Obstructive Jaundice DR HARDIK ASSISTANT PROFESSOR DEPT OF

Obstructive Jaundice DR HARDIK ASSISTANT PROFESSOR DEPT OF SURGERY GMC SURAT

Jaundice • It’s a French word meaning Yellow. • Jaundice is a term used for yellow pigmentation of sclera skin or mucus membrane due to deposition of Bilirubin. • Normal Bilirubin is 0. 2 -1. 0 mg/d. L. • Jaundice clinically detected in sclera when S. Billirubin is >2. 5 mg/dl. • Jaundice is clinically detected in Skin/Mucus Membrane when S. Billirubin is >6. 0 mg/dl.

Billirubin Metabolism • Bile contains 1. Bile salt. 2. Lecithin 3. Cholesterol 4. Bile Pigment • Biles Salt are 1. Primary(Cholate & Chenodeoxycholate) 2. Secondary(Deoxycholate & Lithocholate)

Entero hepatic Circulation Bile salt in Bile Jejunum & Ileum it help in fat Digestion Reabsorption in terminal Ileum Portal Vein Blood Liver • Entire Bile Salt Pool of 2. 5 -4. 0 gm circulates twice through the enterohepatic circulation during each Meal.

Bilirubin Metabolism

Difference Between the types of Jaundice HEMOLYTIC HEPATIC OBSTRUCTIVE AGE YOUNG/MIDDLE AGE OLDER AGE GROUP ABDOMINAL PAIN NO +/- + COLOR OF URINE Normal Yellow Dark Yellow COLOR OF STOOL Normal Clay Colour PRURITUS -- -- + ICTERUS Lemon Yellow Greenish/Dark Yellow LIVER -- + + GALL BLADDER -- -- + S BILLIRUBIN 4 -5 mg/dl(Indirect) Up to 1012 mg/dl(Indirect/Direct) 15 -20 mg/dl(Direct) SGOT/SGPT Elevated Markedly Elevated Normal/Elevated ALK PHOSPHATASE Noraml Normal/Elevated S PROTEINS Normal Decrease Normal

Causes of Obstructive Jaundice • Most Common is 1. Common Bile Duct Stone 2. Periampullary Carcinoma( Ca Head Pancreas most Common) Periampullary Malignancy includes Malignancy of Head Pancreas Ampulla of Vater Malignancy Lower End CBD Malignancy & Duodenal Malignancy

Causes • Hepatic Duct 1. Cholangiocarcinoma e. g KLATSKIN TUMOR( TUMOR involving Hepatic Duct Bifurcation). 2. Extrinsic Pressure by Portal Lymphnodes due to Metastasis or Lymphoma.

• Common Bile Duct 1. Common Bile Duct Stone. 2. Common Bile Duct Stricture. 3. Gall Bladder Carcinoma. (Extrinsic Compression) 4. Choledochal Cyst 5. Obstruction by Ascaris Lumbricoides & Clonorchis Sinensis. 6. Mirrizi’s Syndrome Stone in Cystic Duct or Hartmann’s Pouch causing pressure obstruction of Common Bile Duct.

• Pancrease 1. Periampullary Carcinoma 2. Carcinoma of Head of Pancreas. 3. Pseudocyst of Pancreas. (Extrinsic Compression)

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

History • Age • Abdominal Pain • Fever • Urine • Stool • Pruritus • Anorexia & Weight Loss

Physical Examination • Icterus: Usually dark yellow may have a greenish tinge if bilirubin is reduced to billiverdin. • Jaundice 1. Fluctuant in case of CBD Stones & Ampullary Growth. 2. Progressive in case of malignant obstruction by Carcinoma of Head of Pancrease • Hepatomegaly

Physical Examination

COURVOISIER’S LAW • PALPABLE GALL BLADDER A nontender palpable gall bladder in a patient of jaundice is normally not due to stone obstructing the bile duct whereas other causes are common by comparison. Explanation of Courvoisier's Law: : If in a jaundice patient GB is enlarged it is not a case of stone impacted in the CBD as previous inflammation leads to Gall Bladder Fibrotic and non distensible. Causes are Carcinoma of Head of Pancreas & Periampullary Carcinoma. Exceptions of Curvoisier’s Law 1. Double Impaction of Stone( CBD & Cystic Duct) 2. Stone at Ampulla Of Vater 3. Oriental Cholangiohepatitits 4. Mirrizi’s Syndrome

Bio Chemical Test 1 • S Billirubin: In Surgical Jaundice there will be(Direct) hyperbilirubinemia. • Normal 0. 2 -1. 0 mg/dl • Usually in CBD Stones S Bil(Total) is <10 mg/dl. • Usually in Neoplastic Obstruction S Bil(Total) is >10 mg/dl. • Total Billirubin rise upto a plateau level of 25 -30 mgdl at this lever patient has loss in urine=daily Production. • Liver Function Test Interpretation is (Total B/Direct B/AST/ALT/Alk Pho)

Bio Chemical Test 2 • SGOT/SGPT(AST/ALT) : Normal level is 5 -35 IU/L • Modest rise in Surgical Jaundice. • AST if more than 1000 IU/L s/o Medical Jaundice due to Hepatitis. • ALT (SGPT) more specific for Liver Injury due to any cause.

