Obstructive Jaundice Dr. Alex A. Erasmo De Veyra Dee A. Dela Cruz J. Dela Cruz

Obstructive JaundiceObstructive JaundiceDr. Alex A. ErasmoDr. Alex A. Erasmo

De Veyra • Dee • A. Dela Cruz • J. Dela De Veyra • Dee • A. Dela Cruz • J. Dela CruzCruz

Jaundice in a 58 year old Jaundice in a 58 year old malemale

2 months PTA2 months PTA Progressively icteric scleraeProgressively icteric sclerae Tea-colored urineTea-colored urine Acholic stoolAcholic stool 20% weight loss20% weight loss PruritusPruritus


Past Personal History:Past Personal History: Heavy smoker (3 pack-years)Heavy smoker (3 pack-years) Occasional alcoholic beverage Occasional alcoholic beverage

drinkerdrinker No history of hepatitisNo history of hepatitis Hypertensive for 10 yearsHypertensive for 10 years

CaptoprilCaptopril MetoprololMetoprolol

No history of DMNo history of DM


BP 150/90 BP 150/90 HPN?HPN? PR 86/min PR 86/min Temp 36.7°CTemp 36.7°C RR 17/minRR 17/min Ht: 5’7”; Wt: 155 lbs Ht: 5’7”; Wt: 155 lbs BMI: 24.3BMI: 24.3 Skin: yellowishSkin: yellowish Icteric sclerae; no palpable cervical Icteric sclerae; no palpable cervical

lymph nodes; oral cavity normallymph nodes; oral cavity normal H/L: essentially normalH/L: essentially normal


Abdomen: Abdomen: Slightly globularSlightly globular

Ascites? Ascites? Ill-defined ballotable mass at the RUQ, Ill-defined ballotable mass at the RUQ,

not tender, smooth in surface, moves not tender, smooth in surface, moves with respiration; with respiration;

Liver edge not palpableLiver edge not palpable Rectal exam: Rectal exam:

Acholic stoolsAcholic stools

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Lab Work-upLab Work-up

Hgb: 110 gramsHgb: 110 grams Hct: 35Hct: 35 WBC: 8000; normal differential countWBC: 8000; normal differential count Platelet: 350,000Platelet: 350,000 Serum Crea: 1.2 mgSerum Crea: 1.2 mg Total bil: 10 mg; Total bil: 10 mg;

B1(unconj): 2 mg B1(unconj): 2 mg B2 (conj): 8 B2 (conj): 8 mgmg

Alkaline phosphatase: 500 U/LAlkaline phosphatase: 500 U/L CA 19-9: 350 units/mlCA 19-9: 350 units/ml Total protein: 6.5 grams; albumin: Total protein: 6.5 grams; albumin:

3.5; globulin: 2.53.5; globulin: 2.5


Hgb: 110 gramsHgb: 110 grams Hct: 35Hct: 35 WBC: 8000; normal differential countWBC: 8000; normal differential count Platelet: 350,000Platelet: 350,000 Serum Crea: 1.2 mgSerum Crea: 1.2 mg Total bil: 10 mg; Total bil: 10 mg;

B1(unconj): 2 mg B1(unconj): 2 mg B2 (conj): 8 B2 (conj): 8 mgmg

Alkaline phosphatase: 500 U/LAlkaline phosphatase: 500 U/L CA 19-9: 350 units/mlCA 19-9: 350 units/ml Total protein: 6.5 grams; albumin: Total protein: 6.5 grams; albumin:

