approach to a case of obstructive jaundice
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INVESTIGATIONS AND THEIR RATIONALE
IN OBSTRUCTIVE JAUNDICE
INTRODUCTION
Jaundice, or icterus, is a yellowish discoloration of tissue resulting from the deposition of bilirubin.
Tissue deposition of bilirubin occurs only in the presence of serum hyperbilirubinemia and is a sign of either liver disease or, less often, a hemolytic disorder
I. INDIRECT HYPERBILIRUBINEMIA
A. Hemolytic disorders1. Inheriteda. Spherocytosis, elliptocytosisGlucose-6-phosphate dehydrogenase and pyruvate kinase deficienciesb. Sickle cell anemia2. Acquireda. Microangiopathic hemolytic anemiasb. Paroxysmal nocturnal hemoglobinuriac. Spur cell anemiad. Immune hemolyticB. Ineffective erythropoiesis1. Cobalamin, folate, thalassemia, and severe iron deficienciesC. Drugs1. Rifampicin, probenecid, ribavirinD. Inherited conditions1. Crigler-Najjar types I and II 2. Gilbert's syndromeII. DIRECT HYPERBILIRUBINEMIAA. Inherited conditions B. Acquired conditions C. Extra hepatic obstrn1. Dubin-Johnson syndrome2. Rotor's syndrome
CAUSES
Intrahepaticextrahepatic
intraductal extraductal Cirrhosis
Hepatitis
Drugs Neoplasm
Stone disease
Biliary stricture
Parasites
PSC
Aids related
cholangiopathy
Biliary TB
Secondary
to neoplasm
Pancreatitis
Cystic duct
stones
drugs
cholestasis
gallstone
Acute
cholestatic
injury
Hepatocellular
necrosis
• Anabolic steroids• chlorpromazine
• Thiazide diuretics
• amoxyclav
• Acetaminophen• isoniazid
Typically, drug-induced jaundice appears early with
associated pruritus, but the patient's well-being shows
little alteration.
Generally, symptoms subside promptly when the
offending drug is removed
Clinical classification Of Obstructive Jaundice(Benjamin Classification)
Type I : Complete obstruction
Classical symptoms with biochemical changes
Tumors : Ca. head of PancreasLigation of the CBDCholangio carcinoma Parenchymal Liver diseases
Type II : Intermittent obstructionSymptoms and typical biochemical changes But jaundice may or may not be present
CholedocholithiasisPeriampullary tumorDuodenal diverticula Choledochal CystPapillomas of the bile duct Intra biliary parasitesHemobilia
TYPE III : Chronic incomplete obstructionWith or without classical symptoms but pathologicalchanges are present in bile duct and liver Strictures of the CBD
CongenitalTraumaticSclerosing cholangitis Post radiotherapy
Stenosed biliary enteric anastamosisCystic fibrosisChronic pancreatitis Stenosis of the Sphincter of Oddi
TYPE IV : Segmental Obstruction
one or more segment of intrahepatic biliary tract is obstructed
TraumaticSclerosing cholangitisIntra hepatic stonesCholangio carcinoma
INVESTIGATIONS IN OBSTRUCTIVE JAUNDICE
LABORATORY INVESTIGATIONS
RADIOLOGICAL INVESTIGATIONS
Goals
of investigations
Determine level of
obstruction
Severity of jaundice
Ductal dilatation
jaundice
Cause of
obstruction
ROUTINE INVESTIGATIONS
1. HB
2. TLC
3. DLC
4. RFT ( serum urea, serum creatinine, serum sodium, serum potassium )
5.BLOOD SUGAR
TESTS FOR ASSESSMENT OF LIVER FUNCTION
Tests for liver functioning
Based on
detoxification
& excretory
function
Enzymes
indicating
liver injury
Measure
biosynthetic
function
Damage to
hepatocytescholestasis
Serum
bilirubin
Urine
bilirubin
Blood
ammonia Aspartate
aminotransferase
Alanine
aminotransferase
Alkaline
phosphatase
5 nucleotidase
GGT
Serum albumin
Serum globulin
Coagulation
factors
BilirubinRise by 25-43 micromol/litre/day
Mechanism of hyperbilirubinemia
--- Biliary venous & biliary regurgitation of conjugated bilirubin due to
disruption of tight intracellular junction
--- Trans hepatocytic regurgitation due to reversal of the secretory
polarity of hepatocytes
--- Rupture of dilated canaliculi in to sinusoids due to necrosis of
hepatocytes
BILIRUBIN METABOLISM
SGOT AND SGPT LEVELS
SGOT (AST)/ ASPARTATE TRANSAMINASE
* Marker for hepatocellular toxicity
* Along with ALT is considered biomarker for liver health* Non specific* 2 isoenzymes* Normal Values….
