OBSTRUCTIVE JAUNDICE

By
Getachew D.(HPB & Laparascopic
Surgeon)
Nov 23,2022 Gc.
• Jaundice (also termed icterus) is a condition of
yellow discoloration of the skin, conjunctivae,
and mucous membranes,resulting from
widespread tissue deposition of the
pigmented metabolite bilirubin
• Medical Vs Surgical Jaundice
 Obstructive Jaundice
Approach
• With careful Hx taking, P/E and blood tests
– overall accuracy of clinical assessmentranges from 87% to
97%
– a clinical approach alone does not accurately identify the
level of biliary obstruction in a patient with post hepatic
jaundice
– Multidisciplinary team approach
– Developing specific logical algorithms
 Obstructive Jaundice
Approach
• Hx
– Rapidity of onset & course of jaundice
– Age and sex
– Symptoms
• Change in the color of urine and stool
• Presence of pruritus
• Abdominal pain
• Digestive symptoms
• Constitutional and other accompanying symptoms
 Obstructive Jaundice
Approach
• Hx of exposure
– any chemical or medication
– Occupational exposure to hepatotoxins
– to people with jaundice
– Sexual activity
• HIV status
– Blood contamination
– to possibly contaminated foods
– Alcohol consumption
– Recent travel history
 Obstructive Jaundice
Approach
• Previous history
– symptoms goes with gall stone and its complications

– Joundice,liver disease,

– Surgery

• Family Hx
– Hx of inherited disorders including
• liver diseases
• hemolytic disorder
 Obstructive Jaundice
Approach
Physical exam:-
• Nutritional status
• Scleral icterus
• virchow's nodes
• The abdominal exam should focus on :-
– Size and consistency of liver
• Large, tender liver with rounded edge ---
viral/alcoholic hepatitis
• Grossly enlarged nodular liver/abdominal mass---
malignancy
• Bruit heard over the liver ---- hepatoma
– Stigmas of CLD , Ascites
– ,splenomegaly,
• Murphy's sign --- A. cholecystitis
• Courvoisier's gall bladder---malignant obstruction
• Blood on DRE---malignancy
12/09/2022
 Obstructive Jaundice
Investigations
• LAB. TESTS
– CBC, U/A
– Hemolysis
• elevated serum lactate dehydrogenase (LDH) level,
• a decreased serum haptoglobin level, and
• evidence of hemolysis on microscopic examination of the blood smear
• LFT=
– Tests of liver
• secretion– Bilirubin, AP
• cell synthesis-- plasma Alb, prthrombin
• inflammation– Transaminase levels
– Helpful in differentiating b/n
• hepatocellular process and a cholestatic process,
– a critical step in determining
• what additional workup is indicated
 Obstructive Jaundice
Investigations
• isolated hyperbilirubinaemia
– conjugated >>
– unconjugated
• cojugated hyperbilirubinaemia with other biochemical liver
test abnormalities
– hepatocellular conditions
– cholestatic conditions
• intrahepatic
• extrahepatic
 Obstructive Jaundice
Charactersic lab findings in jaundice pt
Obstructive Jaundice
 Obstructive Jaundice
imaging
• goals
– (1) to confirm the presence of an extrahepatic obstruction
• verify that the jaundice is indeed posthepatic rather than hepatic),
– (2) to determine the level of the obstruction,
• the gold standard for defining the level of a biliary obstruction is direct
cholangiography,
– endoscopic retrograde cholangiopancreatography (ERCP)
– percutaneous transhepatic cholangiography (PTC).
– (3) to identify the specific cause of the obstruction, and
– (4) to provide complementary information
• relating to the underlying diagnosis (e.g., staging information in cases of
malignancy).
 Obstructive Jaundice
imaging
• Ultrasonography
– differentiating hepatic Vs post hepatic causes of jaundice,
– suggesting the level of obstruction.
• identify the presence of extrahepatic ductal obstruction with a high degree of
reliability
• Operator dependant ,Difficalt to see distal cbd/gas shadow
– may fail to detect a post hepatic cause of jaundice
• very early in the course of an obstructive process/ HIDA
• Nondisanable duct secondary to fibrosis/extern compression
• extensive hepatic fibrosis, cirrhosis, sclerosing cholangitis, and liver transplantation
• Intermittant obstruction=cholidochololitiasis
– point to a specific hepatic cause of jaundice
• (e.g., cirrhosis or infiltration of the liver by tumor).
 Obstructive Jaundice
imaging

