Extrahepatic Cholestasis

download Extrahepatic  Cholestasis

of 31

  • date post

  • Category


  • view

  • download


Embed Size (px)

Transcript of Extrahepatic Cholestasis

Extrahepatic CholestasisProf. Dr. Salih Pekmezci IU Cerrahpaa Medical Faculty Department of General Surgery

DefinitionCholestasis is any condition in which the flow of bile from the liver is blocked.

Extrahepatic cholestasis = obstructive jaundice = mechanical extrahepatic bile duct obstruction = posthepatic jaundice

Etiology Bile duct tumors Cysts Narrowing of the bile duct (strictures) Stones in the common bile duct Pancreatitis Pancreatic cancer or pseudocyst Periampullary tumor Pressure on an organ due to a nearby mass or tumor Primary sclerosing cholangitis Parasites: ascariasis

Diagnosis Symptoms & Signs Physical examination Laboratory Imaging

Symptoms & Signs History: duration and onset, progression Jaundice (skin, sclera) Dark urine Pale stool Pruritus Weight loss Abdominal pain

Physical examination Jaundice Scratch Marks Masses Liver/Spleen Gall Bladder Murphys Sign Courvoisiers Law

Physical examination Jaundice Scratch Marks Masses Liver/Spleen Gall Bladder Murphys Sign Courvoisiers Law

Laboratory tests Conjugated bilirubin Alkaline phosphatase

Bilirubin: normal range 0.3-1.2 mg/dL Clinically obvious hyperbilirubinemia: >2.5 mg/dL

Pre-hepatic Jaundice Normal / Total bilirubin Increased Normal Conjugated bilirubin /decreased Unconjugated Increased bilirubin Urobilinogen Urine Color Stool Color Alkaline phosphatase levels Alanine transferase and Aspartate transferase levels Increased Normal Normal Normal

Hepatic Jaundice Increased Normal /increased Normal / Increased Normal / Increased Dark Normal/pale Increased

Post-hepatic Jaundice Increased Increased Normal Decreased / Negative Dark Pale Increased




Conjugated Bilirubin Not Present in Urine



Imaging Ultrasound: More sensitive than CT for gallbladder stones Portable, cheap, no radiation, no IV contrast

CT: Better imaging of the pancreas and abdomen

MRCP: Imaging of biliary tree comparable to ERCP

ERCP Therapeutic intervention Brushing and biopsy for malignancy


CBD stones vs. Tumor Differential Diagnosis Clinical features favoring CBD stones: Age < 45 Biliary colic Fever Intermittent jaundice

Clinical features favoring cancer: Painless and progressive jaundice Weight loss Palpable gallbladder

Choledocholithiasis Gallstones within common bile duct (or common hepatic duct DD: cholelithiasis, hepatitis, sclerosing cholangitis, cholangiocarcinoma

Choledocholithiasis Management ERCP Laparoscopic procedures Trancystic exploration Laparoscopic choledochotomy

Open procedures

Cholangiocellular Carcinoma Originates from epithelium of extrahepatic or intrahepatic large or medium sized bile ducts 5-10% of malignant liver tumors, occurs in noncirrhotic livers

Clinical Presentation Jaundice Pain Weight loss High CA 19.9

Surgical therapy In tumors located at distal 1/3 of bile ducts Whipple operation In tumors of middle and upper 1/3 combined liver (right hepatect, left hepatect, trisectionectomy, central resection) and extrahepatic bile duct resection +/- vascular resection

Primary Sclerosing Cholangitis Cholestatic liver disease (ALP) Inflammation of large bile ducts 90% associated with IBD but only 5% of IBD patients get PSC

Diagnosis: ERCP (now MRCP) Biopsy: concentric fibrosis around bile ducts

Cholangiocarcinoma: 10-15% lifetime risk

Periampullary TmWhipple procedure n:1000

Mean age: 63.4 (15-103) Malignant periampullary tm: 652

Pancreatic head tm Ampulla Vateri tm Distal CBD tm Duodenum tm Total

n 405

5 year survival 18% 39% 22% 52%





652Cameron JL, Ann Surg 2006

Pancreatic head Ca 1,3 and 5 year survival %64, %27 ve %18 Lymph node (-) and surgical margin (-) 1,3 and 5 year survival %80, %49 ve %41 5 year survival Lymph node (-): %23 Lymph node (+): %14

Pancreatic head carcinoma

S. Pekmezci

S. Pekmezci

Ampulla Vateri Tumor May be originated from bile duct, duodenum or Wirsung duct epithelium Prognosis is related to the epithelial origin s ba kanserine gre daha iyidir (%35-67ye karn %20)

Ampulla Vateri Tumor Local resection Radical surgery (treatment of choice)

S. Pekmezci

Distal CBD Tm

Resectability is high PD is the standard treatment

Bahra et al, Chirurg, 2006