MALES 8-40 IU/L
FEMALES 6-34 IU/L
SGPT ( ALT ) / ALANINE AMINOTRANSFERASE
* Better predictor of hepatic injury than SGOT alone
* Significant elevations in HEPATITIS INFECTIOUS MONONUCLEOSISCHF
* NORMAL VALUES IN MALES < 50 IU/LFEMALES < 32 IU/L
ALKALINE PHOSPHATSE
*Most sensitive indicator Of EXTRA HEPATIC BILIARY OBSTRUCTION
* Factor responsible are
Biliary component regurgitation
Increase in hepatic synthesis
* Biliary component is secreted by BILIARY DUCTULAR ENDOTHELIUM
* Normal range 20-140 IU/L
* May remain elevated for a long time even after the obstruction is
relieved
GAMMA GLUTAMYL TRANSFERASE & 5’NUCLEOTIDASE
GGT
* Predominantly used as a marker for liver diseases* enhanced sensitivity for detection of BILIARY OBSTRUCTION if correlated with ALKALINE PHOSPHATASE* NORMAL VALUE 0-51 IU/L
5’ NUCLEOTIDASE
* An enzyme synthesized in liver* Values if grossly elevated is indicative of biliary obstruction* NORMAL VALUE 2-17 UNITS/L
Measure biosynthetic function
serum albuminnormal value 3.5 – 5.5 gm /dl
prothrombin timenormal value 12 – 14 sec
URINE ANALYSIS
1 Bile salts2 Bile pigments3 Urobilinogen
STOOL EXAMINATION
1 Occult blood
RADIOLOGICAL EVALUATION OF BILIARY TRACTINTRA OP METHODSPRE OPERATIVE METHODS
PLAIN ABDOMINAL X RAY
ABDOMINAL USG
ENDOSCOPIC USG
CT
M R C P
ERCP
PTC
BILIARY SCINTILLOGRAPHY
PER OP CHOLANGIOGRAPHY
INTRA OP BILIARY ENDOSCOPY
LAPROSCOPIC USG
IMAGING GOALS
* To confirm the presence of an extrahepatic obstruction
* To determine the level of the obstruction
* To identify the specific cause of the obstruction
* To provide complementary information relating to the underlying diagnosis (eg., Staging information in cases of malignancy).
* What is the best therapeutic approach
PLAIN X RAY
* Cholelithiasis in 10-20 % of patients with radio opaque stones
* Radiolucent gas in a BI and TRI RADIATE FISSURE, in centre of stone
* May sometimes show rare cases of calcification of GB (PORCELAIN GB )
* Gas in wall of GB ( EMPHYSEMATOUS CHOLECYSTITIS)
* SPECKLED CALCIFICATION in the head of pancreas suggestive of CHRONIC PANCREATITIS
* DUCT DILATATION WILL NOT BE REVEALED IN PLAIN FILMS
RADIO OPAQUE STONES IN GALL BALDDER
PORCELAIN GALL BLADDER
GAS IN GALL BLADDER AND ITS WALLS
ABDOMINAL ULTRASONOGRAPHY
* Is the initial imaging modality of choice as - it is accurate- readily available - quick to perform- inexpensive
OPERATOR DEPENDANT AND MAY GIVE SUBOPTIMAL RESULTS DUE TO EXCESSIVE BODY FAT AND BOWEL GAS
* Biliary obstruction is characterized by BILIARY DILATATION
THIS DILATATION MAY BE CONSPICUOUSLY ABSENT IN 15 % OF PATIENTS
* Prospective evaluation of USG suggests that level of obstruction can be defined in 90 % of the cases
* COLOR FLOW DOPPLER SONOGRAPHY may assist in distinguishing dilated ducts from Portal venous and Hepatic arterial branches
* Provides useful information about the nature and etiology of BILIARY OBSTRUCTION
* Mass lesion visualization is possible
THE RELIABILITY WITH WHICH A BENIGN DISEASE MAY BE DISTINGUISHED FROM A MALIGNANT PROCESS REMAINS UNCLEAR
*Upper limits of normal diameter of CBD-8mmCHD-6mm
ENDOSCOPIC ULTRASOUND (EUS)
Combines Endoscopy and US
Higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs. 20 MHz) and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA).
EUS has been reported to have up to a 98% diagnostic accuracy in patients with obstructive jaundice
The sensitivity of EUS for the identification of focal mass lesions in pancreas has been reported to be superior to that of CT scanning, both traditional and spiral, particularly for tumors smaller than 3 cm in diameter.
Compared to MRCP for the diagnosis of biliary stricture, EUS has been reported to be more specific (100% vs. 76%) and to have a much greater positive predictive value (100% vs. 25%), although the two have equal sensitivity (67%).
The positive yield of eus-fna for cytology in patients with malignant obstruction has been reported to be as high as 96%.
Endoscopic ultrasonography.
CBD, common bile duct; PD, pancreatic duct.
COMPUTED TOMOGRAPHY
* Unlike USG CT is less affected by body habitus and is less operator dependant
* It allows visualisation of the liver,bile ducts, gall bladder and pancreas and is particularlyuseful in detecting hepatic and pancreatic lesions andis the modality of choice in the staging of cancers of the liver,gall bladder, bile ducts and pancreas.