Endoscopic Retrograde Cholangiography (ERCP)

• distal obstruction
– Therapeutic interventions:
• Removal of stones
• Sphincterectomy
• Stenting :Dilatation of strictures
• Placement of biliary drainage
• Percutaneous Transhepatic Cholangiography(PTC)
– Proximal obstruction
• Drainage of intrahepatic ducts

12/09/2022 18
12/09/2022 19
ERCP demonstrates extrinsic
compression of the common hepatic
duct by a stone in Hartmann's pouch.
A biliary stent has been inserted for
drainage
Jaundice has occurred after laparoscopic
cholecystectomy as a result of bile leakage
from a distal biliary tributary. A stent has
been inserted to decrease bile duct luminal
pressure and foster spontaneous resolution.
ERCP (a) and corresponding MRCP (b) demonstrate presence of a stone in the
distal CBD.
 Obstructive Jaundice
imaging
• Second line tests
– important considerations=local expertise and cost-effectiveness
• MRCP and endoscopic ultrasonography (EUS)
– both appear to be excellent at diagnosing biliary obstruction and establishing its location
and nature.
– MRCP exhibits more modest detection rates when diagnosing small CBD stones.
– Preferred
• EUS for periampullary pathologic conditions and
• MRI with MRCP for more proximal diseases of the biliary tree
• Spiral (helical) CT scanning
– useful in diagnosing biliary obstruction and determining its cause,
– concomitant oral or I.V. cholangiography is required to detect choledocholithias
• spiral CT, EUS, and MRCP
– in combination with abdominal MRI are very useful in diagnosing and staging biliopancreatic
tumors.
– Cytology specimens are readily obtained via (FNA) during CT or EUS.
 Obstructive Jaundice
imaging
• Workup and Management of Post hepatic Jaundice
– Once US has confirmed that ducal obstruction is present, there are three possible clinical
scenarios:
• 1.suspected cholangitis,
– ERCP /PTC is indicated for Dx and Rx after
• appropriate resuscitation,
• correction of any coagulopathies present, and
• administration of antibiotics,
• 2. suspected choledocholithiasis without cholangitis=based on local expert
– LC with either preoperative ERCP, IO cholangiography/ US
– preoperative ERCP in this setting of jaundice
• it allows confirmation of the diagnosis preoperatively
• it is capable of clearing the CBD of stones in 95% of cases
• 3.a suspected lesion other than choledocholithiasis.
– before the decision is made to proceed to cholangiography or operation
• another imaging modality besides the US should be considered
• assessment of resectability and operability
(a) ERCP demonstrates missing liver segments
(b) .PTC of segment VI reveals excluded liver ductal system
(c) . MRCP shows the excluded liver segments, as well as the biliary system,
which still communicates with the common hepatic duct.
 Mx of Choledocholithiasis

ERCP with distal common bile duct stone prior to

cholecystectomy
 Obstructive Jaundice
Choledocholithiasis

Benign Biliary Stricture Malignant Biliary

Stricture/obstruction
1. Postoperative (80%)
1. Intraluminal
– Cholecystectomy
– Bile duct cancer
– Choledochotomy
– Ampullary carcinoma
– Gastrectomy
2. Inflammatory (20%)
– Stones 2. Extrinsic compression
– – Pancreatic cancer
Cholangitis
– – Gallbladder cancer
Parasitic
– Pancreatitis – Hepatocellular cancer
– Sclerosing cholangitis
– Radiotherapy Congenital
Idiopathic
 Obstructive Jaundice …
• Choledocholithiasis
• in 6% to 12% of patients with gallbladder stones.
• Classification:
– 1o stones -- originate in the CBD
– 2o stones -- originate in the gallbladder

Most CBD stones are 2o stones.

