OBSTRUCTIVE

JAUNDICE
Dr Shashi kumar
Professor of general surgery
Mmc ri Mysore
26/11/24
 JAUNDICE

• French word “Jaune” means Yellow.

• Yellowish discoloration of skin, mucous membrane , sclera
due to hyperbilirubinemia resulting from deposition of
bilirubin.
• Total Bilirubin : 0.2-1.2 mg/dl
• Yellowing of sclera at 2.5-3mg/dl
• Yellowing of skin and mucous membrane at 6mg/dl
SURGICAL
ANATOMY
SURGICAL ANATOMY OF
CBD
SPHINCTER OF ODDI
COMPLEX
 BILIRUBIN
METABOLISM
250-350mg bilirubin is excreted/day in Bile

SOURCE

80-85% 15-20%

-
Due to breakdown of
Hb in senescent RBCs Bone Marrow TURNOVER OF HEMOPROTEINS
PREMATURE DISTROYED • MYOGLOBIN
ERYTHROID CELLS • CYTOCHROMES
 (Blood stream) Unconjugated Bilirubin + Albumin*

LIVER Sinusoids

Space of Disse
Albumin
Hepatocyte
Unconjugated Bilirubin

Glucuronic acid UDP-GT 1A1*

Endoplasmic
Reticulum

CONJUGATED BILIRUBIN
 BILE
• Bile secretion occurs for 2 purposes :
1. Excretion of hepatic metabolites – Bilirubin, Cholesterol,
drugs, toxins
2. Facilitation of intestinal absorption of Lipids, fat soluble
vitamins.
• 750-1000ml bile is produced/day

• Composition of bile :
1. Water (85%)
2. Organic solutes – cholesterol, phospholipids,
Bile acids, bile pigments, bile salts,.
3. Inorganic solutes – Na, k, Ca, Mg, Cl, HCO3
BILE ACIDS

• 500-600mg produced per day

• Primary Bile acids :

- Produced from cholesterol in hepatocytes
- Cholic acid (70%), Chenodeoxycholic acid

• Secondary Bile acids :

- Produced in distal ileum where intestinal bacteria convert primary bile acids
into secondary bile acids
- Deoxycholic acid, Lithocholic acid
BILE SALTS
• Na and K salts of conjugated bile acids

Bile acids

Conjugation Taurine/Glycine

Taurocholic acid/Glycocholic acid

Na/K

Na/K Taurocholate ; Na/K Glycocholate

 FUNCTIONS OF BILE SALTS
By forming micelles with
FAT ABSORPTION
lecithin and cholesterol
Emulsification of fats
VITAMINS Absorption of fat soluble
ABSORPTION vitamins A,D,E,K

Enhances secretion of
bile CHLORETICS

Prevention of gallstone
GALLSTONE formation with lecithin by
solubilizing cholesterol
 ENTEROHEPAT
IC
CIRCULATION

The following undergo EHC

1. Bilirubin
2. Bile salts/acids
3. Bile pigments
4. Vit D / Vit B12
5. Thyroxine
 OBSTRUCTIVE JAUNDICE
• Obstructive jaundice also known as Surgical jaundice, develops due to the biliary
obstruction, partial or complete or intermittent, which causes conjugated
hyperbilirubinemia.
• Mostly attributed to gall stones-54.1%
• More common in female population.
• 29.8% of the presentations are due to malignant cause, of which 11.5% is due to
pancreatic cancer.
 CLASSIFICATION OF JAUNDICE
PRE-HEPATIC HEPATIC POST-HEPATIC

1. Decreased Delivery Of Bilirubin

To Liver INTRA- EXTRA-
BILIRUBIN OVER 2. Decreased Uptake Of Bilirubin HEPATIC HEPATIC
PRODUCTION By Liver
3. Impaired Conjugation
4. Impaired Excretion Of Bile
 VIRAL HEPATITIS
01 05 INHERITED CONDITION

PRIMARY
BILIARY CHOLANGITIS 02 06 PARANEOPLASTIC
CONDITION

CAUSES OF
INTRAHEPATIC
CHOLESTASIS OF
PREGNANCY 03 JAUNDICE 07 INFECTIONS

DRUG TOXICITY
04 08 INFILTRATION
DISORDERS
 CLASSIFICATION OF SURGICAL
JAUNDICE

• Stricture • Periampullary ca
• Atresia • CA head of pancreas
• Calculi • GB cancer
• Sclerosing
• Parasites ( Clonorchis, • Pseudocyst
Cholangitis
Schistosomiasis) • Malignant involvement
• Primary Biliary
• Hydatid cyst of biliary of Porta hepatis lymph
Cirrhosis
tree node
• Choledochal Cysts
• Cholangiocarcinoma
 ETIOLOGICAL CLASSIFICATION OF
SURGICAL JAUNDICE
CONGENITAL INFLAMMATORY OBSTRUCTIVE NEOPLASTIC EXTRINSIC
COMPRESSION