3.5; globulin: 2.53.5; globulin: 2.5


Significant Elevation of: Significant Elevation of: NVNV

Total Total BilirubinBilirubin

10 mg10 mg 0.3 – 1.0 0.3 – 1.0 mg/dLmg/dL

B1B1 2 mg2 mg < 0.2 mg/dL< 0.2 mg/dL

B2B2 8 mg8 mg < 0.8 mg/dL< 0.8 mg/dL

Alkaline Alkaline phosphatasphosphatasee

500 U/L500 U/L 20-70 U/L20-70 U/L

CA 19-9CA 19-9 350 U/mL350 U/mL < 37 U/mL< 37 U/mL

Differentiating JaundiceDifferentiating Jaundice

Pre-Pre-hepatichepatic

IntrahepatiIntrahepaticc

ObstructivObstructivee

Plasma Plasma BilirubinBilirubin

B1B1 bothboth B2B2

Urine Urine bilirubinbilirubin

Often Often absentabsent

Stercobilin Stercobilin & fecal & fecal colorcolor

, dark, dark /N, pale/N/N, pale/N , pale, pale

Plasma Plasma Alkaline Alkaline PhosphatasPhosphatasee

NN

Differentiating JaundiceDifferentiating Jaundice

Pre-Pre-hepatichepatic

IntrahepatiIntrahepaticc

ObstructivObstructivee

Plasma Plasma BilirubinBilirubin

B1B1 bothboth B2B2

Urine Urine bilirubinbilirubin

Often Often absentabsent

Stercobilin Stercobilin & fecal & fecal colorcolor

, dark, dark /N, pale/N/N, pale/N , pale, pale

Plasma Plasma Alkaline Alkaline PhosphatasPhosphatasee

NN


Others:Others: Prothrombin time Prothrombin time ProlongedProlonged Serum amylaseSerum amylase ElevatedElevated TransaminasesTransaminases ElevatedElevated

Obstructive JaundiceObstructive Jaundice

Gradual obstruction of CBD(weeks or months)

Jaundice PruritusWithout assoc. Sx

of biliary colic or cholangitis

Differential DiagnosisDifferential Diagnosis

Painless Jaundice

CholedocholithiasisBiliary Obstruction

2o to malignancy

Periampullary Tumors

Hilar Cholangiocarcinoma

CholedocholithiasisCholedocholithiasis

Clinical PictureClinical Picture May be silentMay be silent Often discovered incidentallyOften discovered incidentally May cause obstructionMay cause obstruction

CompleteComplete Incomplete Incomplete

May manifest with cholangitis May manifest with cholangitis or gall bladder pancreatitisor gall bladder pancreatitis

PE: may be normalPE: may be normal Mild epigastric or RUQ painMild epigastric or RUQ pain JaundiceJaundice

Completely impacted stones:Completely impacted stones: Severe progressive Severe progressive

jaundicejaundice

Lab WorkupLab Workup serum bilirubinserum bilirubin alkaline phosphatasealkaline phosphatase transaminasestransaminases


Assoc. with chronic calculous Assoc. with chronic calculous cholecystitis cholecystitis PAIN PAIN

Absence of a palpable GBAbsence of a palpable GB Courvoisier’s LawCourvoisier’s Law

Presence of a palpably enlarged GB Presence of a palpably enlarged GB suggests biliary obstruction suggests biliary obstruction secondary to an underlying secondary to an underlying malignancy rather than a calculous malignancy rather than a calculous disease.disease.


CholedocholithiasisCholedocholithiasisImaging StudiesImaging Studies

Differential DiagnosisDifferential Diagnosis

Painless Jaundice

CholedocholithiasisBiliary Obstruction

2o to malignancy

Periampullary Tumors

Hilar Cholangiocarcinoma

Ampulla of VaterAmpulla of Vater Distal common bile ductDistal common bile duct DuodenumDuodenum Head of the Pancreas Head of the Pancreas

Periampullary TumorsPeriampullary Tumors


Clinical PictureClinical Picture Painless progressive jaundicePainless progressive jaundice

PruritusPruritus Acholic stoolAcholic stool Tea-colored urineTea-colored urine

Weight loss (Average 10 kg)Weight loss (Average 10 kg) Mild RUQ painMild RUQ pain AnorexiaAnorexia FatigueFatigue

PE is usually normalPE is usually normal Palpable GB (Courvoisier’s Law)Palpable GB (Courvoisier’s Law)

Lab WorkupLab Workup alkaline phosphatasealkaline phosphatase total bilirubin & B2total bilirubin & B2


Hilar CholangiocarcinomaHilar Cholangiocarcinoma

Klatskin’s tumorKlatskin’s tumor

Clinical Picture:Clinical Picture: Painless jaundicePainless jaundice PruritusPruritus Mild RUQ painMild RUQ pain AnorexiaAnorexia Weight lossWeight loss Acholic stoolsAcholic stools

PE is usually normalPE is usually normal HepatomegalyHepatomegaly Collapsed GBCollapsed GB

Lab WorkupLab Workup alkaline phosphatasealkaline phosphatase gammaglutaryltransferasegammaglutaryltransferase

Hilar Hilar CholangiocarcinomaCholangiocarcinoma

Resectable?

