3. Definition
• Jaundice is the yellowish pigmentation of the skin,
the conjunctival membranes over the sclerae, and
other mucous membranes caused by
hyperbilirubinemia.
• Total serum bilirubin values are normally 0.2-1.2
mg/dL. Jaundice may not be clinically recognizable
until levels are at least 3 mg/dL.
• Jaundice is not a diagnosis.
• Surgical jaundice is any jaundice amenable to
surgical treatment. Majority are due to extrahepatic
biliary obstruction.
• Not all obstructive jaundice is surgical jaundice e.g
hepatitis and not all surgical jaundice is due to
obstruction e.g congenital spherocytosis
4. Epidemiology
RACE
• The racial predilection depends on the cause of
the biliary obstruction.
• Gallstones are the most common cause of
biliary obstruction.
• Persons of Hispanic origin and Northern
Europeans have a higher risk of gallstones
compared to people from Asia and Africa.
• Native Americans (particularly Pima
Indians)have a lifetime chance of developing
gallstones as high as 80%.
5. SEX
• Women are much more likely to develop
gallstones than men.
• This increased risk is likely caused by the effect
of estrogen on the liver, causing it to remove
more cholesterol from the blood and diverting
it into the bile.
6. Pathophysiology
• To better understand these disorders, a brief discussion of
the normal structure and function of the biliary tree is
needed.
• Bile is the exocrine secretion of the liver and is produced
continuously by hepatocytes. It contains cholesterol and
waste products, such as bilirubin and bile salts, which aid in
the digestion of fats. Half the bile produced runs directly
from the liver into the duodenum via a system of ducts,
ultimately draining into the common bile duct (CBD). The
remaining 50% is stored in the gallbladder.
• In response to a meal, this bile is released from the
gallbladder via the cystic duct, which joins the hepatic ducts
from the liver to form the CBD. The CBD courses through the
head of the pancreas for approximately 2 cm before passing
through the ampulla of Vater into the duodenum
7. • Biliary obstruction refers to the blockage of any
duct that carries bile from the liver to the
gallbladder(intrahepatic) or from the
gallbladder to the small intestine(extrahepatic).
• This can occur at various levels within the
biliary system.
• The major signs and symptoms of biliary
obstruction result directly from the failure of
bile to reach its proper destination.
• The failure of biliary flow may be due to biliary
obstruction by mechanical means or by
metabolic factors in the hepatic cells.
8. • For the sake of simplicity, the primary focus of
this presentation is mechanical causes of biliary
obstruction, further separating them into
intrahepatic and extrahepatic causes.
• The discussion of intracellular/metabolic causes
of cholestasis is very complex, the pathogenesis
of which is not always clearly defined.
Therefore, these causes are mentioned but are
not discussed in detail.
9.
10. • Intrahepatic cholestasis generally occurs at the
level of the hepatocyte or biliary canalicular
membrane. Causes include hepatocellular
disease (eg, viral hepatitis, drug-induced
hepatitis), drug-induced cholestasis, biliary
cirrhosis, and alcoholic liver disease.
• In hepatocellular disease, interference in the 3
major steps of bilirubin metabolism, ie, uptake,
conjugation, and excretion, usually occurs.
Excretion is the rate-limiting step and is usually
impaired to the greatest extent. As a result,
conjugated bilirubin predominates in the serum.
11. • Extrahepatic obstruction to the flow of bile may
occur within the ducts or secondary to external
compression. Overall, gallstones are the most
common cause of biliary obstruction. Other
causes of blockage within the ducts include
malignancy, infection, and biliary cirrhosis.
• External compression of the ducts may occur
secondary to inflammation (eg, pancreatitis) and
malignancy. Regardless of the cause, the physical
obstruction causes a predominantly conjugated
hyperbilirubinemia
12. • The lack of bilirubin in the intestinal tract is
responsible for the pale stools typically
associated with biliary obstruction.
• The cause of itching (pruritus) associated with
biliary obstruction is not clear. Some believe it
may be related to the accumulation of bile acids
in the skin. Others suggest it may be related to
the release of endogenous opioids.