Biliary atresia Ascending CBD stones Ca head of Tumors

Cholangitis Pancreas
Choledochal Sclerosing Biliary Periampullary Lymph nodes
cyst Cholangitis stricture Carcinoma
Parasitic Cholangio
infestation carcinoma
Klatskin tumor
BENJAMIN’S CLASSIFICATION OF SURGICAL JAUNDICE

TYPE I :
COMPLETE OBSTRUCTION

1) Ca head of the pancreas

2) Cholangiocarcinoma
3) Gallbladder cancer
4) CBD Ligation( Iatrogenic)

TYPE 2 :
INTERMITTENT OBSTRUCTION

1) Choledocholithiasis
2) Periampullary Ca
3) Duodenal diverticula
4) Choledochal cyst
 BENJAMIN’S CLASSIFICATION
OF SURGICAL JAUNDICE
TYPE 3 :- TYPE 4 :-
CHRONIC INCOMPLETE OBSTRUCTION
SEGMENTAL OBSTRUCTION
1) Intrahepatic stones
1) Strictures of the common bile duct 2) Sclerosing cholangitis
2) Congenital biliary atresia 3) Cholangiocarcinoma
3) Sclerosing cholangitis
4) Post radiotherapy
5) Stenosis of biliary-enteric anastamosis
6) Chronic pancreatitis
7) Sphincter of Oddi stenosis
 HEPATOBILIARY CHANGE IN SURGICAL JAUNDICE

Normal Biliary system pressure Increased biliary pressure

is 5-10cm of water

Disrupts the tight junction

between hepatocyte and Leads to increase
permeability
bile duct

Bile contents reflux into

sinusoids

Inflammatory response Fibrogenesis occur due to

by neutrophil infiltration reticulin deposit
 HEPATOBILIARY CHANGE IN SURGICAL JAUNDICE

IMPAIRMENT IN IMPAIRMENT IN
IMPAIRMENT IN IMPAIRMENT IN
METABOLIC KUPFFER CELL
LIVER PERFUSION BILE PRODUCTION
FUNCTIONS FUNCTION

Prolonged obstruction Elevated biliary Decrease synthesis of Impairment in

causes increase risk of pressure causes albumin, clotting phagocytosis
hepatocellular reflux of excretory factors
dysfunction
products
 CLINCAL APPROACH TO OBSTRUCTIVE JAUNDICE
CHARACTERISTICS OF
JAUNDICE 01 05 PRURITIS

HIGH COLORED URINE

02 06 VITAMIN DEFICIENCY

PRESENTING
COMPLAINTS
STEATORRHEA
03 07 WEIGHT LOSS

PAIN ABDOMEN
04 08 FEVER
 CHARACTERISTICS OF JAUNDICE
Fluctuating/intermittent jaundice: Progressive Jaundice :
- The intensity of the jaundice waxes - The intensity of the jaundice keeps on
and wanes during the course of the increasing as the obstruction follows
an unrelenting course.
disease.
- This is commonly seen in
- This is commonly seen in:
1. Periampullary carcinoma
1. Choledocholithiasis 2. Cholangiocarcinoma
2. Carcinoma of ampulla of Vater - 3. Strictures of extrahepatic billiary
3. Primary sclerosing cholangitis tree

4. Choledochal cyst 4. Chronic pancreatitis

5. Sphincter of Oddi stenosis
5. Biliary parasites
High colored urine
- The colour of the urine become dark yellowish – brown due to presence of conjugated
bilirubin (water soluble) in urine. The urine is sometimes called ‘tea coloured urine’.
- This is associated with a low urinary urobilinogen as the conversion of bilirubin into
urobilinogen which takes place in the intestines, does not occur.

