INVESTIGATION AND TREATMENT

OF SURGICAL JAUNDICE

Seminar Presentation
Dr Ujas Patel
 Definition
• Biliary obstruction refers to the blockage of any duct carries bile from the liver
to the gallbladder or from the gall bladder to the small intestine.
• It causes conjugated hyperbilirubinemia.(normal s.bilirubin is 0.2-0.8mg%)
• Accumulation of billirubin in the bloodstream and subsequent deposition in
the skin causes jaundice.
• Scleral icterus is generally more sensitive.
• Jaundice may not be clinically recognizable until levels are at least 2.5mg /dL.
 Investigations

 Routine hematological investigations

• LFT
• GGT
• PT
• Hepatitis serology
• Urine Analysis
 Imaging studies
 Imaging studies
• USG
• CT
• MRCP
• ERCP
• Endoscopic ultrasound (EUS)
• Percutaneous transhepatic cholangiogram
(PTC)
 Tests for Liver Functioning
Based on detoxification and secretory function
 BIOCHEMICAL PROFILE
• Conjugated bilirubin - raised
• Urine bilirubin –present
• Urobilinogen will be present
• S.alkaline phophate – raised ( most sensitive) in nearly 100% of patients
with extra hepatic obstruction EXCEPT in some cases of intermittent
obstruction . Values usually greater than 3 times the upper limits of
reference range, and in most typical cases , they exceed 5 times the upper
limits)
• GGT (gamma –glutamyl transpeptidase) is a sensitive marker of billiary
tract disease is raised.
• ALT , AST may raised.
• PT prolonged and clotting factors decreased.
• HEMATOLOGICAL PROFILE – Hb usually decreased in case of
malignancy.RFT are usually impaired.
 RADIOLOGY

IMAGING GOALS
• To confirm the presence of an extrahepatic obstruction.
• To determine the level of the obstruction, to identify the specific cause of
the obstruction.
• To provide complementary information relating to the underlying
diagnosis.( eg ., staging information in case of malignancy).
• What is the best therapeutic approach.
 USG
(ULTRASONOGRAPHY)
• Initial test of choice in billiary obstruction.
• Limited in distal billiary tree by overlying bowel gas.
• More sensitive than CT for gallbladder stones and other pathology of GB.
• Sensitive for dilated ducts.
Dilatation of extrahepatic (> 10 mm) or intrahepatic (>4mm) bile ducts
suggests billiary obstruction.
• Liver parenchymal mass and Mets.
• Portable ,cheap , no radiation.
• Operator dependent.
 ENDOSCOPIC ULTRASOUND ( EUS )
• Combines endoscopy and USG to provide remarkably detailed images of
pancreas and billiary tree.
• EUS has been reported to have up to a 98% diagnostic accuracy in
patients with obstructive jaundice.
• This makes ERCP unnecessary in patients who are found not to have
extrahepatic obstruction.
• It allows diagnostic tissue sampling via EUS guided fine-needle aspiration
(EUS-FNA).
• The sensitivity of EUS for the identification of focal mass lesion in
pancreas has been reported to be superior to that of CT scanning
,particularly for tumors smaller than 3 cm in diameter.
• EUS is more portable than ERCP or MRCP.
• Compared to MRCP for the diagnosis of billiary stricture , EUS has been
reported to be more specific (100% vs. 76%).
Normal

EUS guided FNA

 CT-SCAN
• Main role in malignant conditions mainly for localization of primary
tumors and Metastasis.
• Best for pancreatic carcinoma ( highly sensitive for lesion >1mm).
• Mainly done when USG fail or when there is ductal dilation on ultrasound.
• Also to find level and cause of obstruction.

PANCREATIC MASS
 PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM (PTC)
• PTC indicated when percutaneous intervention is needed and ERCP either
is inappropriate or has failed.
• Useful for intrahepatic biliary disease.
• PREREQUISITES – normal PT, blood transfusion(in case of bleed), consent,
antibiotic prophylaxis.
• A needle passed directly into the liver to access one of the biliary radicals,
and the tract is then used for insertion of transhepatic catheters.
• PTC can decompress biliary obstruction, stent obstructions nonoperatively,
and provide anatomic information for biliary reconstruction.

PTC BILIARY
DRAINAGE

DIATED BILIARY
RADICALS
 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY
(ERCP)

• It is an invasive procedure and has therapeutic potential.