Yes No

Good riskGood risk Poor risk Poor risk

Whipple’s

PPPD

Endoscopic drainage Bypass

Cholecystojejunostomy with Gastrojejunostomy

Hepaticojejunostomy with Gastrojejunostomy

ERCP

TreatmentTreatment

Outcomes in Outcomes in PancreaticoduodenectomyPancreaticoduodenectomy

1-year mortality rate1-year mortality rate 57%57% 3-year mortality rate3-year mortality rate 26%26% 5-year mortality rate5-year mortality rate 21%21%

Median survival rate: 15 monthsMedian survival rate: 15 months 11 5-year survivors11 5-year survivors 7 6-year survivors7 6-year survivors 1 15-year survivor1 15-year survivor

Outcomes in Outcomes in PancreaticoduodenectomyPancreaticoduodenectomy

Strongest independent predictors Strongest independent predictors of favorable outcome of favorable outcome Tumor DNA content, Tumor DNA content, Tumor diameter, Tumor diameter, Status of resected lymph nodes, Status of resected lymph nodes, Margin status Margin status Use of postoperative combined Use of postoperative combined

modality chemoradiation therapymodality chemoradiation therapy

ReferencesReferences

Brunicardi et. al. Schwartz's Principles of Surgery, 8/e. Brunicardi et. al. Schwartz's Principles of Surgery, 8/e. McGraw-Hill Professional. 2004.McGraw-Hill Professional. 2004.

Sabiston et. al. Sabiston Textbook of Surgery: The Sabiston et. al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. W.B. Biological Basis of Modern Surgical Practice. W.B. Saunders Co. 2001.Saunders Co. 2001.

Greenfield, et. al. Essentials of Surgery: Scientific Greenfield, et. al. Essentials of Surgery: Scientific Principles & Practice. Lippincott-Raven Publishers. 1997Principles & Practice. Lippincott-Raven Publishers. 1997

American Cancer Society. http://www.cancer.orgAmerican Cancer Society. http://www.cancer.org Sosa et. al. Importance of hospital volume in the overall Sosa et. al. Importance of hospital volume in the overall

management of pancreatic cancer. Ann Surg. 1998 management of pancreatic cancer. Ann Surg. 1998 Sep;228(3):429-38.Sep;228(3):429-38.

Gordon et. al. Statewide regionalization of Gordon et. al. Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg. 1998 Jul;228(1):71-8.mortality. Ann Surg. 1998 Jul;228(1):71-8.

Body Mass Index (BMI)Body Mass Index (BMI)

BMIBMI Weight StatusWeight Status

< 18.5< 18.5 UnderweightUnderweight

18.5 – 24.918.5 – 24.9 NormalNormal

25.0 – 29.925.0 – 29.9 OverweightOverweight

> 30.0> 30.0 Obese Obese

Sites of Metastasis in Sites of Metastasis in Pancreatic CA (Head)Pancreatic CA (Head)

Regional Lymph Nodes Regional Lymph Nodes 80%80% Juxtaregional Lymph NodesJuxtaregional Lymph Nodes 49%49% LiverLiver 75%75% Lungs & PleuraLungs & Pleura 27%27% Adrenals & StomachAdrenals & Stomach 14%14% No metastasisNo metastasis 14%14%

TNM Classification for TNM Classification for Staging of Pancreatic CAStaging of Pancreatic CA

T Categories of Cancer of the PancreasT Categories of Cancer of the Pancreas

T1: The cancer has not spread beyond the T1: The cancer has not spread beyond the pancreas and is smaller than 2 cm (about ¾ pancreas and is smaller than 2 cm (about ¾ inch). inch).