• Other definitions of CBD stones:

– Retained -- discovered within 2yrs of cholecystectomy
– Recurrent -- detected >2yrs of cholecystectomy
 Obstructive Jaundice …
• Choledocholithiasis
• Complications of CBD stone
– Obstructive Jaundice

– Cholangitis
Fever, RUQ pain, jaundice => Charcot’s triad

Charcot’s triad + Altered mental status + Shock

=> Reynolds’s pentad

• Other Complications
– Supportive cholangitis=>liver abscess

– Impaired LF =>Biliary cirrhosis

 Obstructive Jaundice
• Intraoperatively,
– palpation is a reliable
method of detecting
common duct stones.
– The use of routine operative
cholangiography can detect
unsuspected stones.
– Once the common bile duct
is opened, choledochoscopy
—either flexible or rigid
A: Operative cholangiography
demonstrating good flow of contrast into the duodenum.
No filling defects are present.
There is opacification of both right and left hepatic ducts.
B:Ultrasonography is an acceptable substitute for operative cholangiography.
 Obstructive Jaundice
• Mx of Choledocholithiasis
• Indications for Intraoperative Cholangiogram   
– Elevated preoperative liver enzymes ( ALP, bilirubin)
–   Jaundice  
– Dilated common bile duct on preoperative imaging   
– Unsuccessful preoperative ERCP for choledocholithiasis
– Gallstone pancreatitis without endoscopic clearance of CBD
– ?Large CBD /CD and small stones  
– Unclear anatomy during laparoscopic dissection  
–   Suspicion of intraoperative injury to biliary tract  
–     
 Obstructive Jaundice
• Mx of Choledocholithiasis
• Summary of Objective and Intra-Operative Criteria for Possible Presence of
CBD Stones
• Clinical  
–  Jaundice (present, recent, recurrent)
–   Acholic stools ,Dark urine (bilirubin)  
–  Fever
• Laboratory values  
–  Serum bilirubin >1.2 mg/dL  
–  Serum alkaline phosphatase >250 U/L
• Radiologic studies
–   Multiple small stones
–  CBD diameter >6 mm  ,CBD calculi
• Intraoperative findings  
–  Multiple small stones
–  CBD diameter >10 mm  
–  Cystic duct diameter 0.5 mm
 Obstructive Jaundice
Mx of Choledocholithiasis

I. Non surgical
– Endoscopic sphincterotomy or balloon dilation +
Extraction of CBD stones.

II. Surgical
– CBD exploration =Laparoscopic/Open surgical

– Alternatives – if all above are not successful:

- Choledochoduodenostomy
- Roux-en-Y Choledochojejunostomy
 Obstructive Jaundice

• BILIARY DUCT STONE REMOVAL

• choledochotomy
– Methods used to clear stones from the bile ducts.
• Stone forceps,a biliary Fogarty catheter, scoops,
• Irrigation
• a choledochoscope,
• retrieval instruments
– =baskets, balloons, forceps, and a mechanical lithotriptor.
– impacted stone, fragmentation may be successful
• electrohydraulic lithotriptor,
• garnet laser, or a tunable dye laser.
– If these techniques for fragmentation are not successful or not available,
• a duodenotomy and sphincterotomy may be necessary to extract the
stone
 BILIARY DUCT STONE REMOVAL
Stone forced through ampulla with saline flush.
IV glucagon administration may also be used as
an adjunct to flushing.
Flushing may be accomplished with the
cholangiocatheter or a red rubber catheter
inserted via the cystic duct or common duct (if a
choledochotomy has been made).
Stone retrieval using a balloon
catheter inserted via the cystic or
common bile duct. The diameter of
the inflated balloon should not be
larger than the diameter of the CBD.
Open common bile duct exploration.
(a) After common bile duct exploration, a T tube is fashioned and is placed into the duct.
(b) Interrupted 4-0 absorbable sutures are used to close the choledochotomy snug around
the tube.
A completion cholangiogram may then be performed.
The tube is brought out through the right abdominal wall, through a separate stab incision,
and secured to the skin.
Management of common bile duct (CBD) stones with laparoscopic cholecystectomy.
 Mx of Choledocholithiasis

ERCP and common bile duct stone extraction.