* It can identify the extentof the primary tumour and defines its relationship to otherorgans and blood vessels
*Improvements in CT technology, such as multidetector scanners,which allow for three-dimensional reconstruction of thebiliary tree have led to greater diagnostic accuracy and haveincreased the accuracy of CT in assessing benign disease.
Computed tomography scan demonstrating a gallstonewithin the gall bladder (arrowed).
Computed tomography scan demonstrating a hilar mass.
Intraductal stones appear as target sign on ct CT. 75-88% sensitive, 97%specific for Choledocholithiasis79%sensitive, 100% specific for gallstones
.
MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP)
•Noninvasive test to visualize the hepato biliary tree
•No contrast
•Fluid found in the biliary tree is hyper intense on T2-weighted images.
Surrounding structures do not enhance and can be suppressed during image
analysis.
•Sensitive in detecting biliary and pancreatic duct stones, strictures, or dilatations
within the biliary system.
•MRCP combined with conventional MR imaging of the abdomen can provide
information about surrounding structures (eg, pseudocysts, masses).
• ERCP and MRCP similarly effective in detecting malignant hilar and perihilar
obstruction
• MRCP is better able to determine the extent and type of tumor as compared to
ERCP
Absolute contraindications cardiac pacemakercerebral aneurysm clipsocular or cochlear implants
Fluid stasis in the adjacent duodenum or ascitic fluid may produce image artifacts on MRCP, making it difficult to clearly visualize the biliary tree.
MRCP Showing Choledocholithiasis
MRCP is also highly
accurate
MRCP sensitivity
88-92%, specificity
91-98% in detecting
Choledocholithiasis
Endoscopic retrograde cholangiopancreatography (ERCP )
Its an invasive procedure and has therapeutic potential.
Allows biopsy or brush cytology
Stone extraction or stenting
COMPLICATIONS Pancreatitis
Cholangitis
Hemorrhage
Sepsis
CONTRAINDICATIONS Unfavorable anatomy
Pseudo cyst
Red a/c pancreatitis
ERCP film showing Choledocholithiasis
Endoscopic retrograde cholangiopancreatography: partialocclusion of the bile duct by a malignant stricture
Percutaneous Transhepatic Cholangiography (PTC)
PTC is indicated when Percutaneous intervention is needed and ERCP either is inappropriate or has failed.
Can be used to drain biliary obstructions.
Transhepatic cholangiogram showing a stricture of thecommon hepatic duct
Radioisotope scanning
* Technetium-99m (99mTc)-labelled derivatives of iminodiaceticacid (HIDA, IODIDA) when injected intravenously are selectivelytaken up by the retroendothelial cells of the liver andexcreted into the bile.
* This allows for visualisation of the biliarytree and gall bladder. In 90 per cent of normal individuals thegall bladder is visualised within 30 minutes following injectionwith 100 per cent being seen within 1 hour
* Non-visualisation of the gall bladder is suggestive of acutecholecystitis. If the patient has a contracted gall bladder as oftenseen in chronic cholecystitis, the gall bladder visualisation maybe reduced or delayed.
*Biliary scintigraphy may also be helpful in diagnosing bileleaks and iatrogenic biliary obstruction.
It can identify and quantitate the leak thus helping the surgeondetermine whether or not an operative or conservative approachis warranted
Dimethyl iminodiacetic acid (HIDA) scan.
INTRA OPERATIVE TECHNIQUES
A. PER OPERATIVE CHOLANGIOGRAPHY
* During open or laparoscopic cholecystectomy, a catheter can beplaced in the cystic duct and contrast injected directly into thebiliary tree. The technique defines the anatomy and in the mainis used to exclude the presence of stones within the bile ducts
*A single x-ray plate or imageintensifier can be used to obtain and review the images intraoperatively
*In addition, care should betaken when injecting contrast not to introduce air bubbles intothe system as these may give the appearance of stones and leadto a false-positive result
Normal common bile duct: gentle The common bile duct is dilated infusion of contrast with multiple Stoneswhich passes without hindranceinto the duodenum.
Operative biliary endoscopy (choledochoscopy)
* At operation, a flexible fibre optic endoscope can be passed viathe cystic duct into the common bile duct enabling stone identificationand removal under direct vision
* The technique canbe combined with an x-ray image intensifier to ensure completeclearance of the biliary tree.
* After exploration of the bile duct,a tube can be left in the cystic duct remnant or in the commonbile duct (a T-tube) and drainage of the biliary tree established
*After 7–10 days, a track will be established. This track can beused for the passage of a choledochoscope to remove residualstones in the awake patient in an endoscopy suite.
LAPROSCOPIC ULTRASONOGRAPHY
* At laparoscopy the use of laparoscopic probe can be used to image the extra hepatic biliary system
* Useful in BILIARY & PANCREATIC tumor staging and identify the primary tumors and determine its relationship to the major vessels such as hepatic artery, superior mesenteric artery , portal vein and superior mesenteric vein
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