SURGICAL

JAUNDICE
PRESENTER : PRAJWAL RAO K;

MODERATOR : Dr. P N SREERAMULU

BILIRUBIN
METABOLISM
 INTRODUCTION

• It is the jaundice that develops due to biliary

obstruction, partial or complete or intermittent.
• It causes conjugated hyperbilirubinaemia.

• Normal serum bilirubin level is 0.2–0.8 mg%.

• Scleral icterus is visible when serum bilirubin

level exceeds 2.5 mg%.
 CAUSES OF OBSTRUCTIVE
JAUNDICE

1. Congenital: Biliary atresia, choledochal cyst.

2. Inflammatory: Ascending cholangitis, sclerosing cholangitis.

3. Obstructive: CBD stones, biliary stricture, parasitic

infestation.

4. Neoplastic: Carcinoma of head or periampullary region of

pancreas, cholangiocarcinomas, Klatskin tumour.

5. Extrinsic compression of CBD by lymph nodes or tumours.

PATHOPHYSIOLOGY
 EFFECTS OF OBSTRUCTIVE
JAUNDICE
• In liver: Enlarged green bile stained liver (hydrohepatosis)

shows dilated intrahepatic biliary radicles.

• In the biliary tree: Recurrent inflammation—cholangitis—

fibrosis can occur.

• In bowel: Absence of bile from bowel impairs digestion,

reduces fat absorption making faeces bulky and fatty. Vitamin

K absorption is reduced causing fall in prothrombin level

raising PT-INR.
 Cont’d

• Retention of bile salts and bile pigments in

blood and body fluids occurs.
• Altered coagulation profile; hepatorenal
syndrome and renal failure; sepsis.
 LIVER IN OBSTRUCTIVE
JAUNDICE
• Liver where an obstruction
has caused an interruption
to the drainage of bile.
• This condition, known as
obstructive or post-hepatic
jaundice, causes a build up
of bilirubin in the blood and
tissues, leading to a
yellowing of the skin
(jaundice).
• The most common causes
are gallstones in the
common bile duct and
pancreatic cancer.
C L I N I C A L F E AT U R E S
1) Severe jaundice.

2) Pruritus, more on the back and forearms.

3) Fever, may or may not be present.

4) Loss of weight.

5) Loss of appetite.

6) Pain in right hypochondrium, palpable gallbladder, hydrohepatotic palpable,

smooth, soft, non-tender liver are other features.

7) Courvoisier’s law may suggest inflammatory/neoplastic cause.

8) Charcot’s triad/Reynold’s pentad as presentation in cholangitis.

9) Steatorrhoea (more fatty stool) due to improper absorption of fat soluble

vitamins.
 HISTOLOGY
• Liver in obstructive jaundice.
• Light micrograph of a
section through a liver where
an obstruction has caused
an interruption to the
drainage of bile.
• This condition, known as
obstructive or post-hepatic
jaundice, causes a build up
of bilirubin in the blood and
tissues, leading to a
yellowing of the skin
(jaundice).
• The most common causes
are gallstones in the
common bile duct and
pancreatic cancer.
 HISTOLOGY

a) cholestasis (H & E
; X 400);

b) bile ductular proliferation

(H & E ; X 100);

c) portal inflammation
(H & E ; X 400);

d) cholangitis (H & E
; X 400).
 HISTOLOGY

a) Incidental steatosis
(H & E X 400);
b) portal foreign body
granuloma (H
& E X 400)
 I N V E S T I G AT I O N S F O R
OBSTRUCTIVE JAUNDICE

• Serum bilirubin. Normal value is less than 1.0 mg%. Both

direct and indirect bilirubin are assessed. Direct is increased

in obstructive jaundice, i.e. conjugated hyperbilirubinaemia.

van den Bergh’s test is done.

• Serum albumin, globulin and A:G ratio. Normal S. albumin is

more than 3.5 gm%.

• Serum alkaline phosphatase, SGPT, SGOT, 5’ nucleotidase.

• Prothrombin time. Normal value is 12–16 seconds. It is

significant if it is more than 4 from the control or more than

one and half times the control. It is corrected by injection

vitamin K, 10 mg IM OD for 5 days or by FFP—5–10 units.

• Ultrasound abdomen.

• ERCP to visualise the site of obstruction, brush biopsy, bile

sample for analysis.

IMAGING
• Total count may be raised with neutrophilia in

inflammatory conditions.
– Serum alkaline phosphatase (ALP) and γ glutamyl

transpeptidase (GCT) are relevant enzymes in biliary

obstruction; especially ALP/GCT ratio is more
relevant in differentiating between obstructive
jaundice and hepatitis.
• PTC to decompress, assess proximal dilated obstructed

biliary system if ERCP fails; dine polythene catheter can be

kept in situ to have biliary drainage; PTC—stenting across
the obstruction can be done under image (C-arm) guidance.

• MRCP—Noninvasive diagnostic tool. It shows 96%

sensitivity; 99% specificity.

• CT scan in case of tumours to assess operability.

