing cholangitis
  hepatis lymph nodes
 Ampullary              Cholangiocarcinoma
  carcinoma              Biliary atresia
 Pancreatitis
 ,pseudocysts            Choledochal cysts
Round Worm
CBD Stone
            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
Intra/Extra? Ultrasound Examination
C.T.
MRCP/ERCP
Site:
 USG
ERCP
MRCP
EUS
• 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.
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?
                     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
                      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
•
                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.
Biopsy not possible   Biopsy Possible
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
  Choledocholithiasis Identified
  during Cholecystectomy.
       Therapeutic Options

(1) Conversion to an open operation with Lap.U.S.
    Common bile duct exploration,       Cholangiogram
                                         Transcystic
                                       Choledochoscopy
    (2) Laparoscopic common bile duct exploration,


  (3) completion of the laparoscopic cholecystectomy
  with postoperative endoscopic sphincterotomy
   and stone extraction
 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
Interventional Radiology
For retrieving the stone from
 CBD by balloon Catheter
Choledochoduodenostomy
• Thank you Dr. Jamkar , Dr. Shere and the
  members of organising committee of CME
  for inviting me

				
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posted:9/17/2012
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