Obstructive Jaundice

Original article by Mohammad T Agha | Last updated on 17/6/2014
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Introduction

Obstructive Jaundice is a fairly common presentation to the emergency department and surgical teams. The most common cause is gallstones. You may also want to read about Gallstones and Jaundice for more information.

Aetiology of obstructive jaundice

Common

  • Common bile duct stones
  • Carcinoma of the head of pancreas
  • Malignant porta hepatis lymph nodes

Infrequent

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 Common Bile Duct (CBD) <8 mm diameter
  • CBD diameter increases with age and after previous biliary surgery
  • For obstructive jaundice ultrasound has a sensitivity 70 - 95% and specificity 80 - 100%
  • In the 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

Radionucloetide 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

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, X
  • Vitamin K is fat soluble, therefore is not absorbed due to decreased bile in the GI tract.
  • 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

  • o   If elevated bilirubin, ALP and CBD > 12 mm risk of CBD stones is 90%
  • o   If normal bilirubin, ALP and CBD diameter risk of CBD stones 0.2%

ERCP and endoscopic sphincterotomy is investigation of choice
 
Stones extracted with balloons or Dormia basket

  • 90% successful
  • Complication rate 8%
  • Mortality

If fails to clear stones will require one 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