Case Scenario -History

A 73-year-old man with 3-months H/O progressively

deepening yellow discoloration of skin. He has also
noticed that his urine has darkened and his stools
have become pale and difficult to flush.

His appetite has reduced significantly and he has found

that his clothes have become loose.
Case Scenario -Examination

Patient appears underweight with yellow discoloration

of the skin and sclera.

The abdomen is soft with a smooth mass present in the

right upper quadrant, which moves with respiration.
Case Scenario

 What is the most likely diagnosis?

 What is the underlying cause?
 Why is stool pale?
 What is Courvoisier’s law?
 What further investigations are needed in this
patient?
Causes, Investigations & Management of

Obstructive Jaundice
Faisal Ghani Siddiqui
MBBS; FCPS (General Surgery); PGDIP-BIOETHICS; MCPS-HPE; FICLS; (MHPE)
Professor & Chairman, Department of Surgery, &
Director, Directorate of Medical Education
Liaquat University Of Medical & Health Sciences
Jamshoro
Learning Objectives

At the end of the presentation, the students will be able

to:
Define obstructive jaundice
Enlist causes of obstructive jaundice
Identify clinical features of obstructive jaundice
Order and interpret investigations
Outline a management plan
Learning Objectives

At the end of the presentation, the students will be able

to:
Define obstructive jaundice
Enlist causes of obstructive jaundice
Identify clinical features of obstructive jaundice
Order and interpret investigations
Outline a management plan
Normal serum level of bilirubin is
17 micromoles/L
Jaundice is a syndrome which is
recognized clinically when
serum bilirubin exceeds
> 40 micromoles/L
 Obstructive Jaundice
-Definition
Jaundice due to
partial or complete obstruction
to the flow of bile
into the GIT
Carcinomas Causing Obstructive Jaundice
Learning Objectives

At the end of the presentation, the students will be able

to:
Define obstructive jaundice
Enlist causes of Obstructive jaundice
Identify clinical features of obstructive
jaundice
Order and interpret investigations
Outline a management plan
Obstructive Jaundice
Clinical features
 Jaundice
 Dark urine
 Clay-colored stools
 Itching
 Pain
 Weight loss; anorexia
Learning Objectives

At the end of the presentation, the students will be able

to:
Define obstructive jaundice
Enlist causes of Obstructive jaundice
Identify clinical features of obstructive jaundice
Order and interpret investigations
Outline a management plan
Case Scenario -Investigations

Bilirubin 82 mmol/L (↑) 3-17 mmol/L

G-GT 163 IU/L (↑) 11-51 U/L
Aspartate transaminase (AST) 66 IU/L 5-35 IU/L
Alkaline phosphatase (ALP) 229 IU/L (↑) 35-110 IU/L
Role of Ultrasound in Obstructive Jaundice

Ultrasonographic detection
of dilated biliary tract is
the first step in the
investigation of patients
with biochemical evidence
of obstructive jaundice
Role of Ultrasound in Obstructive Jaundice

 Ultrasound does not provide information on the cause

and site of the lesion causing obstruction
 Further investigations with CT, MRCP or ERCP is
required
 Obstructive Jaundice
-ERCP
 Defines cause of obstruction
 Therapeutic
• Sphincterotomy / stone removal
• Balloon dilatation of strictures
• Stenting of strictures
ERCP
-multiple stones in
common bile duct
ERCP
-malignant stricture at
lower end of CBD
Obstructive Jaundice -CT Scan

 Useful when the outcome of ultrasound/ERCP

equivocal
 Guided biopsy of tumours
 Tumour staging
Learning Objectives

At the end of the presentation, the students will be able

to:
Define obstructive jaundice
Enlist causes of Obstructive jaundice
Identify clinical features of obstructive jaundice
Order and interpret investigations
Outline a management plan
Management of Patient with
Obstructive Jaundice
. . . In summary

 Definition of obstructive jaundice

 Causes of Obstructive jaundice
 Clinical features of obstructive jaundice
 Investigations in obstructive jaundice
 Management
Case Scenario

 73-year-old man with 3-months H/O progressively

deepening yellow discoloration of skin, dark urine
and pale stools, difficult to flush. Appetite is reduced
and his clothes have become loose

 Underweight with yellow discoloration of skin /

sclera. Smooth mass in RUQ, moves with respiration
Case Scenario

 What is the most likely diagnosis?

 What is the underlying cause?
 Why is stool pale?
 What is Courvoisier’s law?
 What further investigations are needed in this
patient?