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% casesBlood results

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

Urinalysis findings 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

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

• 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.
Hungness E S, Soper N J. Management of common bile duct stones. J Gastrointest Surg 2006; 10: 612-619
Hunter J G, Bordelon B M. Laparoscopic and endoscopic management of common bile duct stones. Current Practice in Surgery 1993; 5: 105 - 111.