• It is an invasive test using endoscopy and fluoroscopy to inject contrast
material through the ampulla to image the biliary tree.
• For malignant obstruction, ERCP can be used to provide tissue samples for
diagnosis while also decompressing an obstruction.
• Stone extraction or stenting.
• Complications - pancreatitis, cholangitis, hemorrhage, sepsis.
• Contraindications – Unfavorable anatomy ,pseudo cyst, acute pancreatitis.
 MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY
(MRCP)
• MRI uses the water in bile to delineate the biliary tree and thus provides
superior anatomic definition of the intrahepatic and extrahepatic biliary tree and
pancreas.
• Noninvasive, diagnostic, no radiation exposure, and can prove extremely useful
in planning resection of biliary disease.
• By use of water content of bile, a cholangiopancreatogram can be created, which
makes it an excellent modality for cross-sectional imaging of the biliary tree.
• It is 95% sensitive in detecting obstruction but inaccurate in assessing grade of
obstruction.
 Other Investigation

• Oral cholecysctogram – to study function of Gall bladder.

• HIDA (Hepatic iminodiacetic acid)- to evaluate the physiologic secretion of

bile. It is dynamic scintiscan that assesses function of gall bladder and
cystic duct patency.
• Tumor markers – CA 19/9 (for CA pancreas - >70 units/L)
 MANAGEMENT
• PREOPERATIVE PREPARATION
• Proper diagnosis and assessment.
• Adequate hydration is most important .
• Broad spectrum antibiotics prophylaxis.
• Mannitol 100-200 ml IV BD to prevent hepatorenal syndrome.
• Preoperative biliary decompression is indicated if bilirubin is >12mg%,
sepsis, hepatorenal syndrome, severe malnutrition or cardiopulmonary
disease.
• Correction of coagulopathy, prevention of renal failure, infection, hepatic
encephalopathy and electrolyte imbalance.
 TREATMENT
( based on the cause )
• Congenital : Biliary atresia, choledochal cyst
• Inflammatory: ascending cholangitis,
sclerosing cholangitis.
• Obstructive : CBD stone, biliary stricture, parasitic infection.
• Neoplastic : Ca head of pancreas,
Cholangiocarcinoma,
klatskin tumor

• Extrinsic compression of CBD by lymph nodes or tumors.

 Benjamin Classification of Obstructive Jaundice

• Type 1 : Complete obstruction • Type 2 : Intermittent Obstruction

• Ca head of pancreas • Choledocholithiasis

• Ligation of CBD • Periampullary tumor

• Cholangiocarcinoma • Duodenal diverticula

• Choledochal cyst

• Papillomas of bile duct

• Intrabiliary parasites
• hemobilia
 Benjamin Classification of Obstructive Jaundice

• Type 3 :Chronic incomplete • Type 4 : Segmental Obstruction

obstruction
• Stricture of CBD –congenital, • Traumatic
traumatic, sclerosing cholangitis, • Sclerosing cholangitis
post radiotherapy. • Intra hepatic stones
• Stenosed biliary enteric • Cholangio carcinoma.
anastomosis
• Cystic fibrosis
• Chronic pancreatitis
• Stenosis of sphincter of oddi.
 Cholelithiasis
• Chronic calculus cholecystitis :
Non-operative treatment- rarely used and generally unsuccessful.
- oral bile salt therapy ( < 1.5 cm single stone)
- Extra corporeal shock wave lithotripsy ( 0.5 cm to 2 cm size single stone)
INVESTIGATION - USG abdomen
OPERATIVE – Elective cholecystectomy ( laparoscopic / open)

• Acute calculus cholecystitis :

Investigation : USG abdomen
Treatment : keep pt NBM + Conservative and Delayed cholecystectomy.
( after 6 week)
IMMEDIATE CHOLECYSTECTOMY :
in case of -Empyema of GB
- Persisting symptoms
- Progressing symptoms
 CHOLEDOCOLITHIASIS (CBD stones)
• Investigation : USG abdomen (CBD diameter > 8 mm is s/o abnormal)
- ERCP ( Gold standard) - MRCP -LFT (raised)
-EUS (more accurate)

• Treatment : ERCP ( treatment of choice) – endoscopic sphincterotomy and

stone extraction ( through dormia basket or balloon catheter).
Fragmentation of stone done if needed.
+
CBD stent placed in situ.
+
Delayed cholecystectomy.

DORMIA BASKET
 CHOLEDOCOLITHIASIS (CBD stones)

• In open cholecystectomy – after removal of GB

Intra operative cholangiogram done to see CBD stones.

choledochotomy done to remove CBD stones.

Confirm CBD patency by Bake’s CBD dilator.

T-tube(kehr’s) in CBD is placed—kept for 14 days.

• After 14 days a post-op T-tube cholangiogram done to see CBD patency

T-tube remove if there is no CBD stone.

 CHOLEDOCOLITHIASIS (CBD stones)
 If t-tube cholangiogram persistent CBD stone- then follow
• Small stone may spontaneously pass down.
• After 6 weeks once T-tube track gets matured, track if needed ,is dilated.
• Then stone removal done through T-tube under C-arm using dormia
basket/ fogarty catheter/ choledochoscope.
• If everything fails –transduodenal sphincteroplasty or
choledochojejunostomy done.

