‫بسم اهلل الرحمن الرحيم‬

Obstructive jaundice
 Contents
•Definition
•Metabolism of bilirubin
•Anatomy of the biliary
system
•Causes of obstructive
jaundice
•Clinical presentation

•Diagnosis

•Management

•Complications

•Post operative jaundice

 Introduction
Jaundice or icterus
Yellowish discolouration
skin, sclera& mucous
membrane
Due to excess plasma
bilirubin
Normal range; Is <1mg/dl
Clinically obvious
When it is>3mg/dl
1mg/dl=17mmol/l
:DEFINITION OF OBSTRUCTIVE JAUNDICE

A condition where blockage of bile flow

causes over spills of bile products into the
blood & incomplete bile excretion from the
body
 Metabolism of bilirubin
Produced in the reticuloendothelial sysetm break down of haem

Carried to the liver bound to albumin, within the

hepatocytes it is cojugated byGlucouronyl transferase
into bilirubin glucouronide,which secreted by the bile
canaliculi
In the intestine it is reduced by the bacterial flora into
urobilinogen ,small amount is excreated in the stool
stecobilinogen
The remainder reach the liver to enter the enterohepatic
circulation
Bile metabolism
Types of Jaundice
 Surgical anatomy of the biliary system
Composed of Rt & Lt hebatic duct which unite at the porta hepatis
To form the common hepatic duct
Which join cystic duct to form the common bile duct
The CBD is 11-12cm in length & 4-10 mm in diameter it is devided
into supraduodenal,retrodudenal,interapancreatic & interaduodenal
part it then joined the pancreatic duct to opened in the 2nd part of the
duodenum in the major duodenal papilla
Gall bladder is pear-shped sac 10cm in length
Commposed of fundus body & neck
Blood supply by the cystic artery
 Aetiology of obstructive jaundice
Common
Common bile duct stones
Carcinoma of the head of pancreas
Lymph nodes in the porta hepatis
Infrequent
carcinoma Ampullary
Pancreatitis
Liver secondaries
Rare
Benign strictures - iatrogenic, trauma
syndromeMirriz’s
cholangitissclerosing
Cholangiocarcinoma
atresia Biliary
cystschoydochal
 Anatomical classifications
•Obstruction within the lumen:

stone or parasite
•Pathology within the wall

*Atresia of CBD
*Tumor of the bile duct
*Traumatic stricture
*Chronic cholangitis
•External compression;

*Periampullary tumor
*Chronic pancreatitis
 Clinical features

• Yellowish discoloration of the sclera , skin &

mucous membrane
• Dark urine

• Pale stool

• Pruritis
 physical examination
•Deep jaundice
• High fever and chills suggest a coexisting cholangitis
•Imatiated
•Scratch marks on the skin
•Bruses on the skin suggestive of vitK defeciency

•Bradycardia

•Gallbladder may be palpable (Courvoisier sign)..

•There may be ascite

.•
 Investigation of obstructive jaundice

:Aims

• TO conferm the diagnosis

• To know the type of jaundice

• To detect the underline cause

• To detect the complications

• TO ASSES THE FITNESS FOR SURGERY

 Urinalysis
• Macroscopic appearance of the urine

• Presence of bile pigment

• Absence of urobilinogene

strips are very sensitive to

bilirubin, detecting as little as 0.05 mg/dL. Thus, urine
bilirubin may be found even in the absence of
hyperbilirubinemia or clinical jaundice
 Serum bilirubin
Doesn’t give aclue about the the cause of obstruction
Conjugated & unconjugatd
• Extra hepatic obstruction;
initially it is mainly conjugated, but later on the
unconjugated is rises

•Intera hepatic obstruction;

both conjugated & unconjugated are rise
 Liver enzymes
ALP secreted from the endothelium of the biliary canaliculi,
not specific, unless it is associated with elevation in GGT
The degree of elevation may be used in the differentiation
between extera & interahepatic obstrution

AST mild to moderate in extera hepatic obstruction

ALT both of them are elevated in interahepatic obsruction

A 3-fold or more increase in ALT strongly suggests pancreatitis*

 Prothrombin time (PT):

•This may be prolonged because of malabsorption of

vitamin K.