Biochemical Test 3 • Serum Alkaline Phosphatase • Normal level 3 -13 KA Units/L or 60 -300 IU/L. • S ALK Phosphatase is usually raised in obstructive jaundice but not so in hepatocellular Jaundice. • If the level is more than >30 KA Units S/O Significant Obstructive Jaundice. • Increased value are because of increase production so it may be elevated before the S Billirubin value raises. • Serum Alk Phosphatase also increased in disease of intestine and bone.

Bio Chemical Test 4 • Serum 5’ Nucleotidase. • Leucine Aminopeptidase • Gamma Glautamyl Transpeptidase All of the above enzymes are more specific for Biliary Obstruction.

Bio Chemical Test 5 • Serum Albumin : Noraml level is 3. 0 to 5. 5 gm/Dl • Usually normal in Obstructive Jaundice but low value suggest parenchymal dysfunction as in hepatocellular Jaundice. • It may decrease when liver is affected by metastatic Nodules.

Bio Chemical Test 6 • Prothrombin Time • It is usually expressed as INR • Normal: Control is 15 Seconds & Normal INR is <1. 5 • PT is elevated because of decrease in synthesis of VIT K depedent clotting factors( which is a fat soluble vitamins which is not absorbed in obstructive jaundice)

Bio Chemical Test 7 • Urine Examination : Froth’s Test to detect Conjugated Billirubin. Hay’s Test to detect presence of Bile Salt in Urine. Fouchet’s Test to detect Bile Pigment in Urine. ABSENT UROBILLINOGEN IN URINE • Stool: : Clay Color • Stool for Occult blood in case of Ampullary Malignancy

Radiological Investigation: USG • Findings will be 1. Presence of Dilated IHBR is s/o of Obstructive Jaundice. 2. CBD Diameter (Normal is 7 -8 mm) if it is more than 8 mm suggestive of dilatation. 3. Gall Stone and CBD Stone Can be identified. 4. Mass in CBD can be detected if it is >2 cm. 5. Pancreatic Head Malignancy detected if >2 cm. 6. Presence of Liver Metastasis and Ascites.

USG Images

Radiological Investigation CECT Abdomen • Higher Sensitivity and Specificity than USG for detection of bile duct/pancreatic masses of 1 -2 cm diameter. • It is useful in determining resectability of cancer of Bile Duct or Pancreatic Head Masses. • It visualise the course of Bile Duct better than USG and hence more likely demonstrated the level & Cause of Ductal Obstruction. • Although USG better (more Sensitive )than CT Scan for detecting GB Stone CECT is better(More Sensitive) for documenting CBD Stone.

CECT Abdomen

CECT • Best for Pancreatic Carcinoma(Highly sensitive for lesion >1 mm).

Gallbladder Dilated bile ducts Mass in head of the pancreas

Radiological Investigation: • Barium Meal: Reverse 3 Sign of Frostberg. • Hypotonic Duodenography: : Rose Thorn appearance

Clinical Classification of Obstructive Jaundice • Type I Complete Obstruction(Classical Symptoms with Biochemical Changes) 1. Malignancy of Head of Pancreas. 2. Ligation of Common Bile Duct. 3. Cholangiocarcinoma. 4. Parenchymal Liver Disease. • Type II Intermittent Obstruction(Symptoms with Biochemical Changes But Jaundice may or may not be Present). Ø 1. Choledocholithiasis ØPeriampullary tumor ØDuodenal diverticula ØCholedochal Cyst ØPapillomas of the bile duct ØIntra biliary parasites ØHemobilia

Clinical Classification • Type III Chronic Intermittent Obstruction(With or without classical symptoms but pathological changes are present in bile duct and liver ) Ø 1. Strictures of the CBD Congenital Traumatic Sclerosing cholangitis Post radiotherapy ØStenosed biliary enteric anastomosis ØCystic fibrosis ØChronic pancreatitis ØStenosis of the Sphincter of Oddi • Type IV Segmental Obstruction( One or more segment of IHB Radical) 1. 2. 3. 4. Traumatic Slerosing Cholangitis Intra. Hepatic Abscess Cholangiocarcinoma

Endoscopic Retrograde Cholangiopancreatography(ERCP) • It is combined Endoscopic & Radiological Approach. • IND: : When USG s/o dilated IHBR with dilated CBD i. e Obstruction is suspected to be at the lower biliary tract or near pancreatic head.

