OBSTRUCTIVE JAUNDICE : Dr. Srinivas
Dept. of Surgery OBSTRUCTIVE JAUNDICE Obstructive jaundice : Definition :
Is a condition characterized by Yellow discoloration of the skin , sclera & mucous membrane as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. Obstructive jaundice Classification of obstructive jaundice : Type I : complete obstruction
Tumors : Ca. head of Pancreas
Ligation of the CBD
Parenchymal Liver diseases Classification of obstructive jaundice Slide 4: Type II : Intermittent obstruction
Papillomas of the bile duct
Intra biliary parasites
Hemobilia TYPE III : Chronic incomplete obstruction : Strictures of the CBD
Stenosed biliary enteric anastamosis
Stenosis of the Sphincter of Oddi TYPE III : Chronic incomplete obstruction ERCP showing distal common bile duct stricture with proximal dilation Slide 6: TYPE IV : Segmental Obstruction
Cholangio carcinoma PATHOPHYSIOLOGY OF OBSTRUCTION : Alterations in
– Systemic and renal hemodynamics
– Hepatic function
– Hemostatic mechanism
– Gastrointestinal barrier
– Immune function
– Wound healing • Protein synthesis,
• Reticulo-endothelial function
• Hepatic metabolism PATHOPHYSIOLOGY OF OBSTRUCTION Slide 8: Coagulation system
Prolonged bile duct obstruction leads to significant defects in clotting factors
Before surgery these defects should be corrected by Fresh frozen plasma and Vitamin K
Even if there is no measurable coagulation
dysfunction Vitamin K should be given to all patients with obstructive jaundice Slide 9: ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile Slide 10: ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile X Abnormal LFTs : Abnormal LFTs Slide 12: • Fever, persistent (90%)
Abdominal pain (70%)
• Jaundice (60%)
• Tea-colored urine/pale stools
• Altered mental status (10-20%)
• Hypotension (30%)
• RUQ tenderness What are reliable signs & symptoms (more than 90% certainty) that a patient with obstructive jaundice need urgent intervention ? Slide 13: Obstructive Jaundice
• Relief of Obstruction
• Prevent Complication
• Prevent Recurrence Goal of Treatment Slide 14: Are the ducts dilated
What is the level of obstruction
What is the cause
What is the best therapeutic approach The role of Radiology JAUNDICE : JAUNDICE Investigations : Non-invasive
Biopsy Investigations Obstructive Jaundice : CBD stones (Choledocholithiasis) vs. tumor
Clinical features favoring CBD stones:
Age < 45
Transient spike in AST or amylase
Clinical features favoring cancer:
Bilirubin > 10 Obstructive Jaundice Unconjugated vs. Conjugated : Unconjugated
production exceeds ability of liver to conjugate
Ex. Hemolytic anemia's, hemoglobinopathies, in-born errors of metab., transfusion rxn. Conjugated
Can produce but not excrete
Intra- or extra hepatic obstruction Metabolic defect Unconjugated vs. Conjugated Choledocholithiasis : Defined as stones in the CBD
Patho physiology : intermittent obstruction of CBD
Symptoms are indistinguishable from other causes of Biliary pain
Predisposes to Cholangitis & Acute Pancreatitis
Elevated sr. bilirubin & Alk. Phos. Choledocholithiasis Evaluation : ERCP
Primary diagnostic and therapeutic modality
Sphincterotomy and stone extraction
Placement of stent if stone extraction
Mortality rate 1.5% Evaluation Open CBD Exploration : Indications
Presence of multiple stones (more than 5)
Stones > 1 cm
Multiple intra hepatic stones
Distal bile duct strictures
Failure of ERCP
Recurrence of CBD stones after sphincterotomy Open CBD Exploration CBD Exploration - SurgicalOptions : Common bile duct exploration with T-tube
Transduodenal sphincterotomy and
Roux-en-Y Choledocho jejunostomy CBD Exploration - SurgicalOptions CHOLEDOCHAL CYSTS : Congenital anomalies of the biliary tract that manifest as cystic dilatation of the extra hepatic and intra hepatic bile ducts
Females are most commonly affected
Congenital weakness of the bile duct wall
Congenital obstruction of the bile ducts
Reo virus association is seen in 78% of patients
40% of anomalies are seen at the junction of pancreatic and common bile ducts CHOLEDOCHAL CYSTS CLASSIFICATION OF CHOLEDOCHAL CYST : Proposed by Todani & colleagues
TYPE I : accounts for 80 – 90 % of cases
exhibit segmental or diffuse fusiform dilatation of the CBD.
TYPE II : consists of a true Choledochal diverticulum
TYPE III : consists of dilatation of the intra duodenal portion of the CBD.
