CONCERNED INVESTIGATIONS

Obstructive jaundice

definition Biliary obstruction refers to the blockage of any

duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine.

This can occur at various levels within the biliary system.

The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination.

Accumulation of bilirubin in the bloodstream and subsequent deposition in the skin causes jaundice

Conjunctival icterus is generally more sensitive Jaundice may not be clinically recognizable until

levels are at least 2 mg/dL

Urine bilirubin is normally 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..

The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction.

The cause of pruritus associated with biliary obstruction is due to accumulation of bile salts in the skin.

CAUSES

Intrahepatic

extrahepatic

intraductal extraductal

Cirrhosis Hepatitis Drugs

Neoplasm Stone disease Biliary

stricture Parsites PSC Aids related

cholangiopathy

Biliary TB

Secondary to neoplasm

Pancreatitis

Cystic duct stones

Evaluation of obstructive jaundice begins with careful history & physical examinationJAUNDICE- hallmark of obstructionPruritis, fever, weight loss, color of feces & urinePrevious h/o pancreatitis, ulcerative colitis, hepatitis, or cholangitisINTERMITTENT JAUNDICE- stone related disease ampullary Ca papillary cholangioCaPrior h/o biliary surgery s/o stricture possibilityLate jaundice after pancreaticoduodenectomy s/o recurrent disease technical anastomotic failure iatrogenic stricture if radiation is

administered

Medical causes of jaundice :Hepatitis Cirrhosis Alcohol HemolysisImpaired uptake or conjugation of bilirubinDrugs

drugs

cholestasis

gallstoneAcute

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

Other physical findings are:LymphadenopathyEvidence of nutritional deprivationA palpable non tender GB in a jaundiced pt. s/o malignant obstruction CURVOISIER’S LAWSigns of cirrhosis or portal HTN as ascites, spleenomegaly Cirrhosis is characterized by generalized

disorganization of hepatic architecture with nodule formation and scarring on the parenchyma.

Cirrhosis may be a result of intrinsic liver disease or secondary to biliary obstruction

Goalsof

investigations

Determine level of

obstruction

Severity of

jaundice

Ductal dilatation

jaundice

Cause of obstruction

investigationsLFTGGTPTHepatitis serologyAntimitochondrial antibodyUrine bilirubinImaging studies

Imaging studies USG CT MRCP ERCP Endoscopic ultrasound (EUS) Percutaneous transhepatic

cholangiogram (PTC)

Tests for liver

functioning

Based on detoxification & excretory

function

Enzymes indicating

liver injury

Measure biosynthetic function

Damage to hepatocyte

scholestasis

Serum bilirubinUrine biliruninBlood ammonia

Aspartate aminotransferaseAlanine aminotransferase

Alkaline phosphatase5 nucleotidaseGGT

Serum albumin Serum globulin Coagulation factors

Features Hepato cellular injury

cholestasis

Alanine aminotransferase10–40(U/L)  in males7–35 U/L  in females

>10 URL , persists for weeks in most forms

Transient increase to >10URL with complete obstruction falls quickly

ALP (20 to 140 IU/L) <3 URL in most forms

>3URL, may be normal in early obstruction

GGT (0-30 IU/L) <5URL >5URL, may be lower in early obstruction

Bilirubin 0.1-1.2 Direct , 0.1-0.4 mg/dL (< 7 µmol/L); Indirect, 0.2-0.7 mg/dL (< 12 µmol/L)

50-80% direct 50-80% direct

PT (10 to 14 seconds) Normal or slightly increased , no response to vit-k

Normal maybe incresead with prolonged obstruction uaually respond to vit-k

Imaging studies Normal ducts Abnormal ducts with complete obstruction

Imaging studies may be used to look for presence of dilated biliary ducts However bile duct obstruction without dilatation may occur when there is :Recent obstruction Chronic low grade obstruction Intermittent obstructionPrimary sclerosing cholangitisSuspicion of obstruction should prompt cholangiography even when ducts are of normal caliber Some may present with dilated ducts without obstruction if there was previous obstruction Percutaneous liver biopsy may be required in some cases to exclude hepatitis

Causes based on level of

obstruction

Proximal obstruction Distal

obstruction

Biliary Extrinsic Biliary Extrinsic

•cholangioCa.•Choledocholithiasis•GB cancer•Biliay stricture•Malignant masquerade•Mirrizzi syndrome•Sclerosing cholangitis

•Hepatic  neoplasm•Extra  hepatic  mass •lymphadenopathy

•cholangioCa•Choledocholithiasis•Choledochal cyst•Biliary stricture 

•Periampullary neoplasm•Pancreatitis•Pancreatic  cyst 

Imaging studiesUsg initial test of choice in biliary obstruction Determinelevel of biliary dilatation in 92% cases Cause of obstruction in 71%cases Limited in distal biliary tree by overlying bowe gas Upper limits of normal diameter of CBD-8mmCHD-6mm

CT 95% accurate in determining level & cause of an

obstruction Segmental or lobar atrophy of liver from portal vein or

duct obstruction best visualised

DIRECT CHOLANGIOGRAPHY

Done via percutaneous transhepatic cholangiography (PTC) & endoscopic retrograde cholangiopancreaticography(ERCP)

Provides most anatomical detail of biliary tree

Enables inspection for :• Filling defects • Stenoses• Occlusion • Masses • Biliary dilatation

ERCP is preferred for distal duct obstruction , PTC for proximalBoth ERCP & PTC have similar accuracy in diagnosing jaundiceGB isn’t visualized by direct cholangiography & better examined with USG

mrcp Provides detail of liver parenchyma, biliary tree, pancreas, & vasculature & identify anatomical variants Noninvasive Averts risk of pancreatitis, bleeding, perforation

Can be employed when ERCP/PTC is contraindicated or when they are failed Can be used when there is biliary enteric anastomosisMRCP enables visualization of biliary tree both above & below the level of obstruction When therapeutic intervention is required ERCP or PTC is preferred MRCP 95% sensitive in detecting obstruction Inaccurate in assessing grade of obstruction Strictures can’t be well characterized

Endoscopic ultrasound (EUS) combines endoscopy and USG to provide

remarkably detailed images of the pancreas and biliary tree.