Steatorrhea:
- The patient passes clay coloured, bulky, foul-smelling stools in obstructive jaundice.
- The colour of the stool corresponds with the intensity of biliary tract obstruction.
- Due to the absence of emulsifying function of bile in the gut, there is fat malabsorption. Such
a stool floats on water and is difficult to flush due to its increased fat content
Pain:
- Intermittent pain predominantly in right upper abdomen is a frequent complaint in
patients with calculus disease.
- The pain is colicky/ gripping in nature and moderate to severe in intensity.
- A constant dull aching/ boring pain radiating to back is suggestive of a malignancy
(carcinoma head of pancreas) or a benign condition (chronic pancreatitis).

PAINFUL JAUNDICE PAINLESS JAUNDICE

Choledocholithiasis Ca ampulla of vater
Strictures Ca head of pancreas
Distal cholangiocarcinoma
 Generalized pruritus:
- Itching is a very common and characteristic symptom seen in almost 80%-100% of
patients presenting with obstructive jaundice.

 Vitamin deficiency:
- Steatorrhea is also associated with malabsorption of fat-soluble vitamins (A, D, E and
K) and the consequent symptoms of vitamin deficiency like
• Easy bruisability (vit E)
• Ostemalacia
• Osteoporosis (vitd)
• Prolonged bleeding time (vit K)
• Xerophthalmia(vit A).
Loss of weight/appetite:
- Significant loss of weight (more than 10% weight loss over 6 months) and loss of appetite with
obstructive jaundice is suggestive of a malignant cause of obstruction.

Fever:
- Fever in a patient with jaundice indicated presence of infection in the biliary system.
- Usually such a patient has high grade fever with associated chills and rigors.
- Presence of Charcot’s triad – intermittent pain, fever with chills and intermittent jaundice is
suggestive of Acute cholangitis and is more commonly seen in choledocholithiasis than malignancy.
GENERAL PHYSICAL EXAMINATION
VITALS
Pulse :- Relative Bradycardia
Blood pressure :- Hypotension in case of
shock
 ICTERUS
- Icterus is the yellowish discolouration of the various body tissues due to an accumulation
of bile pigments.
- Icterus can be seen in sclera (Usually best seen in the upper sclera above the superior
limbus), under surface of tongue, hard palate, mucous membranes and skin.
- It is earliest appreciable against the white background of sclera as the bilirubin has high
affinity to elastin fibres present in sclera
Clubbing
- Clubbing of fingernails can be seen in a patient with
1. Primary biliary cirrhosis
2. Hepatocellular carcinoma
3. Chronic liver disease.

Enlarged Virchow’s node (left supraclavicular lymph node)

- This node is palpable between the two heads of
sternocleidomastoid muscle on the left side.
- The sign is known as Troisier’s sign and it indicates metastatic
disease.
- It is usually seen in malignancy of hepatobiliary tract, pancreas,
stomach, ovary, testis and breast
SIGNS OF LIVER CELL FAILURE
Abdominal examination on inspection:
- The skin may show presence of icterus and itch marks.

Hepatomegaly:
- Liver enlargement and liver span should be checked in a patient with obstructive jaundice.
- Characteristics of liver that should be noted are enlargement, tenderness, surface (smooth or
nodular) and edge (sharp or rounded).

 Splenomegaly :
- Spleen may be enlarged in a jaundiced patient due to haemolytic anaemia, portal hypertension
secondary to liver cirrhosis and SMV or portal vein thrombosis
Gall bladder:

- Courvoisier's law states that "In a jaundiced patient, when obstruction of the bile duct is due to
stones; gall bladder is seldom palpable, the organ usually is already shrivelled; in obstruction due
to other causes, distension is common by comparison" meaning thereby that if the gallbladder is
palpable in a patient of obstructive jaundice, it is unlikely to be due to gallstones. It is usually due
to a downstream obstruction due to malignancy.
- A hard gall bladder is suggestive of carcinoma of gall bladder
- Exceptions to Courvoisier's law :
1. Double impaction of stone – 1 in CBD & other in cystic duct
2. Hilar cholangiocarcinoma
3. Intrahepatic GB in a distal malignancy
4. Previous cholecystectomy in distal malignancy
5. Congenital absence of Gall bladder
6. Mucocele of gallbladder due to stone in the cystic duct
Ascites :
- Free fluid may be present in the peritoneal cavity of a patient with obstructive jaundice.
- The causes can be due peritoneal spread of malignancy, chronic liver disease or portal hypertension.

Sister Mary Joseph’s nodule :

- A palpable nodule bulging into the umbilicus is indicative of metastatic intra peritoneal malignancies
like carcinoma of stomach, pancreas, colon and ovarian and uterine malignancies
BIOCHEMICAL INVESTIGATIONS

• CBC, Blood sugar levels , RFT ,Serum electrolytes .