 Treatment of primary CBD stones:

• Transduodenal sphincteroplasty (open method)
• Open choledochoduodenostomy; side to side
• Open choledochojejunostomy –Roux-en-Y method.
 GALLBLADDER CARCINOMA
• Investigations : USG abdomen - CT scan abdomen to see operability
-US guided FNAC - LFT -MRCP
- CA 19-9 is elevated in 80% of cases.
• TREATMENT : Extended cholecystectomy with perihepatic and
pericholedochal nodal clearance.(with resection of liver segments
4 and 5.)

frozen section biopsy from cystic duct stump.

- If its positive; CBD resection and hepaticojejunostomy done.
-Hemihepatectomy with cholecystectomy with nodal clearance.
- Chemotherapy either systemic or intra-arterial, and adjuvant radiotherapy
but with poor success rate.
 GALLBLADDER CARCINOMA
 During laparoscopic cholecystectomy, any suspicious of CA GB—
procedure converted to open method.
 If after lap.cholecystectomy histology confirmed carcinoma, then staging
should be done.
• Extended resection of liver segment 4 and LN clearance may be needed.
• All ports areas should be re-excised to prevent port site recurrence.
 CHOLANGIOCARCINOMA (Bile duct carcinoma)
• Investigations : ERCP , LFT ,PTC , USG abdomen , CT scan abdomen.
MR scan : best scan . MRCP to see ducts; MRI to see LN,
MR angiogram to see vascularity.
 CHOLANGIOCARCINOMA (Bile duct carcinoma

• TREATMENT : (According to anatomical type)

• Removal of bile ducts at very early stage, just the bile duct s containing the
cancer are removed. The remaining duct in the liver are then joined to the
small bowel, allowing the bile to flow again.
• Intrahepatic (10%) is treated with hemihepatectomy.
• Perihilar is treated with hemihepatectomy or extensive bile duct resection,
nodal clearance, caudate lobe removal, cholecystectomy.
• Distal tumor is treated with Whipple’s pancreatoduodenectomy.
• Mostly if it is inoperable, stenting can be done to relieve jaundice through
PTC/ERCP
• Chemotherapy , ERBT (external beam radiotherapy).
 CHOLANGIOCARCINOMA (Bile duct carcinoma

• Treatment : According to Bismuth –Corlette classification:

• For type 1 and 2 : local tumor excision with portal lymphadenectomy,
cholecystectomy, CBD excision and bilateral Roux-en-Y
hepaticojejunostomy.
• For type 3 and 4 : right or left hepatic lobectomy;
frequently ,resection of adjacent caudate lobe.
 CA Head of Pancreas / Periampullary carcinoma/
Malignancy of lower 3rd of CBD.
• WHIPPLE RESECTION ( pancreatoduodenectomy) is mainly done which
involves removal of ---- head and neck of pancreas, duodenum, distal 40%
of stomach , lower CBD,GB, upper 10 cm of jejunum, regional LNs.
Then reconstruction through Gastrojejunostomy, choledochojejunostomy
and pancreatojejunostomy.
• If inoperable , then we go for endoscopic sphincterotomy + stenting with
percutaneous transhepatic biliary drainage.
Periampullary Carcinoma
 CHOLEDOCHAL CYST
• Type 1 : Dilatation of extrahepatic biliary tree (60%)
TREATMENT: Excision of cyst with its mucosa and reconstruction by Roux-
en-Y hepaticojejunostomy.
• Type 2 : Diverticulum of extrahepatic biliary tree(5%).
TREATMENT : Excision of the diverticulum and suturing of the CBD wall,
can be done.
• Type 3 : Choledochocele – cystic dilatation intraduodenal part of CBD(5%).
TREATMENT : Endoscopic sphincterotomy done. Excision is often needed.
 CHOLEDOCHAL CYST
• Type 4 : Dilatation of extra- and intrahepatic or multiple parts of
extrahepatic biliary tree (30%).
TREATMENT : Lily’s operation – if cyst is adherent to portal vein
posteriorly, that part of cyst wall over the portal vein is left behind.But
mucosa of the part should be removed.

• Type 5 :Dilatation of the only intrahepatic biliary tree (caroli’s disease).

TREATMENT : It is difficult to treat.
- If it is localised – Hepatectomy is sufficient.
- If it is diffuse – Liver transplantation may be required.
 BILIARY STRICTURES
• It is abnormal narrowing of CBD.
• TREATMENT : - ERCP stenting
- OPERATIVE ( for complete ductal obstruction / ERCP failed.)
1) Choledochoduodenostomy or jejunostomy.
2) Roux-en- Y hepaticojejunostomy--- Ideal.
Thank you