Up ] Abdominal incisions ] Groin hernias ] Other hernias ] Peritonitis ] Appendicitis ] Ovarian cysts ] Oesophageal perforation ] Perforated peptic ulcer ] Diverticular disease ] Upper GI haemorrhage ] Lower GI haemorrhage ] Small bowel obstruction ] Large bowel obstruction ] Sigmoid and caecal volvulus ] Pseudo-obstruction ] Enterocutaneous fistulae ] Mesenteric ischaemia ] Acute pancreatitis ] Pyogenic liver abscess ] Amoebic liver abscess ] Hydatid disease ] Gynecological pain ] GORD ] Achalasia ] Oesophageal carcinoma ] Peptic ulcer disease ] Gastric carcinoma ] Hepatocellular carcinoma ] Pancreatic cancer ] Chronic pancreatitis ] Colonic polyps ] Colorectal carcinoma ] Liver metastases ] Anal carcinoma ] Inflammatory bowel disease ] Anal fissure ] Haemorrhoids ] Perianal sepsis ] Pilonidal sinus ] Rectal prolapse ] [ Jaundice ] Gall stones ] Portal hypertension ] Ascites ] Stomas ] Abdominal pain ] Abdominal masses ]

Obstructive jaundice

Clinical features of jaundice

Aetiology of obstructive jaundice

  • Common
    • Common bile duct stones
    • Carcinoma of the head of pancreas
    • Malignant porta hepatis lymph nodes
  • Infrequent
    • Ampullary carcinoma
    • Pancreatitis
    • Liver secondaries
  • Rare
    • Benign strictures - iatrogenic, trauma
    • Recurrent cholangitis
    • Mirrizi's syndrome
    • Sclerosing cholangitis
    • Cholangiocarcinoma
    • Biliary atresia
    • Choledochal cysts

Investigation of obstructive jaundice

Investigation will differentiate hepatocellular and obstructive jaundice in 90% cases

Blood results

  • Conjugated bilirubin >35 mmol/l
  • Increase in ALP / GGT >> AST / ALT
  • Albumin may be reduced
  • Prolonged PTT

Urinalysis findings

Haemolysis

Obstruction Hepatocellular
Conjugated bilirubin normal increased normal
Urobilinogen increased nil normal

Ultrasound

  • Normal CBD <8 mm diameter
  • CBD diameter increase with age and after previous biliary surgery
  • For obstructive jaundice ultrasound has a sensitivity 70 - 95% and specificity 80 - 100%
  • In future endoscopic ultrasound may become more widely available

CT Scanning

  • Sensitivity and specificity similar to good quality ultrasound
  • Useful in obese or excessive bowel gas
  • Better at imaging lower end of common bile duct
  • Stages and assesses operability of tumours

Radionuclide scanning

  • 99 technetium iminodiacetic acid (HIDA)
  • Taken up by hepatocytes and actively excreted into bile
  • Allows imaging of biliary tree
  • Failure to fill gallbladder = acute cholecystitis
  • Delay of flow into duodenum = biliary obstruction

Endoscopic retrograde cholangiogram (ERCP)

  • Allows biopsy or brush cytology
  • Stone extraction or stenting

Percutaneous transhepatic cholangiogram (PTC)

  • Rarely required today
  • Performed with 22G Chiba Needle
  • Also allows biliary drainage and stenting

MRCP showing a bile duct stricture

 

Complications of obstructive jaundice

  • Ascending cholangitis
    • Charcot's triad is classical clinical picture
    • Intermittent pain, jaundice and fever
    • Cholangitis can lead to hepatic abscesses
    • Need parenteral antibiotics and biliary decompression
    • Operative mortality in elderly of up to 20%
  • Clotting disorders
    • Vitamin K required for gamma-carboxylation of Factors II, VII, IX, XI
    • Vitamin K is fat soluble. No absorbed.
    • Needs to be given parenterally
    • Urgent correction will need Fresh Frozen Plasma
    • Also endotoxin activation of complement system
  • Hepato-renal syndrome
    • Poorly understood
    • Renal failure post intervention
    • Due to gram negative endotoxinaemia from gut
    • Preoperative lactulose may improve outcome
    • Improves altered systemic and renal haemodynamics
  • Drug Metabolism
    • Half life of some drugs prolonged. (e.g. morphine)
  • Impaired wound healing

Perioperative management of obstructive jaundice

  • Preoperative biliary decompression improves postoperative morbidity
  • Broad spectrum antibiotic prophylaxis
  • Parenteral vitamin K +/- fresh frozen plasma
  • IVI and catheter
  • Pre operative fluid expansion
  • Need careful post operative fluid balance to correct depleted ECF compartment
  • Consider 250 ml 10% mannitol. No proven benefit in RCT

Common bile duct stones

  • Accurate prediction of the presence of common bile duct stones can be difficult
    • If elevated bilirubin, ALP and CBD > 12 mm risk of CBD stones is 90%
    • If normal bilirubin, ALP and CBD diameter risk of CBD stones 0.2%
  • ERCP and endoscopic sphincterotomy is investigation of choice

Dilated common bile duct at ERCP due to common bile duct stones

  • Stones extracted with balloons or Dormia basket
    • 90% successful
    • Complication rate 8%
    • Mortality
  • If fails to clear stones will require on of:
    • Open cholecystectomy + exploration of CBD
    • Laparoscopic exploration of CBD
    • Mechanical lithotripsy
      • 80% successful after failure of ERCP
    • Extra-corporeal shockwave lithotripsy
    • Chemical dissolution with cholesterol solvents
      • Methyl terbutyl ether or mono-octanoin
      • Administered via T Tube or nasobiliary catheter
      • 25% complete response and 30% partial response
  • If retained stones after CBD exploration need to consider:
    • Early ERCP
    • Exploration via T tube tract at 6 weeks

Bibliography

Huang J. Decision making in surgery: the management of obstructive jaundice. Br J Hosp Med 1997; 57: 40 - 42.

Diamond T, Parks R W. Perioperative management of obstructive jaundice. Br J Surg 1997; 82: 147 - 148.

Hulse P A, Nicholson D A. Investigation of biliary obstruction.  Br J Hosp Med 1994; 52: 103-107.

Hatfield A R W. Palliation of malignant obstructive jaundice - surgery or stent.  Gut 1990; 31: 1339-1340.

Hunter J G, Bordelon B M. Laparoscopic and endoscopic management of common bile duct stones.  Current Practice in Surgery 1993; 5: 105 - 111.

 

 
 

Copyright 1997- 2013 Surgical-tutor.org.uk