• LFT- ALT & AST may be elevated, Serum alkaline phosphatase will be elevated in
most of the cases
• Urinalysis : Direct bilirubin present, urobilinogen absent
• Stool for occult blood: periampullary carcinoma
• Clotting profile: PT deranged
• Hepatitis serology: HbsAg, HCV
LIVER FUNCTION TESTS
SERUM
BILIRUBIN

Conjugated Bilirubin Unconjugated bilirubin

- Water soluble - water insoluble

- Excreted in urine
- Increases seen in Liver diseases Increases seen in Hemolytic diseases
& biliary tract disease & genetic diseases

TB : 0.2-0.9 mg/dl
DB >> 15-30% of TB
If DB is < 15% of TB – Unconjugated Hyperbilirubinemia
 SERUM ENZYMES

THAT REFLECTS
THAT REFLECT DAMAGE TO CHOLESTASIS
HEPATOCYTES

1. Alkaline
1. Aspartate Phosphatase
tranaminase 2. Gamma glutamyl
2. Alanine transpeptidase
transaminase 3. 5-nucleotidase
Aminotransferases Diseases
AT upto 300 IU/L Non specific liver disorder
AT > 1000 IU/L Extensive hepatocellular injury
1. Viral hepatitis
2. Ischaemic liver injury
3. Toxin/Drug induced
AST : ALT < 1 1. Chronic viral hepatitis
2. Non alcoholic fatty liver
AST : ALT > 1 Liver cirrhosis
AST : ALT > 2:1 Alcoholic Liver disease
ALKALINE PHOSphate
- Found near bile canalicular membrane of hepatocytes

- More specific
• ALP is elevated 4 times in
- Cholestatic liver disorders
- Infiltrative liver diseases : Carcinoma, Amyloidosis
- Bone diseases with rapid bone turnover : Pagets disease
SERUM ALBUMIN
• Synthesised by hepatocytes
• T1/2 is 18-20 days
• Therefore low albumin – Chronic liver disease

SERUM GLOBULIN
• Alpha & beta globulins – produced in hepatocytes
• Gamma Globulins- produced by B lymphocytes
• Elevated gamma globulin indicates Chronic hepatitis or cirrhosis as liver fails to clear
antigens,
• Prothrombin time (PT):
- This may be prolonged because of malabsorption of vitamin K.
- Correction of the PT by parenteral administration of vitamin K may help distinguish
hepatocellular failure from cholestasis

• Hepatitis serology:

• Urine bilirubin:
- Urine bilirubin normally is absent. When it is present, only conjugated
bilirubin is passed into the urine. This may be evidenced by dark-colored
urine seen in patients with obstructive jaundice or jaundice due to
hepatocellular injury.
IMAGING MODALITIES FOR THE
BILIARY SYSTEM
• GOALS :
1. Confirm the presence of obstructive jaundice
2. To determine the severity and the level of obstruction
3. Staging malignant disease
4. Guiding therapy with image based assistance.
X-RAY
• Multiple gallstones in a plain
abdominal X-ray. Only 10%
Gallstones are radio-opaque.

• Centre of the gallstone is often

found radiolucent and is called as
Mercedes Benz sign/Seagull sign
TRANS ABDOMINAL ULTRASONOGRAPHY
• Transabdominal Ultrasonography (US) is the least expensive, safest, and most sensitive
technique for visualizing the biliary system, particularly the gallbladder.
• Ultrasound sensitivity : 95% for gall stones and intrahepatic obstruction ; 50% for CBD
stones, other pathology and lesions of pancreas.
• USG evidence of common bile duct dilatation of more than 7mm has been described as
the best predictor of choledocholithiasis.
• USG accurately predicts the level of biliary obstruction in majority of the cases(92%), but
less accurate in suggesting cause (72%)
COMPUTED TOMOGRAPHY

• Delineates the biliary anatomy .