 IMAGING

Ultrasound image
showing a smooth tapering
of the distal CBD with
possibility of a
communication between
the distal CBD and the
cystic pancreatic lesion (as
shown b y arrow)
IMAGING

• PTC showing the

obstruction in the
middle CBD and the
presence of
bilioenteric fistula
(arrow).
• No metallic stents
are visible.
• Tumour markers: CA 19/9 is useful for carcinoma

pancreas (more than 70 units/L) with 70% sensitivity

and 90% specificity. But it may also increase in other
causes of biliary obstruction and cystadenoma.

• CT/MR angiogram or venogram to assess vascularity

and portal venous system in malignancy.

• Endoscopic US (EUS): It is done through

endoscope. It is more accurate in assessing

pancreatic mass, staging of the disease, to identify
involvement of portal venous system, CBD stones.
It is also useful in EUS-guided FNAC, celiac axis
neurolysis, EUS-guided immunotherapy.
IMAGING

A patient with obstructive jaundice

and dilated common bile duct on
computed tomography (CT) scan.
A. Pancreatic duct is not dilated and
a mass lesion is not identifiable on
computed tomography scan.
B. Endoscopic ultrasound images
showing dilated common bile duct
terminating into a mass lesion in
the pancreas and
C. Another view of the same mass
arising from the uncinate process;
D. Patient with abnormal liver
function test s but without elevated
serum bilirubin and dilated
common bile duct noted on
computed tomography scan.
E. Endoscopic ultrasound identified
markedly dilated common bile duct
F. No obstructive lesions were noted
and the pancreatic head appeared
normal.
• Intraductal US (IDUS): It is very useful in
assessing tumour stage, tumour margin in bile duct
cancer. It is also used in assessing pancreatic duct
to differentiate pancreatic cancer and chronic
pancreatitis.
• Urine tests: Fouchet’s test for bile pigments, Hay’s
test for bile salts and test for urobilinogen in urine.
 URINE TESTS
FOUCHET’S TEST HAY’S TEST EHRLICH’S TEST
10 ml of urine + 5 ml of Sprinkle sulphur to 2 ml 5 ml of freshly voided
BaCl2 + pinch of MgSO4 of urine. urine + 1 ml of Ehrlich
causes formation of In presence of bile salts reagent (p-dimethyl
BaSO4 which is filtered sulphur sinks to the amino benzaldehyde)
over a filter paper and bottom. and wait for 5 minutes.
few drops of Fouchet’s Formation of red colour
reagent is added. signifies presence of
Green or blue colour urobilinogen in urine.
signifies presence of bile Normally it is present in
pigments in the urine. traces; in obstructive
jaundice, it is absent;
and in haemolytic
jaundice, it is in excess.
 PREOPERATIVE PREPARATION OF
PATIENT WITH SURGICAL JAUNDICE

• Proper diagnosis and assessment

• Injection vitamin K IM 10 mg for 5 days

• Fresh Frozen plasma—often requires 6 bottles or more

• Adequate hydration is most important 5/10% dextrose

• Blood transfusion in case of anaemia

• Oral neomycin, lactulose

• Mannitol 100–200 ml BD IV to prevent hepatorenal syndrome

• Repeated monitoring by doing prothrombin time, electrolytes.

 Cont’d
• Antibiotics like third generation cephalosporins.

• Calcium supplements as calcium chloride IV

• Preoperative decompression is indicated if bilirubin is > 12 mg%,

sepsis, hepatorenal syndrome, severe malnutrition or

cardiopulmonary disease.

• Correction of coagulopathy, prevention of renal failure, infection,

hepatic encephalopathy and electrolyte imbalance (correction of

hypoglycaemia and dilutional hyponatraemia due to water

retention; avoiding isotonic saline infusion).

 T R E AT M E N T O F
OBSTRUCTIVE JAUNDICE
CARCINOMA
CBD STONES PERIAMPULLARY/HEAD BILIARY STRICTURE
OF PANCREAS
ERCP stone removal Whipple’s operation Stenting
Choledocholithotomy Triple bypass Choledochojejunostomy
Transduodenal ERCP stenting Rouxen – Y
sphincteroplasty Hepaticojejunostomy
Choledochojejunostomy
Choledochoduodenostomy

KLATSKIN TUMOUR BILIARY ATRESIA CHOLEDOCHAL CYST

Radical resection Kasai’s operation Excision
Palliative stenting Liver transplantation Hepaticojejunostomy
Mucosal resection
 MANAGEMENT OF
PRURITUS
• Once cause is treated and obstruction is relieved,
pruritus will regress.
• Drugs and therapies used are—cholestyramine
(ion exchange resin binds bile salts in intestine
inhibiting their absorption), rifampin, ondansetron,
gabapentin, sertraline, ursodeoxycholic acid,
antioxidants, phototherapy, plasmapheresis.
 P O S T O P E R AT I V E
MANAGEMENT
• Monitoring with prothrombin time, bilirubin, albumin, creatinine,

electrolyte estimation.

• FFP or blood transfusion.

• Antibiotics.

• Observation for septicaemia, haemorrhage, pneumonia, pleural

effusion, bile leak.

• Care of T-tube and drains.

• T-tube cholangiogram in 10–14 days.

• TPN, CVP line, nasogastric tube, urinary catheter.

THANK
YOU