 Cholangitis
• Charcot triad
• Raynolds pentad
• Tokyo guidline
• Periampullary tumors
.HOP Tumors
.Distal CBD CCA
.Ampullary Tumors
.Duodenal tumors
• Ddx CBD Stones
• Mx……Best surgical
 Other causes of OJ
• Stricture
• CCAs
• PSC,PBC
• GB Ca
• Pancreatic,gastric ,Duodenal tumors
• Chronic pancreatitis
• etc
• Thank u.
 Obstructive Jaundice
post operative biliary duct injury
Obstructive Jaundice
Intraoperative cholangiogram
obtained during laparoscopic
cholecystectomy.
Cholangiogram demonstrates
an injury to the common bile
duct (which is clipped such
that contrast does not fill the
proximal biliary tree).
Contrast fills the normal distal
bile duct and duodenum
 Obstructive Jaundice
Management of post operativ biliary duct injury
• Approach dependes on the time of detection
• Intra operative detection
– suspects an injury or variant anatomy,
– clearly defined biliary anatomy using intraoperative cholangiography / careful
dissection,,then
– Options
• Immediate Surgical Repair if experienced surgeon is available
• Refer to the better center
• Post operative detection
– Establish diagnosis & define biliary anatomy
– to control the bile leak with percutaneous stents
– Proximal biliary decompression
– Correct derengements-
• F &E,coagulation, nutrition
CT scan demonstrating
biloma associated with
biliary leak after bile duct
injury.
Diagnostic MRCP demonstrating biliary anatomy
associated with a cystic duct leak after
laparoscopic cholecystectomy. There is an intact
biliary system with extravasation of contrast in
the subhepatic space
A. Endoscopic retrograde cholangiopancreatogram demonstrating cystic duct leak.
B. B. Endoscopic retrograde cholangiopancreatogram with multiple clips across the
common bile duct without visualization of the proximal biliary tree in a patient with
total transection of the common bile duct during laparoscopic cholecystectomy.
 Obstructive Jaundice
Primary sclerosing cholangities
• PSC is predominantly a disease of young men.
• PSC can occur with multifocal fibrosclerosis syndromes,
– retroperitoneal, mediastinal, and/or periureteral fibrosis,
– Riedel's thyroiditis, or
– pseudotumor of the orbit.
• The typical presentation includes either
– an asymptomatic with abnormal liver function tests or
– an individual with intermittent jaundice.
• Imaging
– multifocal strictures and dilatations, "beading," of the intrahepatic and
extrahepatic ducts
– , brushings for cytology should be obtained to help distinguish between
benign and malignant strictures.
 Obstructive Jaundice

An endoscopic retrograde cholangiopancreatographic image of a patient with primary

sclerosing cholangitis that shows the classic features of primary sclerosing cholangitis,
includingdiffuse multifocal strictures involving both the intrahepatic and extrahepatic
bile ducts. B: Apercutaneous transhepatic cholangiopancreatographic image of a
similar patient.
Obstructive Jaundice

The management algorithm for a patient with primary sclerosing cholangitis

(PSC).
 Obstructive Jaundice
secondary sclerosing cholangitis
• The inciting factors include
– infectious cholangiopathy associated with acquired
immunodeficiency syndrome,
– congenital biliary abnormalities,
– ischemic cholangiopathy secondary to intrahepatic arterial infusion
of 5-fluorouracil,
– hepatic allograft rejection,
– graft-versus-host disease in bone marrow transplantation,
– collagen vascular diseases,
– histiocytosis X,
– sarcoidosis, and
– mast cell cholangiopathy.
Cholidochal cysts
Obstructive Jaundice
Cholidochal cysts