13. Causes
• Causes of biliary obstruction can be separated
into intrahepatic and extrahepatic.
• intrahepatic causes are most commonly hepatitis
and cirrhosis, Drugs e.g thiazides,
chlorpromazine,augmentin etc
• Extrahepatic causes may be further subdivided
into intrinsic, intraluminal and extrinsic
14.
15.
16. • Stone disease is the most common cause of
obstructive jaundice.Larger stones can become
lodged in the CBD and cause complete
obstruction, with increased intraductal
pressure throughout the biliary tree.
• Mirizzi syndrome is the presence of a stone
impacted in the cystic duct or the gallbladder
neck, causing inflammation and external
compression of the common hepatic duct and
thus biliary obstruction.
17. • Of biliary strictures, 95% are due to surgical
trauma and 5% are due to external injury to
the abdomen or pancreatitis or erosion of the
duct by a gallstone.
• A tear in the duct causes bile leakage and
predisposes the patient to a localized infection.
In turn, this accentuates scar formation and the
ultimate development of a fibrous stricture.
18. • Of parasitic causes, adult Ascaris lumbricoides
can migrate from the intestine up through the
bile ducts, thereby obstructing the extrahepatic
ducts.
• Eggs of certain liver flukes (eg, Clonorchis
sinensis, Fasciola hepatica) can obstruct the
smaller bile ducts within the liver, resulting in
intraductal cholestasis. This is more common in
Asian countries
19. • PSC is most common in men aged 20-40 years,
and the cause is unknown.
• PSC is characterized by diffuse inflammation of
the biliary tract, causing fibrosis and stricture of
the biliary system. It generally manifests as a
progressive obstructive jaundice and is most
readily diagnosed based on findings from
endoscopic retrograde
cholangiopancreatography (ERCP).
20. • AIDS-related cholangiopathy manifests as
abdominal pain and elevated liver function
test results, suggesting obstruction. The
etiology of this disorder in patients who are
HIV-positive is thought to be infectious
(cytomegalovirus, Cryptosporidium species,
and microsporidia have been implicated).
Direct cholangiography often reveals
abnormal findings in the intrahepatic and
extrahepatic ducts that may closely resemble
PSC.
21. • Biliary tuberculosis is extremely rare.
• Histopathologic evidence of caseating
granulomatous inflammation with bile cytology
revealing M tuberculosis is confirmatory.
Polymerase chain reaction is useful to expedite the
diagnosis if biliary tuberculosis is being considered
22. • Biliary obstruction associated with pancreatitis is
observed most commonly in patients with dilated
pancreatic ducts due to either inflammation with
fibrosis of the pancreas or a pseudocyst.
• Notably, intravenous feedings predispose patients
to bile stasis and a clinical picture of obstructive
jaundice. Consider this in the evaluation of biliary
obstruction.
• Sump syndrome is an uncommon complication of
a side-to-side choledochoduodenostomy in which
food, stones, or other debris accumulate in the
CBD and thereby obstruct normal biliary drainage
24. History
• Patients commonly complain of pale stools, dark urine, yellowness of the eye,
and pruritus.
• The following considerations are important:
• Patients' age
• Jaundice (duration ,onset, progresion,
Associated symptoms:
• the presence of abdominal pain( location and characteristics of the pain)
• The presence of systemic symptoms (eg, fever, weight loss)
• Symptoms of gastric stasis (eg, early satiety, vomiting, belching)
• Change in bpwel habit:
• History of anemia
• Previous malignancy
• Known gallstone disease
• Gastrointestinal bleeding
• Hepatitis
• Previous biliary surgery
• Diabetes or diarrhea of recent onset
• Also, explore the use of alcohol, drugs, and medications
25. Physical
• Upon physical examination, the patient may display signs of jaundice
(sclera icterus).
• When the abdomen is examined, the gallbladder may be palpable
(Courvoisier sign). This may be associated with underlying pancreatic
malignancy.
• Also, look for signs of weight loss, adenopathies, and occult blood in
the stool, suggesting a neoplastic lesion.
• Note the presence or absence of ascites and collateral circulation
associated with cirrhosis.
• A high fever and chills suggest a coexisting cholangitis.