EUS has been reported to have up to a 98% diagnostic accuracy in patients with obstructive jaundice.

This makes ERCP unnecessary in patients who are found not to have extrahepatic obstruction.

In addition, those patients who may require operative biliary drainage are reliably identified and similarly need not undergo ERCP for further evaluation.

EUS provides highly detailed imaging of the pancreas.

EUS is more portable than ERCP or MRCPEUS-FNA

Choledocholithiasis

• May be asymptomatic or present with jaundice, cholangitis, or pancreatitis

• Direct cholangiography is the gold standard investigation appear as filling defects

• ERCP film showing choledocholithiasis

MRCP Showing choledocholithiasis

MRCP is also highly accurate MRCP sensitivity 88-92%, specificity 91-98% in detecting choledocholithiasis

USG showing choledocholithiasisNot reliable in visualizing duct stones due to sound wave distortion from valves of heister56% sensitive, 68%specific in detecting choledocholithiasis

Intraductal stones  appear as target sign on ct CT. 75-88% sensitive, 97%specific for choledocholithiasis79%sensitive, 100% specific for gallstones 

In suspected cases of cholangitis due to choledocholithiasis evaluation should begin with USG to define level of obstruction

Emergent drinage by ERCP, PTC or operation may be required in who don’t improve with resuscitation & antibiotics

Biliary strictures 

Long, smooth tapered strictures are usually benign

MC cause is iatrogenic injury following cholecystectomy or less frequently rt. Upper quadrant surgery

Other causes are:• pancreatitis• Radiation • Inflammation due to

stone disease • PSC

Level of stricture

Proximal duct

stricture

Mid bile duct

stricture

Low ductal

stricture

cholangioCa.Malignant masquerade

GB cancercholangioCa.Mirizzi syndrome

Periampullary neoplasmPancreatitisCholelithiasis

ERCP films showing stricture and further dilatation of stricture

•PTC is used for proximal ductal disease whereas ERCP for distal•MRCP provides same information

Primary sclerosing cholangitis

OProgressive fibrosis of biliary of unknown etiology

OFound in association with ulcerative colitis

OMC in men OPSC is best diagnosed by

ERCP

Primary sclerosing cholangitisUSG picture of PSC showing thickening of the wall of the bile duct

CT film showing mild bile duct dilatation with a discontinuous pattern.

Discontinuous dilatationBile wall thickening at the level of the porta hepatisLymphadenopathy

intrahepatic bile duct dilatation with strictures and only mild dilatation, the first diagnosis we think of is primary sclerosing cholangitis (PSC).

Choledochal cyst 

choledochocele extrahepatic and intrahepatic disease

saccular or fusiform dilatations of CBD

MC type is fusiform dilatation of EHBD Presents with jaundice, pain and mass Manifests in childhood & usually involves lower bile duct

Carolis disease: congenital condition of dilatation of intra hepatic ductsmay be diagnosed with CT, USG, PTC, ERCP

ERCP: severe intra hepatic dilatation without any obstruction

Caroli’s disease 

The hallmark of Caroli disease is intrahepatic duct dilatation. The dilatation can be very large and saccular as seen in the case on the left or it can be 

very linear.

central dot sign and the segmental involvement(portal vein that is surrounded by dilated bile ducts)

Cholangiocarcinoma

Often discovered as a result of obstructive jaundice

Papillary variant produces intermittent jaundice

USG is the preferred initial testDetects hilar tumors Predicts extent of bile duct

involvement in 87% cases

Duct dilatation Ill-defined mass Lobar atrophy Vascular invasion

Duplex USG may be accurate in determining extent of disease & vascular involvement MRCP is also one of the best investigation available Determine resectability of tumour through visualisation of tumor extension along the 

biliary tract

Combination of MRCP and duplex USG is sufficient for diagnosis & staging

CT may be used instead of MRCP but direct cholangiography may be preferred

Features determing resectability: • Vascular involvement, • local extension, • liver metastasis, • liver lobe atrophy, • extent of intraductal disease

CECT scan is showing a hypoattenuating irregular large cholangiocarcinoma (arrow) with peripheral rim enhancement (arrowheads) in left lobe 

Gallbladder carcinomaWhen a 

gallbladder cancer is discovered preoperatively MRCP & usg are required for diagnosis & staging 

CT may be used instead of MRCP

PERIAMPULLARY NEOPLASMS

Distal bile duct obstruction is seen with:• Periampullary neoplasm• Pancreatitis• Pseudocyst• Biliary stricturePeriampullary neoplasms include• Cholangiocarcinoma• Pancreatic adenocarcinoma• Duodenal adenocarcinoma• Ampullary adenocarcinoma• Lymphoma or mets

USG demonstrates distal nature of obstruction and is the intial test of choice

Helical CT is best over all for assessing periampullary lesions & determing resectability

On occasion MRCP is needed to define the mass

ERCP is not typically requiredRoutine preoperative bilairy drinage

with a stent should be avoided as it is associated with higher incidence of post-op infections

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