1. DR HARDIK ASSISTANT PROFESSOR DEPT OF SURGERY GMC SURAT
Obstructive Jaundice
DR HARDIK
ASSISTANT PROFESSOR
DEPT OF SURGERY
GMC SURAT

2. 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 mg/dL.
Jaundice clinically detected in sclera when S.Billirubin is >2.5mg/dl.
Jaundice is clinically detected in Skin/Mucus Membrane when S. Billirubin is >6.0mg/dl.

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

4. 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 gm circulates twice through the enterohepatic circulation during each Meal.

5. Bilirubin Metabolism

6. Difference Between the types of Jaundice
HEMOLYTIC
HEPATIC
OBSTRUCTIVE
AGE
YOUNG
YOUNG/MIDDLE AGE
OLDER AGE GROUP
ABDOMINAL PAIN NO
+/- +
COLOR OF URINE
Normal
Yellow
Dark Yellow
COLOR OF STOOL
Clay Colour
PRURITUS --
ICTERUS
Lemon Yello
Greenish/Dark Yellow
LIVER
GALL BLADDER
S BILLIRUBIN
4-5mg/dl(Indirect)
Up to 10-12mg/dl(Indirect/Direct)
15-20mg/dl(Direct)
SGOT/SGPT
Elevated
Markedly Elevated
Normal/Elevated
ALK PHOSPHATASE
Noraml
S PROTEINS
Decrease

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

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

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

10. Pancrease
Periampullary Carcinoma
Carcinoma of Head of Pancreas.
Pseudocyst of Pancreas.(Extrinsic Compression)

11. 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

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

13. 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

14. Physical Examination

15. 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
Double Impaction of Stone( CBD & Cystic Duct)
Stone at Ampulla Of Vater
Oriental Cholangiohepatitits
Mirrizi’s Syndrome

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

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

19. Biochemical Test 3 Serum Alkaline Phosphatase
Normal level 3-13 KA Units/L or 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.

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

21. 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.

22. 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)

23. 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

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

25. USG Images

26. 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.

27. CECT Abdomen

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

29. Gallbladder
Dilated bile ducts
Mass in head of
the pancreas

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

31. Clinical Classification of Obstructive Jaundice
Type I Complete Obstruction(Classical Symptoms with Biochemical Changes)
Malignancy of Head of Pancreas.
Ligation of Common Bile Duct.
Cholangiocarcinoma.
Parenchymal Liver Disease.
Type II Intermittent Obstruction(Symptoms with Biochemical Changes But Jaundice may or may not be Present).
1. Choledocholithiasis
Periampullary tumor
Duodenal diverticula
Choledochal Cyst
Papillomas of the bile duct
Intra biliary parasites
Hemobilia

32. Clinical Classification
Type III Chronic Intermittent Obstruction(With or without classical symptoms but pathological changes are present in bile duct and liver )
1. Strictures of the CBD
Congenital
Traumatic
Sclerosing cholangitis
Post radiotherapy
Stenosed biliary enteric anastomosis
Cystic fibrosis
Chronic pancreatitis
Stenosis of the Sphincter of Oddi
Type IV Segmental Obstruction( One or more segment of IHB Radical)
Traumatic
Slerosing Cholangitis
IntraHepatic Abscess
Cholangiocarcinoma

33. 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.

34. ERCP

35. ERCP
Normal ERCP
Normal ERCP

37. Biliary stricture due to cholangiocarcinoma
Bile duct obstruction
from chronic pancreatitis

38. 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
Pancreatitis
Cholangitis
Hemorrhage
Sepsis

39. 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.

40. 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%).

41. Technique of PTC & corresponding Cholangiogram

42. 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

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

44. MRCP(Magnetic Resonance CholangioPancreatography)
MRCP is based on principle of visualization of ducts containing bile on T2 Weighted Images.
Advnatages:
Non Invasive
No Contrast media is required.
Will show both upper & Lower level of obstruction .
Excellent ductal anatomy is visualized .

45. MRCP
Distal CBD Stone
PSC

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

47. Treatment Surgical /Palliation
Continued
Common Bile Duct
Not Dilated
PTC+CECT
Treatment Surgical /Palliation
Dilated>8.0MM
ERCP+CECT
Treatment
Surgical/Palliation

48. Prognostic factors ( Pitt’s score)
Parameters
Type of obstruction(malignant or benign)
Age > 60 yrs
S.Alb< 3gm/dl
S.Bil > 10mg%
S.Alk P > 100 IU
S.Creatinine >1.3mg%
TLC >10000/mm3
Hematocrit < 30%
Factors
Mortality
Upto 2 0% 3 4% 4 7% 5
44% 6
67% 8
100%

49. Treatment of CBD Stone
**Stone is the CBD & Gall Bladder Open Cholecystectomy with CBDExploaration(Choledochotomy ) 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.

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

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

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

53. Non Resectable Tumors: Palliation to Decrease Symptoms
Non Surgical Palliation
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
Single Bypass:
Cholecystojejunostomy
Double Bypass
Choledochojejunostomy & Jejunojejunostomy
Triple Bypass
Choledochojejunostomy with Gastrojejunostomy with jejunojejunostomy.

54. Bile Duct Cancer Resectable Proximal Duct Cancer
Resect the involved segment with with Roux EnY 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.

55. Complication of Obstructive Jaundice
Renal Failure
Bleeding
Sepsis

56. Thank You !