Obstructive Jaundice - DocDroid

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Obstructive Jaundice

Aetiology :

I ) Causes in the lumen of the bile duct :

Calcular obstructive jaundice : is the commonest cause It is usually due to stone in C.B.D. or rarely stone in C.H.D or

Hartmann's pouch .

Parasitic obstruction is rare due to fasciola hepatica or ascaris .

II ) Causes in the wall of the bile duct :

1- Stricture of C.B.D : is the second commonest cause may be

due to Post-operation stricture (80%) : after cholecystectomy , choledocholithotomy or instrumentation on CBD . Inflammatory stricture (20%) : as site of impacted stone or sclerosing cholangitis . Rarely malignant stricture due to cholangio-carcinoma of C.B.D . 2- Congenital intrahepatic bile ducts atresia is very rare and fatal . III ) Causes outside the wall of the bile duct : Malignant obstructive jaundice , is the 3rd. common cause of obstructive jaundice . I t is usually due to cancer head of pancreas or periampullary carcinoma. Rarely Intrahepatic Malignancy (primary or secondary ) . Enlarged L.Ns. in the hilum of liver or lesser omentum due to lymphoma, secondary from cancer stomach , head of pancreas etc Pathology :

I ) Calcular obstructive jaundice :

Origin of stone : Usually GB stones migrating through the cystic duct into the CBD . Rarely , stones in the CBD or CHD are formed due to prolonged stasis and infection . Site of obstruction : Usually the obstruction occurs in the lower part of CBD . Rarely the obstruction occurs in the pouch or common hepatic duct . Effect on the bile ducts :

1- Dilatation of extrahepatic & intrahepatict biliary passage

proximal to the obstruction .

2- Contents of biliary passage :

First contain thick bile (biliary mud). If cholangitis occurs , bile ducts contain pus. In long standing cases, high pressure in the bile ducts with liver dysfunction , bile secretion by the liver stops and the content becomes mucous (white bile). Effect on Liver:

1-If secondary ascending infection occurs ĺ ascending cholangio-

hepatitis and liver abscesses . 2-Biliary cirrhosis may occur in prolonged intermittent or partial obstruction . Effect on the gall bladder : Couruoisier 's Law In calcular obstruction of CBD , there is no G.B. enlargement but in malignant of CBD , the G.B. is usually enlarged. Explanation : In calcular obstruction of CBD : The G.B. is fibrosed , contracted and incapable to distend due to chronic cholecystitis . Calcular obstruction is intermittent with minimal rise in the intra-biliary pressure . In malignant obstruction of the CBD : The G.B. is healthy , thin walled and distensible. Malignant obstruction is progressive and sever with marked rise in the intra-biliary pressure . Exception to Courvoisier's law (in 20% of cases). a) Calcular obstructive jaundice with palpable G.B. :

1.Metabolic stone with a healthy distensible G.B.

2.Stone in C.B.D.& another stone in cystic duct ~ mucocele.

3.A stone of Hartmann's pouch obstructing both cystic duct and

C.B.D. (Mirrizi syndrome)

b) Malignant Obstructive jaundice without G.B. enlargement:

1.Associated chronic cholecystitis.

2.Malignancy at the porta hepatis.

II) Malignant obstructive jaundice : The commonest is cancer head of pancreas ( mention pathology of cancer head of pancreas ) Pathophysiology : Pathological squeals & clinical pictures : I) The following structures fail to reach the intestine & regurgitate to the blood: a) Conjugated bilirubin : This leading to: 1- Olive green jaundice 2- Dark tea urine contain excess conjugated bilirubin & no urobilinogen 3- Pale clay coloured stool due to abscence of stercobilinogen b) Bile salts: This leading to:

1- Itching, bradycardia & frothy urine.

2- Stool: Steatorrhaea , bulky & offensive.

3- Failure of absorption of fat soluble vitamins including Vitamin K

leading to bleeding tendency due to hypoprothrombinaemia .

4-Over population of intestinal bacteria leads to the main cause

of death in this patient which are endotoxic shock , Acute hepato-renal failure & multiple organ failure .

5- Constipation & abdominal distension due to lack of

stimulation of intestinal peristalsis by bile salts . II) If cholangitis occur , there are attacks of : a) - Pain - Jaundice - Fever & rigors b) Reynold pentad : - - Shock -Altered mental status .

