Contents
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
- 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 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