•Correction of the PT by parenteral administration of

. vitamin K may help distinguish hepatocellular failure
from cholestasis.
 Renal function test

•Blood urea

•Serum creatinine

•Serum electorolytes
 Imaging study
Plain X- Ray of the abdomen

Gallstones Radio-opague 10%

*It may domensterate:

Gas in GB or biliary tree

Calcification of GB
X-RAY abdomen: Radio obaque GB Stones
 U/S abdomen
Accuracy>95%

•Shows;
stones in the GB & biliary tree*
Size of GB & thickness of it’s wall*
Dalitation in the biliary tree*
Diameter of the CBD*
Pancrease inflammation or tumor*
Liver parynchyma & texture*

Differntiate intera hepatic from extera hepatic causes*

The presenc of normal CBD Diameter doesn’t exclude obstruction =recent

& intermittent obstruction
 u/s Abdomen

Advantage:cheap available noninvasive

Disadvantage :doesn’t detect

*small stones
*,stones in the distal part of CBD
*doesn’t give aclue about site & extent of lesion.
*Un satisfactory in obese,ascites,previous surgery
gaseous distention
ultrasound common bile duct stone
Ultrasound abdomen: stone in the neck of GB
 CT abdomen
•detect spcific cause & level of
obstruction
•More accurate

•can be used with contrast to see

biliary tract,pancreatitis &tumour

Disadvantage:less accurate in small

CBD stones ,expensive,hazard of
radiation

Used if US is found to be technically difficuilt

CT bdomen
 MRI

•Excellent soft tissue detection

•Can be used in any plane

MRI abdomen
Magnetic resonance cholangiopancreatography
MRCP
•Detect small stones

•High specificity & sensetivty rate

•Detect CBD tumor staging

•Pancreatic lesion :tumours ,ca ampulla
MRCP :stone in the CBD
MRCP : intera hepatic duct stone
 :Endoscopic retrograde cholangiopancreatography

ERCP
ERCP is procedure that combines endoscopic and
radiologic modalities
•To visualize both the biliary and pancreatic duct systems.

• Endoscopically, the ampulla of Vater is identified and

cannulated.
• A contrast agent is injected into these ducts

• And x-ray images are taken to evaluate their caliber

length, and course•

.•
 ERCP
Accuracy>90%*
•useful for lesions distal to the bifurcation of the hepatic ducts

Ductal stones,tumour of CBD &PANCREASE sclerosing cholangitis•

•Has diagnostic & therapiotic modalities

Sphincterotomy,exteraction stones,insertion of stent

:Disadvantage*
•limited capacity to image the biliary tree proximal to the site of
obstruction
•In ability to visualize intera hepatic biliary system

Complications: haemorrhage ,acute*

,pancreatitis,cholangitis,duodenal perforaion
,impacted dormia basket,gall stone illeus
 ERCP
:DIFFICULTIES
•Duodenal or pyloric stenosis

•Bypass operation:cholecystojuojenostomy

•Uncooperative pt

•Inexpert personnel

Mortality
0.1%when used diagnostic
when used therapeutic 10%
 MRCP versus ERCP

MRCP has the same diagnostic accuracy to

ERCP except for acute pancreatitis

MRCP is noninvasive

MRCP can be used in distorted anatomy

MRCP can visualise interahepatic biliary tree

MRCP can only be used as diagnostic modalities

ERCP
ERCP: periampullary tumor
Normal ERCP
ERCP: Stone in the CBD
 Radionuclide scanning

•technetium iminodiacetic acid

•Taken up by hepatocytes and actively

excreted into bile
•Allows imaging of biliary tree

•Failure to fill gallbladder = acute

cholecystitis
•Delay of flow into duodenum = biliary
obstruction
Percutaneous transhepatic cholangiogram PTC
•Sedative should be used

• The liver is punctured by CHIBA 22 needle to

enter the intrahepatic bile duct system.
•An iodine-based contrast medium is injected into
the biliary system and flows through the ducts.
•Obstruction can be identified on fluoroscopic
monitor
•Pt should be covered by antibiotics.

•VitK or fresh plasma should be given

•Indication: failure of ERCP or in ability

to detect proximal lesion
 PTC
•Complications
•allergic reaction to the contrast medium,

•peritonitis with possible intraperitoneal hemorrhage,

sepsis, cholangitis, subphrenic abscess
•lung collapse.