TYPE IV : multiple intra hepatic & extra hepatic cysts
TYPE V or CAROLIS disease : consists of single or multiple dilatation of the intra hepatic ductal system CLASSIFICATION OF CHOLEDOCHAL CYST Slide 25: Clinical features :
Disease often appears during first months of life
80% of pts. have cholestatic jaundice & acholic stools
Vomiting , irritability & failure to thrive may occur
Spontaneous perforation of a Choledochal cysts may occur
Progressive hepatic injury due to biliary obstruction
BEST established by USG Abdomen
In Older children PTC or ERCP may help define the anatomy of the cyst. TREATMENT : Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree
Biliary drainage is accomplished by Choledocho – jejunostomy with a Roux – en – Y anastamosis
Long term follow up is necessary because of complications like cholangitis , lithiasis , anastomotic stricture TREATMENT Cholangiocarcinoma : 90% are extra-hepatic
60’s and 70’s
Highest incidence in Japan, Israel, and Native Americans
Increased 3 fold in the last 30yrs in the USA
M/F=3/2 Cholangiocarcinoma CholangiocarcinomaEtiology : CholangiocarcinomaEtiology CholangiocarcinomaExtra-hepatic: Distribution : Right or left hepatic duct = 10%
Bifurcation = 20%
Proximal CBD = 30%
Distal CBD = 30% CholangiocarcinomaExtra-hepatic: Distribution CholangiocarcinomaDiagnosis and Initial Workup : Jaundice
Wt loss, anorexia, abdominal pain, fever
US then CT (CTA?) Followed by ERCP, PTC or MRCP
CEA and CA 19-9 can be elevated CholangiocarcinomaDiagnosis and Initial Workup CholangiocarcinomaIntra-hepatic Disease : Suspicious mass on CT. Quadruple phase CT with 0.5 cm cuts through the liver and portal hepatitis. Consider CTA reconstruction.
If adenoncarcinoma: look for primary with a chest CT and upper/lower endoscopy.
Colon, pancreas, and stomach are common primary sites. CholangiocarcinomaIntra-hepatic Disease CholangiocarcinomaIntra-hepatic Disease-Surgery/Ablation : Extent of surgical therapy is determined by the location, hepatic function, and underlying cirrhosis.
Anatomic resections have lowest recurrence rates. However non anatomic resection increases potential surgical candidates and improves survival
Hepatic devascularization prior to resection is preferred
Ablative therapy gives good local control. CholangiocarcinomaIntra-hepatic Disease-Surgery/Ablation MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation : MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation Klatskin tumor ERCP: Distal CBD Cancer : ERCP: Distal CBD Cancer Ca of CBD Bifurcation : Ca of CBD Bifurcation Periampullary Carcinoma and The Whipple : Periampullary Carcinoma and The Whipple Endoscopic View : Endoscopic View Pathology : Adeno carcinoma accounts for 95%
Arises from 4 different tissues of origin
Head of pancreas
Distal Bile duct
Ampullary of Vater
Periampullary duodenum Pathology Pathology : Prognosis for each of these are different.
Five year survival for pancreas: 18%
Five year for ampulla: 36%
Five year for distal bile duct: 34%
Five year for duodenum: 33%
Determination of tissue origin is important for prognosis, extent of resection. Pathology Pathology : Determination of tissue origin from FNA, endoscopic biopsy.
Also from thin section CT scan, ERCP
Determination of k-Ras also helps (95% of pancreatic cancer). Pathology Spread : Loco regional spread results from lymphatic invasion and direct tumor spread to adjacent soft tissue.
Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group.
Duodenal has intermediate spread.
Pancreas metastasizes 88% to multiple sites. Spread Treatment : Standard Whipple pancreaticoduodenectomy thought to provide adequate tumor clearance in the case of non-pancreatic ampullary tumor, because tumor spread is localized.
Biopsy proven paraduodenal LN is thought by most to preclude curative resection Treatment Surgery and Chemotherapy : Low risk patients had 5 year local control and survival of 100% and 80% respectively.
High risk patients had 5 year local control and survival of 50% and 38%, respectively.
Based on these findings, some have proposed a course of preoperative chemoradiation to improve local disease control in these high risk patients. Surgery and Chemotherapy Whipple Procedure : Five basic techniques are used to resect pancreatic cancers
Pylorus preserving pancreaticoduodenectomy
Extended resection (MD Anderson) Whipple Procedure Kocherizing the Duodenum : Kocherizing the Duodenum SMA Involved? : SMA Involved? SMV Identification : SMV Identification Dividing the Neck : Dividing the Neck The End Result : The End Result Adjuvant Therapy : Autopsy series show that 85% of patients will experience recurrence in operative field.
70% have metastases to liver.
So need to address local control (radiation) and distant disease (chemotherapy).
Most commonly used is 5 FU and this only has a 15-28% response on its own, but it’s a radio sensitizer, so it improves response to chemo. Adjuvant Therapy Slide 52: Thank you