OBSTRUCTIVE JAUNDICEOBSTRUCTIVE JAUNDICEOBSTRUCTIVE JAUNDICE

Metin Kapan, M.D.Metin Kapan, M.D.

ProfessorProfessor of General Surgeryof General Surgery

Cerrahpasa School of MedicineCerrahpasa School of Medicine

Department of General SurgeryDepartment of General Surgery

Division of Hepatopancreatobiliary SurgeryDivision of Hepatopancreatobiliary Surgery

JAUNDICEJAUNDICENormal serum bilirubin ranges from 0.5-1.3 mg/dL

Levels exceed 2 mg/dL, bilirubin stains the tissues, and becomes clinically apparent as jaundice

Bilirubin is the normal breakdown product of hemoglobin

Produced from senecent red blood cells by the reticuloendothelial system

Insoluble unconjugated bilirubin is bound to albumin and transported to liver

Transported across the sinusoidal membrane of the hepatocyte into the cytoplasm

Bilirubin MetabolismBilirubin Metabolism

Unconjugated bilirubin is conjugated with glucronic acid via the effect of uridine-diphosphate-glucronyl transferase

Water-soluble molecules of bilirubin monoglucronide and bilirubin diglucronide are formed

Conjugated bilirubin is actively secreted into bile canaliculus

In the terminal ileum and colon, bilirubin is converted to urobilinogen

10-20% of urobilinogen is reabsorbed into portal circulation

Urobilinogen is either re-excreted into the bile or excreted by the kidneys into the urine

Diagnostic EvaluationDiagnostic Evaluation

The differential diagnosis of jaundice parallels the metabolism of bilirubin

A. Medical jaundice1.Increased production2.Decreased hepatocyte transport or conjugation3.Impaired excretion of bilirubinB. Surgical jaundice

1.Impaired delivery of bilirubin into the intestine

IncreasedIncreased productionproduction

Predominant hyperbilirubinemia = unconjugated

1.Multiple transfusions

2.Transfusion reaction

3.Sepsis

4.Burns

5.Congenital hemoglobinopathies

6.Hemolysis

ImpairedImpaired hepatocytehepatocyte uptakeuptake oror conjugationconjugation

Predominant hyperbilirubinemia = unconjugated

1.Gilbert’s disease

2.Crigler-Najjar syndrome

3.Neonatal jaundice

4.Viral hepatitis

5.Drug inhibition

6.Sepsis

ImpairedImpaired transport transport andand excretionexcretion

Predominant hyperbilirubinemia = conjugated

1.Dubin-Johnson syndrome

2.Rotor’s syndrome

3.Cirrhosis

4.Amyloidosis

5.Cancer

6.Hepatitis (viral, drug induced or alcoholic)

7.Pregnancy

BiliaryBiliary obstructionobstruction

Predominant hyperbilirubinemia = conjugated

1.Choledocholithiasis

2.Benign stricture

3.Periampullary cancer

4.Cholangiocarcinoma

5.Chronic pancreatitis

6.Primary sclerosing cholangitis

BiliaryBiliary ObstructionObstruction, , TypeType II

Complete obstruction

1.Tumors, especially of the pancreatic head

2.Ligation of the common bile duct

3.Cholangiocarcinoma

4.Primary or secondary parenchymal liver tumors

Benjamin 1983;

BiliaryBiliary ObstructionObstruction, , TypeType IIII

Intermittent obstruction

1.Choledocholithiasis

2.Periampullary tumors

3.Duodenal diverticula

4.Papillomas of the bile duct

5.Choledochal cyst

6.Polycystic liver disease

7.Intrabiliary parasites

8.Hemobilia

Benjamin 1983;

BiliaryBiliary ObstructionObstruction, , TypeType IIIIIIChronic incomplete obstruction