*Severe complications occur in approximately 3% of

cases
PTC: stone in the CBD
Pre operative percutaneous transhepatic biliary drainage

Seldom used now hence :

•it increses the incidence of infection

•Excessive loss of bile

:Percutaneos insertion of endoprothesis

•Introduction of stent through gide wire

•Valiable methods in the palliative tretment

•in inoperable or incurable tumors

Interaoperative cholangiogram
*Replced by interaoperative flurocholangiogram
: Advantage
•Road map the biliary tree

•Indicate the need for exploration of the CBD

•Detects CBD damage interaoperatively

•Excludes anomalies of the biliary tree

Diadvantage:
Time consuming,
High false+ve results due to air pupples
Can cause hypersensetivity reaction & pancreatitis
:Types OF INTERAOPERATIVE CHOLANGIOGRAM

•Direct puncture to CBD

•Puncture to the
GB=cholecystocholangeogram

•Transhepatic operative cholangeogram

 Management of obstructive jaundice

General measures Specific measures

•Detailed history

•Complete physical examination

•Proper investigations

•Guard against complications

 Infections

•Normal bile is sterile

•Infection result from stasis & reduction in the immunity

of the pt
•More common with ductal calculi than with malignint
obstruction
•Usually due to aerobic bacteria,gram-ve bacilli

•Ranging from ascending colangitis up to septicaemia

C/F charcot’s traiad
(jaundice,fever with rigors &
abdomenal pain

RX use of prophylactic antibiotics(cephalosporins)*

perioperatively
hrs after surgey reduced the incidence of 24 &
infection
: Risk

•elderly pt

•stones in CBD

•after exploratoin of the CBD & Use of T-tube

 Bacteriological examination of bile should
be done in every case as sepsis is common in
an obstructed biliary tree.
Large number of pathogenic bacteria can
be isolated from the bile in 50% of the cases
requiring surgery on the biliary tract
Patients with biliary sepsis may develop
clinical septicaemia before or after operation.
 Coagulation disorders
Prolonged prothrombin time due to*
•Deficiency of Vit K

•Rx: iv use of vit k (10-20mg)

•Can be used to differentiate between intera & extera hepatic

causes!!
•Adminestration of fresh frozen plasma is necessary pefor surgery
DIC :occurs in severly jaundice pt , due to circulating*
endotoxins
Diagnosed by low fibrinogen & high FDP
RX treat infection
Give FFP +_ heparin
 Renal failure
The undeline mechanism is poorly understood
•possibly due to endotoxaemia or

•reduced GFR
RX :
•Adequate hydration

•Use of diuretics at the induction

•Use of catheter

•Recently THE ADMINESTRATION OF ORAL

LACTULOSE has been shown to reduced Post operative
RF
 HEPATIC ENCEPHALOPATHY

•Common in pt with :complete CBD obstruction

•Or those with pre-existing liver disease

•RX if
the bilirubin is high or there is signs of
impending liver failure ;period of decompresion is
needed using endoprosthesis
•Correction of hpokalaemia,treat infection & restrect the
use of sedatives
•External percutaneous decompression
=predisose to infection & lead t loss of bile acid
 Impaired drugs metabolism

•Metabolism of some drugs & anaeshtetic agents are

affected eg MORFINE & HALOTHANE
•Due to hepatocytes malfunction
 Wound healing

Obstructive jaundice doesn’t affect wound healing

It is usually depend on the under line cause of jaundice
.& poor nutrition
 Electrolytes imbalance

• Hyponatraemia & hypokalaemia

•But Iv normal saline should be restricted

•The total body Na is raised

 Specific measure
:According to the under line cause

• DUCTAL CALCULI

• Tumor of the pancrease

• Chronic pancreatitis

• CBD strictures

• Tumor of the biliary system

 Drug induced jaundice
•Common drug used in surgical practice is HALOTHANE

IT causes severe hepatotoxicity

•Especially in pt with:

•compromised liver function or

•Repeated exposure within 4wks

Prevention:
•careful history from any pt

•Repeated exposure should be avoided

•Unexplained jaundice or pyrexia following halothane is an

absolute contraindication
 Common drugs induced jaundice

Category Example Mechanism

Antibiotic Teteracyline Fatty infiltration dose related

Penicillins Hepatitis esp in hypersensitivity

Analgesics Paracetmol Massive liver necrosis dose

dependent
Aspirin Focal hepatic necrois

Anesthetics Halothane Hepatitis massive necrosis

 Management of postoperative jaundice
•Careful history (nature of jaundice & underline cause)

•Proper physical examination

•Revision of the pre operative investigations especially

liver function test
•Perform serum bilirubin & urinalysis

•Assess drugs & anesthetics used during the operation

•Withdrawal all hepatotoxic drugs

•If the pt is febrile consider him as having septicaemia

In the absence of obvious cause and the MRCP or
ERCP confirm the integrity of the biliary system ,
serial LFTs should be done to asses the course of the
illnes
If no no obvious cause is detctected clinically
radiolgically or through biochemical investigation
LIVER BIOBSY SHUOLD BE CONSIDERD