OBSTRUCTIVE

JAUNDICE
-Dr. Ravi Kr. Gupta
-2nd yr resident MS Surgery.
JAUNDICE:

• Yellow staining of body tissue produced by an excess of circulating

bilirubin.

• Normal: 0.2-1.2 mg/dl.

• Jaundice- >2.5 mg/dl.

BILIRUBIN METABOLISM:
CAUSES:
• In the lumen:

1. Gallstones.

2. Parasites.

3. Foreign body- broken T tube.

4. Hemobilia.

5. Benign stricture.

6. Malignant stricture.
• In the wall:

1. Congenital atresia.

2. Traumatic Strictures.

3. Choledochal cyst.

4. Caroli’s disease.

5. Tumors of bile duct.

6. Klatskin’s tumor.

7. Sclerosing Cholangitis.
• Outside the wall:

1. Carcinoma head of pancreas.

2. Periampullary stricture.

3. Porta hepatis metastasis.

4. Pancreatitis.

5. Chronic duodenal diverticulum.

6. Pseudocyst of pancreas.

7. Metastatic carcinoma
POINTS IN FAVOUR OF
OBSTRUCTIVE JAUNDICE:

• Painless progressive Jaundice.

• Itching and scratch marks.

• Presence of palpable gallbladder.

• Loss of weight.
COURVOISIER’S LAW:

• When the gallbladder is palpable and the patient is jaundiced, the

obstruction of the bile duct causing the jaundice is unlikely to be a
stone because the previous inflammation will have made the
gallbladder thick and non distensable.
INVESTIGATION:
• Ultrasound of abdomen.

• CECT abdomen.

• MRCP.

• ERCP and stent.

• Endoscopic US.

• Biopsy.

• Operable/ non operable.

• surgery
MANAGEMENT:

• Hydration.

• Nutrition.

• Correction of coagulation deficiency- vitamin K; FFP; platelet

transfusion. Etc

• Correction of anemia.

• Preoperative biliary decompression.

INDICATIONS FOR PREOPERATIVE
BILIARY DECOMPRESSION:
• Bilirubin > 12 mg/dl.

• Sepsis.

• Hepatorenal failure.

• Severe cardiopulmonary failure.

• Severe Malnutrition.
FEVER IN JAUNDICE:

1. Cholangitis.

2. Septicemia.

3. Hemolysis.

4. Hepatic Abscess
SPECIAL RISKS IN OBSTRUCTIVE
JAUNDICE:
• Hypocoagulability.

• Renal failure.

• Sepsis of bile with or without calculi.

CHARCOTS TRIAD:
CHOLANGITIS:
• Obstruction of bile duct- bacterial infectionof bile duct .
• Partial/ complete obstruction.
• Causes:
1. Choledocholithiasis.
2. Biliary stricture.
3. Neoplasms.
4. Ampullary stenosis.
5. Chronic pancreatitis.
6. Pseudocyst.
7. Duodenal diverticulum.
8. Parasitic.
• Pathophysiology of cholangitis:

 Ductal pressure increases when there is obstruction .

 Bacteria escape to the systemic circulation via hepatic sinusoids.

 Organism will reach blood and blood culture will positive.

• Common organisms for cholangitis:

 E. coli; klebsiella; pseudomonas; enterococci; proteus; bacteroides.

REYNOLD’S PENTAD:
• It is a manifestation of acute toxic cholangitis as a result of obstruction of the bile duct.

• Also called suppurative cholangitis.

• Life threatening condition.

• Managed as emergency.

• Pentad consists of:

oPain.

oFever.

oJaundice.

oMental confusion.

oShock.
Management:

• Emergency.

• Antibiotic- aminoglycoside and clindamycin/ metronidazole.

• Decompress ductal system- sphincterotomy or by trans hepatic

drainage. ( CI of sphincterotomy: stone size>2 cm or stenosis of bile
duct proximal to sphincter)

• Associated gallbladder pathology- tackle later by cholecystectomy.

MANAGEMENT OF OBSTRUCTIVE
JAUNDICE DUE TO CBD STONES:
• Endoscopic sphincterotomy followed by laparoscopic
cholecystectomy.

• Laparoscopic cholecystectomy and CBD exploration.

• Open cholecystectomy with choledochotomy and/ or T tube drainage.

THANK YOU ….