T2: The cancer has not spread beyond the T2: The cancer has not spread beyond the pancreas but is larger than 2 cm (about ¾ pancreas but is larger than 2 cm (about ¾ inch). inch).

T3: The cancer has spread from the pancreas to T3: The cancer has spread from the pancreas to surrounding tissues near the pancreas but not surrounding tissues near the pancreas but not blood vessels. blood vessels.

T4: The cancer has extended further beyond T4: The cancer has extended further beyond the pancreas into nearby large blood vessels.the pancreas into nearby large blood vessels.


N Categories of Cancer of the Pancreas N Categories of Cancer of the Pancreas

N0: Regional lymph nodes (lymph nodes near N0: Regional lymph nodes (lymph nodes near the pancreas) are not involved. the pancreas) are not involved.

N1: Cancer has spread to regional lymph nodes.N1: Cancer has spread to regional lymph nodes.

M Categories of Cancer of the PancreasM Categories of Cancer of the Pancreas

M1: Distant metastasis is present. M1: Distant metastasis is present.


Stage Grouping for Cancer of the PancreasStage Grouping for Cancer of the Pancreas

Stage IAStage IA (T1, N0, M0): The tumor is confined to (T1, N0, M0): The tumor is confined to the pancreas and is less than 2 cm in size. It the pancreas and is less than 2 cm in size. It has not spread to nearby lymph nodes or has not spread to nearby lymph nodes or distant sites. distant sites.

Stage IBStage IB (T2, N0, M0): The tumor is confined to (T2, N0, M0): The tumor is confined to the pancreas and is larger than 2 cm in size. It the pancreas and is larger than 2 cm in size. It has not spread to nearby lymph nodes or has not spread to nearby lymph nodes or distant sites. distant sites.

Stage IIAStage IIA (T3, N0, M0): The tumor is growing (T3, N0, M0): The tumor is growing outside the pancreas but not into large blood outside the pancreas but not into large blood vessels. It has not spread to nearby lymph vessels. It has not spread to nearby lymph nodes or distant sites. nodes or distant sites.


Stage Grouping for Cancer of the PancreasStage Grouping for Cancer of the Pancreas

Stage IIBStage IIB (T1-3, N1, M0): The tumor is (T1-3, N1, M0): The tumor is either confined to the pancreas or growing either confined to the pancreas or growing outside the pancreas but not into large outside the pancreas but not into large blood vessels. It has spread to nearby lymph blood vessels. It has spread to nearby lymph nodes but not distant sites. nodes but not distant sites.

Stage IIIStage III (T4, Any N, M0): The tumor is (T4, Any N, M0): The tumor is growing outside the pancreas into large growing outside the pancreas into large blood vessels. It may or may not have blood vessels. It may or may not have spread to nearby lymph nodes. It has not spread to nearby lymph nodes. It has not spread to distant sites. spread to distant sites.

Stage IVStage IV (Any T, Any N, M1): The cancer (Any T, Any N, M1): The cancer has spread to distant sites. has spread to distant sites.

Symptoms of Pancreatic CA Symptoms of Pancreatic CA (Head)(Head)

Weight LossWeight Loss 92%92% JaundiceJaundice 82%82% PainPain 72%72% AnorexiaAnorexia 64%64% Dark UrineDark Urine 63%63% Light StoolsLight Stools 62%62% NauseaNausea 45%45% VomitingVomiting 37%37% PruritusPruritus 24%24%

Signs of Pancreatic CA Signs of Pancreatic CA (Head)(Head)

JaundiceJaundice 87%87% Palpable LiverPalpable Liver 83%83% Palpable GallbladderPalpable Gallbladder 29%29% TendernessTenderness 26%26% AscitesAscites 14%14% Abdominal MassAbdominal Mass 13%13%

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Obstructive Jaundice Dr. Alex A. Erasmo De Veyra Dee A. Dela Cruz J. Dela Cruz