• Abdominal pain may be misleading; some patients with CBD calculi
have painless jaundice, whereas some patients with hepatitis have
distressing pain in the right upper quadrant. Malignancy is more
commonly associated with the absence of pain and tenderness during
the physical examination.
• Xanthomata are associated with primary biliary cirrhosis (PBC).
• Excoriations suggest prolonged cholestasis or high-grade biliary
obstruction
26. Lab studies
Basic
• FBC+ Blood film: aneamia, infection,Hgbpathy
• Serum E/U/Cr
• Urinalysis : bilirubin present, urobilinogen absent
• Stool for ocult blood: ca ampula
• Stool mcs for ova and parasites
• Clotting profile: PT deranged
• Hepatitis serology: HbsAg, HCV
• LFT: see next slide
pptk
27.
28. Imaging
• Plain radiographs are of limited utility to help
detect abnormalities in the biliary system
• Ultrasonography (USS):USS is the procedure of
choice for the initial evaluation of cholestasis
and for helping differentiate extrahepatic from
intrahepatic causes of jaundice. Extrahepatic
obstruction is suggested by the presence of
dilated bile ducts, but the presence of normal
bile ducts does not exclude obstruction that may
be new or intermittent.
29. • Traditional computed tomography (CT) scan is
usually considered more accurate than US for
helping determine the specific cause and level
of obstruction.
• Percutaneous transhepatic cholangiogram:
done esp if the intrahepatic duct is dilated,
outline the biliary tree, locates stones and is
therapeutic for stent placement and stone
retrieval.
30. • ERCP is an outpatient procedure that
combines endoscopic and radiologic
modalities to visualize both the biliary and
pancreatic duct systems.
• Endoscopic ultrasound (EUS) combines
endoscopy and US to provide remarkably
detailed images of the pancreas and biliary
tree. It uses higher-frequency ultrasonic waves
compared to traditional US (3.5 MHz vs 20
MHz) and allows diagnostic tissue sampling via
EUS-guided fine-needle aspiration (EUS-FNA)
31. • Magnetic resonance cholangiopancreatography
(MRCP) is a noninvasive way to visualize the
hepatobiliary tree.
• MRCP provides a sensitive noninvasive method
of detecting biliary and pancreatic duct stones,
strictures, or dilatations within the biliary
system. It is also sensitive for helping detect
cancer.
32. Treatment
• Medical care:Treatment of the underlying
cause is the objective of the medical
treatment of biliary obstruction. Do not
subject patients to surgery until the diagnosis
is clear.
• In cases of cholelithiasis in which either the
patient refuses surgery or surgical
intervention is not appropriate give
33. • Ursodeoxycholic acid (10 mg/kg/d) works to
reduce biliary secretion of cholesterol. In turn, this
decreases the cholesterol saturation of bile.
• Extracorporeal shock-wave lithotripsy may be used
as an adjunct to oral dissolution therapy. By
increasing the surface-to-volume ratio of the
stones, it both enhances dissolution of stones and
makes clearing the smaller fragments easier.
• Contraindications include complications of
gallstone disease (eg, cholecystitis,
choledocholelithiasis, biliary pancreatitis),
pregnancy, and coagulopathy or anticoagulant
medications (ie, because of the risk of hematoma
formation).
34. • Bile acid–binding resins, cholestyramine (4 g) or
colestipol (5 g), dissolved in water or juice 3
times a day may be useful in the symptomatic
treatment of pruritus associated with biliary
obstruction.
• VIT ADEK SUPPLEMENTS
• Antihistamines may be used for the symptomatic
treatment of pruritus, particularly as a sedative
at night.
35. • Discontinuation of medications that may be
causing or exacerbating cholestasis and/or
biliary obstruction often leads to full recovery.
Similarly, appropriate treatment of infections
(eg, viral, bacterial, parasitic) is indicated.