1.Strictures of the bile duct

a.congenital

b.traumatic (iatrogenic)

c.sclerosing cholangitis

d.post-radiotherapy

2.Stenosed biliary-enteric anastomoses

3.Chronic pancreatitis

4.Cystic fibrosis

5.Stenosis of the sphincter of Oddi

6.Dysfunction of the sphincter of Oddi

Benjamin 1983;

BiliaryBiliary ObstructionObstruction, , TypeType IVIV

Segmental obstruction

1.Traumatic and iatrogenic

2.Sclerosing cholangitis

3.Cholangiocarcinoma

Benjamin 1983;

DifferentialDifferential DiagnosisDiagnosisa. Careful history and physical examination

b. Routine laboratory tests1. Serum direct and indirect bilirubin

2. Alkaline phosphatase

3. Transaminases

4. Amylase

5. Complete blood cell count

c. Noninvasive radiologic imaging1. Confirmation of clinically suspected biliary obstruction

2. Identification of the site and cause of the obstruction

3. Selection of the appropriate treatment modality for managing thejaundice

UltrasonographyUltrasonography (US)(US)

•Initial screening test in suspected extrahepatic biliaryobstruction

•Dilation of the extrahepatic (>10 mm) or intrahepatic(>4 mm) bile ducts suggests biliary obstruction

•US is also accurate at identifying;• gallstones• liver metastases• and masses of the liver and pancreas

as possible causes of jaundice

ComputerisedComputerised TomographyTomography ScanningScanning (CT)(CT)

•CT is very sensitive at identifying biliary dilation

•less sensitive than US at detecting gallstones

•more accurate than US at identifying the site andcause of the extrahepatic biliary obstruction

•Spiral CT scanning provides additional staginginformation including vasculer involvement

CholangiographyCholangiographyOften necessary to delineate the site and cause of biliary obstruction

•MR cholangiography; noninvasive, provides excellent anatomic detail

•Endoscopic retrograde cholangiography (ERCP); invasive, risk of 2-5 % complications. Useful in imaging patients with periampullary tumors and choledocholithiasis

•Percutaneous transhepatic cholangiography (PTC); invasive, risk of 2-5 % complications. Preferred technique in patients with proximal biliary obstruction or in patients in whom ERC is not technically possible

EndoscopicEndoscopic ManagementManagement•Several conditions causing jaundice can also be treated at the time of ERC

•The common bile duct can be cleared of stones using endoscopicallypassed balloon catheters or baskets following a sphincterotomy

•Malignant biliary strictures involving the mid or distal common bile duct are also amenable to endoscopically placed stents to internallydecompress the biliary tract and relieve jaundice

•Polyurethane and metallic expandable stents are available

•Metallic stents remain patent longer, more difficult to exchangeonce they are occluded

PercutaneousPercutaneous ManagementManagement•Percutaneous route is also available for access to the biliary tractand the treatment of obstructing jaundice

•This approach is favored in patients with more proximal bile ductobstruction involving or proximal to the hepatic duct bifurcation

•Percutaneously placed polyurethane or metallic stents can usuallybe passed across an obstructing biliary lesion into the duodenum topermit internal biliary drainage

•Serial dilation of the stent tract can also facilitate passage of a flexible choledochoscope into biliary tree for direct visualization, biopsy or management of any obstructing lesions or stones

OperativeOperative ManagementManagement

Risk factors

•In an obstructive jaundice; hepatic and pancreatic function, thegastrointestinal barrier, immune function, hemostatic mechanisms and wound healing can be impaired

•Hepatic protein synthesis, hepatic reticuloendothelial function, and other aspects of hepatic metabolism may be significantly altered

•Endotoxemia occurs frequently and may contribute renal, cardiac and pulmonary insufficiency observed

•Altered cell-mediated immunity increases the risk of infection

•Coagulation disorders make these patients prone to bleeding problems

•Malnutrition (hypoalbuminemia), and sepsis (cholangitis) and renal insufficiency all are associated with an increase in operative morbidity and mortality