Obstructive Jaundice

Introduction
Obstructive jaundice occurs when there is an obstruction to the passage of conjugated bilirubin from liver cells to intestine. As the patient with obstructive jaundice has a high morbidity and mortality, the early diagnosis is of great importance. Malignancy and stones in the CBD are common causes of obstruction.

 Jaundice indicates excessive levels of conjugated or unconjugated bilirubin in the blood is clinically apparent when the bilirubin level exceeds 2mg/dl (34.2 mol per L).

Obstructive Jaundice
Pathogenesis
it is due to intra- and extra hepatic obstruction of bile ducts intrahepatic Jaundice: Hepatitis (alcoholic or viral), Primary biliary Sclerosis, Drugs Extra Hepatic Biliary Obstruction

 The common ones include: Choledocholithiasis Cancer of the head of Pancreas Ampullary cancers Cholangiocarcinoma Biliary strictures. Iatrogenic - POST CHOLECYSECTOMY

How Common?
In the United States, 20% of persons older than 65 years have gallstones and 1 million newly diagnosed cases of gallstones are reported each year.

 Obstructive jaundice is more common among females. Malignant causes outnumber benign causes. The benign jaundice is prevalent in younger patients while malignant causes in elder age group. Carcinoma of the head of pancreas is the commonest malignant cause of jaundice where as stones in the bile ducts the commonest benign etiology.

Clinical Features
Jaundice, dark urine, pale stools and generalized pruritus are the hallmark of obstructive jaundice. History of fever, biliary colic and intermittent jaundice may be suggestive of cholangitis/choledocholithiasis.

Weight loss, abdominal mass, pain radiating to the back and progressively deepening jaundice may be suggestive of pancreatic cancer. Deep jaundice (with a greenish hue) that appears to fluctuate in intensity may be due to a peri ampullary cancer. A palpably enlarged gall bladder in a jaundiced patient is also suggestive of an extrahepatic malignancy (Couvoissier s statement).

Investigations
Blood workup: FBC, U&Es, LFTs, GGT USS abdomen MRCP ERCP

LFTs
Patients with gallstone disease have less hyperbilirubinemia than those with extra-hepatic malignant obstruction. Serum bilirubin is less than 20 mg/dL. The alkaline phosphatase (ALP) up to ten times normal. The transaminases (AST,ALT) may abruptly rise about ten times normal and decrease rapidly once the obstruction is relieved. ALT levels of less than 100 IU/L with jaundice suggests obstructive jaundice. WBC may be present in cholangitis. Pancreatic Ca and other obstructive cancers: bilirubin 35 to 40 mg/dL, the ALP up to 10X normal, but ALT,AST may remain normal.

Role of GGT ( -glutamyltransferase)

Main sources of ALP are liver and bone. GGT raised levels of ALP originate from biliary tree.

Imaging
Abdominal USS MRCP ERCP Endoscopic ultrasound CT scan PCT (rarely used nowadays).

 If Abdominal USS shows stones proceed to ERCP. If abdominal USS is inconclusive, MRCP Gold standard is Endoscopic Retrograde Cholangiopancreatography (ERCP).

A slide of MRCP: the yellow arrow indicates the extrinsic nodule compressing the common bile duct, the red arrow indicates the dilated common bile duct and the red arrow shows the level of the stenosis at the middle portion of the common bile duct

 Ascending obstructive cholangitis. ERCP shows a dilated intrahepatic and extrahepatic biliary system with multiple filling defects (arrow). The patient recovered after urgent papillotomy and administration of antibiotics and intravenous fluids.

ERCP showing stones in CBD

Treatment Modalities
Extrahepatic biliary obstruction requires mechanical decompression. Other goals include treatment of the underlying cause, symptoms, and complications (e.g., vitamin malabsorption). Decompression of extrahepatic biliary obstruction can be achieved by any of these three methods: ERCP,surgical bypass, resection of obstructing lesions, percutaneous insertion of stents, and endoscopic insertion of stents.

Obstructive cholangitis
Definition:Cholangitis due to bacterial infection due to biliary stasis in obstructed bile duct. 6%-9% of Pts with gallstone disease Injection of contrast medium under pressure above obstruction may exacerbate existing infection or introduce an infection into previously sterile biliary tree Prompt biliary drainage and broad-spectrum antibiotic coverage are mandatory

 Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholescystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.

Take Home message

Malignancy must be excluded Beware of Cholangitis!! USS +/- MRCP ERCP Time is key. Surgery post medical.