Olive green jaundice

Pale clay colored stool

D.D : 1- Other types of jaundice ( see medicine ) .

2- calcular or malignant obstructive jaundice .

*Calcular O.J *Malignant O.J

1. Age

years

2. Sex

3. Onset

4. Course ading to

moderate jaundice

Progressive leading to deep jaundice

except in periampullary carcinoma one or

2 remissions rarely occur .

5. Pain

Dull aching or colic ,

intermittent , in right hypochondrium , epigastrium & back below right scapula.

Early painless then pain in advanced

cases become constant , , progressive , sever in the epigastrium referred to the back .

6. Fever

7. Loss of weight

8. Liver Mild enlargement rgement

9. G.B.

10. Mass

Epigastric mass may be felt due

metastases in left lobe of liver , the lymph nodes or rarely pancreatic mass in very late cases .

11. Ascitis

12. Investigations

Intermittent course of Calcular obstructive jaundice . Investigations :

I) Laboratory investigations :

1- Serum bilirubin :

Normal serum bilirubin is less than 1mg/100ml . Jaundice is clinically recognizable when conjugated bilirubin reaches 2-3 mg/100 ml or unconjugated bilirubin reaches 3-4 mg/100ml . In obstructive jaundice the conjugated bilirubin is elevated . In haemolytic jaundice the unconjugated bilirubin is elevated . In hepatocellular jaundice both types of bilirubin are elevated .

2- Liver function tests : ( see medicine )

Alkaline phosphatase , gamma glutamyl transferase & 5-nucleotidase are maximally & mainly elevated in O.J . SGOT , SGPT are maximally & mainly elevated in hepatocellular jaundice . Serum albumin decreased with liver dysfunction . Prothrombin time & concentration : There is prolongation of prothrombin time and decrease prothrombin concentration in both obstructive and hepatocellular jaundice . To differentiate both conditions , a course of IV vitamin K is prescribed for few days : In obstructive jaundice the prothrombin parameters improve but not in hepatocellular jaundice .

3- Stool: Pale clay coloured, bulky, offensive, steatorrhea and no

stercobilinogen.

4- Urine: Dark tea coloured, frothy urine with excess conjugated

bilirubin and bile salts and no urobilinogen.

5- Full blood picture :

In obstructive jaundice : leucocytosis during cholangitis . Exclude haemolytic jaundice .

6- Blood culture and sensitivity during cholangitis

II) Radiological investigations:

1- Abdominal ultrasonography:

The 1st. investigation & the investigation of choice in calcular O. J. It shows 98% of GB stones & 1/3 of CBD stones, dilatation of bile ducts and the site , nature and extent of obstruction , liver disease (cirrhosis or tumour) or ascites.

2- Abdominal C. T. scanning :

Indication : mainly in suspedted abdominal malignancy , eg. Cancer head of pancreas . It shows site & extent of the tumour , invasion of surrounding structures , metastasis in liver or lymph nodes .

3- Magnetic resonance cholangio-pancreatography : ( MRCP )

It provide the highest resolution of the hepatobiliary and pancreatic structures . It avoid the complications of diagnostic ERCP & PTC ( but these methods should be done if there is therapeutic need )

4- ERCP: (endoscopic retrograde cholangio-pancreatography)

Method : An endoscope is passed and the esophagus , stomach & duodenum are visualized . The duodenal papilla is examined and canulated and a contrast material is injected to visualiz the CBD & pancreatic duct radiologically . Indications : Diagnostic: Show the site, nature & extent of lower biliary obstruction . Biopsy can be taken from ampulary or pancreatic lesions. Therapeutic: a) Endoscopic sphincterotomy ( papilotomy ): For stricture of ampula of Vater or to remove a stone from lower part of

C.B.D.

b) Introduction of biliary stent in stricture of lower part of C.B.D or inoperable carcinoma of head of pancreas . c) Drainage of CBD and pancreatic duct in cholangitis and pancreatitis . It is contraindicated during cholangitis and pancreatitis except for therapeutic procedures. Complications : cholangitis and pancreatitis are rare .

5.PTC: (percutaneous transhepatic cholangiography) Can be used as:

Pre-requisites : a) Normal coagulation : if prothrombin time is prolonged and prothrombin concentration is less than 60% , vitamin K is given IV for few days to correct hypoprothrombinaemia . b) Dilated intra-hepatic biliary ducts , as seen on ultrasound . Method : Under local anesthesia , a Chiba needle is introduced into the right

8th. intercostal space with continuous suction until bile is aspirated .