ERCP

ERCP Normal ERCP

Biliary stricture due to cholangiocarcinoma Bile duct obstruction from chronic pancreatitis

ERCP • Advantages: : • Endoscopic Visualization of duodenum to rule out duodenal obstruction. • Endoscopic Sphincterotomy with dormia basket removal of CBD Stone. • Biopsy & Cytology. • Endoscopic Biliary Stent placement for non surgical palliation. • It is contraindicated in Recurrant Acute Pancreatitis & Unfavourable anatomy. • Complication 1. Pancreatitis 2. Cholangitis 3. Hemorrhage 4. Sepsis

Radiological Investigation ENDO USG • It is more accurate than combined ERCP & CT Scan in defining the nature & extent of the cause of Biliary Obstruction. • It is also quite sensitive in determining the resectability in periampullary malignancy. • EUS 98% Sensitivr in diagnosis of etiology of Obstructive Jaundice. • It allows us to take tissue sampling by EUS guided FNAC.

EUS • 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%).

Technique of PTC & corresponding Cholangiogram

Percutaneous Transhepatic Cholangiography • For Visualization of Biliary Tract by instillation of contrast material directly into a bile duct. • IND: PTC indicated when USG shows dilated IHBR but the CBD is not dilated i. e Obstruction is suspected in the upper Biliary Tract. • CI: Coagulopathy & Ascites • Complication: Bleeding Bile Leak Hemobilia Cholangitis

PTC & ERCP • PTC & ERCP are not contradictory to each other they are supplementary investigation to each other.

MRCP(Magnetic Resonance Cholangio. Pancreatography) • MRCP is based on principle of visualization of ducts containing bile on T 2 Weighted Images. • Advnatages: 1. Non Invasive 2. No Contrast media is required. 3. Will show both upper & Lower level of obstruction. 4. Excellent ductal anatomy is visualized.

MRCP Distal CBD Stone PSC

Algorithm for Diagnostic approach to a patient of Surgical Jaundice Dilated IHBR (True Surgical Jaundice) Physical Examination& LFT Surgical Jaundice USG Abdomen 1. CBD Stone 2. Periampullary Malignancy 3. Liver Metastasis or Peritoneal metastasis

Continued Common Bile Duct Not Dilated>8. 0 MM PTC+CECT ERCP+CECT Treatment Surgical /Palliation Treatment Surgical/Palliation

Prognostic factors ( Pitt’s score) Parameters • Type of obstruction(malignant or benign) • Age > 60 yrs • S. Alb< 3 gm/dl • S. Bil > 10 mg% • S. Alk P > 100 IU • S. Creatinine >1. 3 mg% • TLC >10000/mm 3 • Hematocrit < 30% Factors Mortality Upto 2 0% 3 4% 4 7% 5 44% 6 67% 8 100%

Treatment of CBD Stone **Stone is the CBD & Gall Bladder Open Cholecystectomy with CBDExploaration(Choledochotom y) followed by T Tube Drainage. ERCP with Sphincterotomy with Removal of Stone followed by Lap Cholecystectomy. ** Stones in the CBD but Gall Bladder is Absent (Post Cholecystectomy) or Treatment of Retained Stone: ERCP with Sphincterotomy with Removal of Stone. BURHENNE Technique: Removal of Stone by dilating the T tube Tract through Cystic Duct. Choledochoscopic Removal of Stone.

Periampullary Carcinoma of Head of Pancreas • Resectable Tumors • Resection of Distal Stomach Gall Bladder Whole Common Bile Duct • Curative Surgery is to be done in with Head of Pancreas & 10 -15 cm those cases where no distant of Jejunum with Regional Nodes. metastasis (Liver of Celiac Nodes) & No Vascular(SMA & Portal Vein • Reconstruction done with following Invasion) anastomosis • Surgery : WHIPPLE’S 1. Pancreatico. Jejunostomy Pancreaticoduodenectomy /Pancreato. Gastrostomy 2. Hepaticojejunostomy 3. Gastrojejunostomy

Pylorus Preserving Panceatoduodenoctomy • In this Procedure Pylorus is Preserved to maintain the physiology of GIT. ADVANTAGES: DISADVANTAGES:

Whipple’s PD • Whipple’s Operation has high morbidity & Mortality rates. • 40% if done by inexperienced surgeon. • 5% done by experienced surgeon. • Complication 1. Hemorrhage 2. Pancreatic Fistula 3. Biliary Fistula

Non Resectable Tumors: Palliation to Decrease Symptoms • Non Surgical Palliation 1. Biliary Drainage via Percuataneous Stent ERCP with Metal Stent Preferred for patients in poor general condition & patient those not fit for surgery. For GOO: Either Stent Placement or Gastrojejunostomy is required. • Surgical Palliation 1. Single Bypass: Cholecystojejunostomy 1. Double Bypass Choledochojejunostomy & Jejunojejunostomy 1. Triple Bypass Choledochojejunostomy with Gastrojejunostomy with jejunostomy.

Bile Duct Cancer • Resectable 1. Proximal Duct Cancer Resect the involved segment with Roux En. Y Hepaticojejunostomy. 2. Distal Bile Duct Cancer Whipples Procedure • Unresectable 1. Non Surgical Palliation by Biliary Drainage Procedure via PTBD or ERCP. 2. Surgical Palliation by Roux En Y Hepaticojejunostomy.

Complication of Obstructive Jaundice • Renal Failure • Bleeding • Sepsis

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