36. SURGERY..Preop care
• The following are problems of a jaundiced ptx
and all must be taken care of before surgery
• Infection due to biliary stasis
• Uncontrolled bleeding due to vit k def
• Liver glycogen depletion
• Dehydration
• Hepatorenal syndrome
37. Therefore;
• Fluid resuscitation using dextrose alternate with
Saline. Encourage oral rehydration as well
• Give broad spectrum antibiotics at induction of
anaesthesia to cover for G+,G- and anaerobes
• Bowel prep
• IM VitK 10mg daily until PT/PPTK normlises(
start 5days preop)
• Monitor UO, catheterize night before surgery
• You may consider given mannitol preop,intraop
and post op for diuresis to prevent hepatorenal
syndrome
38. surgery
• the need for surgical intervention depends on
the cause of biliary obstruction.
• Cholecystectomy is the recommended
treatment in cases of choledocholithiasis
.(open or lap)
• Open cholecystectomy is relatively safe, with a
mortality rate of 0.1-0.5 %.
• Laparoscopic cholecystectomy remains the
treatment of choice for symptomatic
gallstones, partially because of the shorter
recovery period, decreased postoperative
discomfort, and improved cosmetic result.
39. • Ca head of pancres
• Early stage: whipples operation, pancreatoduodenectomy+
pancreticojejunostomy+ gastrojejunostomy+ cholecystojejunostomy
• Late surgey: bypass surgery
• Cholangiocarcinoma: hepatodochojejunostomy
• Cancer ampulla of vater: whipples operation
• Chronic pancreatitis: subduodenal exploration,
sphincterectomy, insertion of stent
• Liver transplantation may be considered in
appropriate patients.
40. Prevention
• In patients with risk factors for developing any
of the conditions that lead to biliary
obstruction, awareness of the signs and
symptoms can improve chances for early
diagnosis and improved outcome.
• Diet: Reduce intake of saturated fats, High
intake of fiber has been linked to a lower risk for
gallstones.
• Gradual and modest weight reduction may be of
value in patients who are at risk.
41. • Activity:Regular exercise may reduce the risk of
gallstones and gallstone complications
• Estrogens cause an increase in the risk for
formation of gallstones and may need to be
avoided in patients with known gallstones or a
strong family history of stone disease.
42. Complications
• The complications of cholestasis are
proportional to the duration and intensity of
the jaundice.
• High-grade biliary obstruction begins to cause
cell damage after approximately 1 month and, if
unrelieved, may lead to secondary biliary
cirrhosis.
43. • Acute cholangitis is another complication
associated with obstruction of the biliary tract
and is the most common complication of a
stricture, most often at the level of the CBD. Bile
normally is sterile. In the presence of
obstruction to flow, stasis favors colonization
and multiplication of bacteria within the bile.
Concomitant increased intraductal pressure can
lead to the reflux of biliary contents and
bacteremia, which can cause septic shock and
death.
44. • Biliary colic that recurs at any point after a
cholecystectomy should prompt evaluation for possible
choledocholithiasis.
• Failure of bile salts to reach the intestine results in fat
malabsorption with steatorrhea. In addition, the fat-
soluble vitamins A, D, E, and K are not absorbed, resulting
in vitamin deficiencies.
• Disordered hemostasis with an abnormally prolonged PT
may further complicate the course of these patients.
• Cholestyramine and colestipol, used to treat pruritus,
bind to bile salts and can exacerbate these vitamin
deficiencies.
• Persistent cholestasis from any cause may be associated
with deposits of cholesterol in the skin (cutaneous
xanthomatosis) and, occasionally, in bones and peripheral
nerves.
45. Conclusion
• There are certain signs and symptoms common to all jaundiced
patients (yellow skin, itching).
• Specific items from the history and physical examination along
with blood work can help the clinician classify jaundice into
obstructive and nonobstructive jaundice.
• Surgical or other mechanical intervention almost exclusively is
restricted to cases of obstructive (posthepatic) jaundice.
• Imaging evaluation of the gallbladder and biliary system plays an
important role in the evaluation of obstructive jaundice by
locating the site and disclosing the nature of the obstruction.
• Ultrasound imaging usually is the first step for suspected
biliary stone disease.
• The physician’s level of suspicion about benign versus malignant
causes of obstructive jaundice will lead to different radiologic
tests and interventions.
• Treatment is tailored to the cause of obstruction.
