1. Obstructive jaundice I C Cameron

2. Acute on call Deranged LFTs, esp Alk Ph and GGT Conjugated Bilirubin high Take a good history Onset, drugs, pain, previous attacks, alcohol, gallstones, pale stools, dark urine, wt loss Look for signs of liver failure USS - gallstones? - dilated CBD +/- dilated IH ducts

3. Common causes Gallstones and carcinoma of pancreas Rare cholangiocarcinoma, pancreatitis USS > 90% gallstones No gallstones or significant pain – CT Avoid knee-jerk ERCP Serial LFTs vital – fluctuant or progressive GS in GB but history equivocal - MRCP

6. Case Presentation 52 year old man, previously fit and well 2 week Hx progressive J, dark urine Vague abdo discomfort Uss – gallstones in thin walled GB - dilated CBD 14mm, poor views Next move?

7. ERCP 1 st attempt failed, oedematous papilla Bilirubin continues to rise Next move?

8. 2 nd ERCP No deep cannulation, cholangiogram Short stricture distal CBD stricture PD normal What next?

9. Patient becomes very unwell Pain, pyrexia, amylase 1370 IVI, catherterised, inotropes, HDU 3 days: bilirubin increased, much better Priority?

10. Drain biliary system PTC and external drain CT scan + Transfer

11. RHH management Repeat PTC and internalise stent Bilirubin falling CT review – inflammatory mass centred around HOP, stranding in soft tissue Conservative treatment Next step?

12. Repeat CT 8 weeks later repeat CT – infl change better 2 weeks later – exploratory laparotomy Inflammatory mass involving HOP, stomach, duodenum, TC No procedure

13. Clinic follow up Probable distal CBD cholangiocarcinoma Never well enough for chemotherapy Deceased 7 months later

14. Lessons to learn What Ix after USS? Avoid ERCP if at all possible Preop biliary drainage 20% complication rate (less with PTC and stent) Obst jaundice with GS odd history