A dye is injected to visualize the intra-hepatic and extra-hepatic bile ducts radiologically . Indications : Diagnostic: Particularly indicated to diagnose the cause of O.J in high biliary obstruction . Therapeutic: Drainage of bile in O.J , in high biliary obstruction , by percutaneous transhepatic drainage (PTD) Complications : Biliary peritonitis . Bleeding if there is hypoprothrombinaemia .

6. Barium meal: (rarely done nowadays)

a) Cancer head of pancreas ĺ widening of C shaped duodenum. b)PeriampuJary carcinoma ĺinverted 3 appearance of duodenum. Treatment :

I) Treatment of calcular obstructive jaundice :

In absence of cholangitis , calcular O.J is not an emergency . Aim :

1- Removal of CBD stones to relieve the obstruction .

2- Removal of GB which is the source of CBD stones .

Pre-operative preparation :

1.Hospitalization and rest in bed .

2. IV injections of vitamin K1 to correct coagulation defect .

3.Liver support: high carbohydrate fat free diet.

4.Prevention of endotoxic shock & hepato-renal failure by:

IV fluid and IV mannitol . Bile salts orally . Neomycin orally . Lactulose orally to wash intestinal bacteria . 5. Broad spectrum antibiotic I.V if there is evidence of cholangitis .

6.Repeated follow up by liver function tests specially serum bilirubin

and prothrombin time & concentration. Definitive treatment :

1) Endoscopic sphinctorotomy (or papillotomy) with extraction of

the stones followed later on by elective laparoscopic cholecystectomy. Indication: The treatment of choice nowadays for CBD stones specially in presence of cholangitis or pancreatitis. Method: ERCP is performed then diathermy wire divide the major duodenal papilla. A basket catheter or ballon catheter is then passed into CBD and the stones can be extracted. Large stone can be fragmented by one of the followings : electrohydraulic lithotripsy Laser lithotripsy Ultrasonic lithotripsy Mechanical lithotripsy Complications: Bleeding , cholangitis & pancreatitis.

Ballon catheter

Endoscopic sphincterotomy with extraction of stones

Extraction of stones by basket catheter

2) If Endoscopic sphinctorotomy fails to clear all CBD stone ,

open surgery is indicated . Method : a) Exploration of CBD with Choledocholilothotomy: Through a longitudinal supra-duodenal choledochotomy removal of all stones from the C.B.D by stone forceps, fogerty's biliary catheter & irrigation of bile ducts. Choledochoscopy can be performed to confirm removal of all calculi. A dilator pass to the duodenum to exclude distal stricture. b)Choledochostomy: Drainage of C.B.D. by a T-tube. After closure of CBD completion T-tube cholangiography to ensure removal all stones by abscence of any filling defects and free flow of dye to the duodenum . c) Finally Cholecystectomy is performed . Removal of GB should be performed at the end of the operation because if a stricture is discovered in the distal part of CBD , the GB can be used to by pass this stricture by cholecysto- jejunostomy . d) 10 days after surgery postoperative T-tube cholangiography is performed if free flow of the dye to the duodenum with no filling defect or obstruction the tube is removed.

3) If the patient is unfit with suppurative cholangitis , temporary

relief of biliary obstruction by insertion of stent during ERCP or percutneous transhepatic drainage ( PTD ) and definitive treatment is postponed until the patient becomes fit for surgery . Insertion of stent during ERCP

Percutneous transhepatic drainage ( PTD )

II) Treatment of benign CBD Stricture: After pre-operative preparation one of the followings is done. a) Dilatation and insertion of stent at PTC or ERCP are the recommended nowadays if possible . If this fails , operative treatment should be performed to by pass the obstruction by one of the followings : b) Choledocho-duodenostomy: A stoma is fashioned between the side of the dilated supra-duodenal part of C.B.D and the side of the

1st. part of duodenum .

c) Choledocho-jejunostomy: Usually the upper end of the duct is anastomosed to the side of a Roux -en- Y loop of jejunum. d) Cholecysto-jejunostomy: A loop of jejunum is anastmosed to the G.B. to by pass the stricture. III) Treatment of malignant O. J : ( mention treatment of cancer head of pancreas )