• Main role in malignant conditions for localization of
primary tumors and metastasis.
• Best for Pancreatic Carcinoma(Highly sensitive for
lesion >1mm).
• Mainly done when ultrasound fail or when there is
ductal dilation on ultrasound.
• Also to find level and cause of obstruction and in
malignant conditions
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
(MRCP)
ENDOSCOPIC ULTRASOUND (EUS)
• 98% diagnostic accuracy in patients with
obstructive jaundice
• Allows diagnostic tissue sampling via EUS
guided fine-needle aspiration (EUS-FNA)
• Sensitivity of EUS for the identification of focal
mass lesions in pancreas is superior to that of
CT scanning, both linear and radial, 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.
 ENDOSCOPIC RETROGRADE
CHOLANGIOGRAM (ERCP)
• Indications : • Therapeutic uses :
- Malignancy—irregular filling defect - Extraction of stone from biliary duct
- Chronic pancreatitis—‘chain-of-lakes’ - Stenting of tumour in the CBD or in the
appearance. pancreas
- Congenital anomalies. - Dilatation of the biliary stricture
- Stones. - Endoscopic papillotomy
- Stricture of biliary tree.
- Choledochal cyst.
- Brush biopsy from tumor site
 PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM (PTC)
• Percutaneous transhepatic cholangiogram (PTC) is performed by a
radiologist using fluoroscopic guidance.
• The liver is punctured to enter the peripheral intrahepatic bile duct system.
An iodine-based contrast medium is injected into the biliary system and
flows through the ducts. Obstruction can be identified on the fluoroscopic
monitor.
• The accuracy of PTC in elucidating the cause and site of obstructive
jaundice is 90-100% for causes within the biliary tract.
• Indications :
1. Failure of ERCP
2. High biliary strictures
3. Klatskin tumour
4. High blocks when external internal
catheter drainage is needed
5. Stenting in high tumours

• Complications :
1. Bleeding
2. Biliary leak and biliary peritonitis
3. Septicaemia
 RADIO-ISOTOPE SCANNING
• Technetium-99m labelled derivatives of iminodiacetic acid (HIDA) when injected
intravenously are selectively taken up by the reticuloendothelial cells of the liver
and excreted in bile.
• To evaluate physiologic secretion of bile
• Allows visualization of biliary tree and Gallbladder
- failure to visualize after 2 hours of injection obstruction to cystic duct = Acute
cholecystitis
MANAGEMENT
• PREOPERATIVE PREPARATION
• Proper diagnosis and assessment
• Injection vitamin K IM 10 mg for 5 days
• Adequate hydration is most important
• Blood transfusion in case of anaemia
• Oral lactulose
• Mannitol 100–200 ml BD IV to prevent hepatorenal syndrome
• Repeated monitoring by doing prothrombin time, electrolytes
• Antibiotics
MANAGEMENT OF SURGICAL
JAUNDICE
1. Correction of coagulopathy
2. prevention of renal failure,
3. Prevention of infection,
4. Prevention of hepatic encephalopathy
5. electrolyte imbalance

Preoperative decompression is indicated if

- bilirubin is > 12 mg%
- Sepsis
- hepatorenal syndrome
MANAGEMENT OF SURGICAL
JAUNDICE

• Ursodeoxycholic acid (10-15 mg/kg/d) works to reduce biliary

secretion of cholesterol,
• Bile acid–binding resins, cholestyramine (4 g) or colestipol
• Vitamins A,D,E,K supplements
• Antihistamines.
SURGICAL MANAGEMENT

• CBD stones -ERCP stone removal, choledocholithotomy,

transduodenal sphincteroplasty, choledochojejunostomy or
choledocho-duodenostomy.

• Carcinoma periampullary or head of pancreas—Whipple’s operation

or triple bypass or ERCP stenting.

• Biliary stricture—Stenting, choledochojejunostomy, Roux-en-Y

hepaticojejunostomy.
SURGICAL MANAGEMENT
• Klatskin tumour—Radical resection or palliative
stenting.
• Biliary atresia—Kasai’s operation or liver
transplantation.
• Choledochal cyst—Excision, hepaticojejunostomy,
mucosal resection
COMPLICATIONS of SURGICAL JAUNDICE

• Proportional to the duration and intensity of the

jaundice.
• High-grade biliary obstruction begins to cause cell
damage after approximately one month and, if
unrelieved, may lead to secondary biliary cirrhosis.
• Acute cholangitis -most common complication of a
stricture
• Concomitant increased intra-ductal pressure can lead to
the reflux of biliary contents and bacteraemia, which
can cause Septic Shock and death
CONCLUSION
• Understanding of Obstructive Jaundice is attained through thorough detailed
history taking and clinical examination.
• Adequate and appropriate investigation should be employed to identify the
cause and provide necessary management.
• Ultrasonography stand as the primary modality of investigation , after
biochemical evaluation.
• High incidence of morbidity and mortality , early and appropriate intervention-
endoscopic/ laparoscopic/ open surgical- should be instituted on diagnosis, and
stays as the gold standard for management