Obstructive Jaundice

Dr. Alex A. Erasmo

De Veyra • Dee • A. Dela Cruz • J. Dela Cruz
Jaundice in a 58 year old male

 2 months PTA
 Progressively icteric sclerae
 Tea-colored urine
 Acholic stool
 20% weight loss
 Pruritus
Jaundice in a 58 year old male

 Past Personal History:

 Heavy smoker (3 pack-years)
 Occasional alcoholic beverage drinker
 No history of hepatitis
 Hypertensive for 10 years
 Captopril
 Metoprolol

 No history of DM
Jaundice in a 58 year old male

 BP 150/90 HPN?
 PR 86/min
 Temp 36.7°C
 RR 17/min
 Ht: 5’7”; Wt: 155 lbs BMI: 24.3
 Skin: yellowish
 Icteric sclerae; no palpable cervical lymph
nodes; oral cavity normal
 H/L: essentially normal
Jaundice in a 58 year old male

 Abdomen:
 Slightly globular Ascites?
 Ill-defined ballotable mass at the RUQ, not
tender, smooth in surface, moves with respiration;
 Liver edge not palpable

 Rectal exam:
 Acholic stools
http://www.qub.ac.uk/cm/sur/webpages/FinalYear/Jaundice/jaundice.html
http://www.studentbmj.com/back_issues/1098/graphics/bilirubin.jpg
 Lab Work-up
 Hgb: 110 grams
 Hct: 35
 WBC: 8000; normal differential count
 Platelet: 350,000
 Serum Crea: 1.2 mg
 Total bil: 10 mg;
B1(unconj): 2 mg B2 (conj): 8 mg
 Alkaline phosphatase: 500 U/L
 CA 19-9: 350 units/ml
 Total protein: 6.5 grams; albumin: 3.5; globulin:
2.5
 Lab Work-up
 Hgb: 110 grams
 Hct: 35
 WBC: 8000; normal differential count
 Platelet: 350,000
 Serum Crea: 1.2 mg
 Total bil: 10 mg;
B1(unconj): 2 mg B2 (conj): 8 mg
 Alkaline phosphatase: 500 U/L
 CA 19-9: 350 units/ml
 Total protein: 6.5 grams; albumin: 3.5; globulin:
2.5
 Lab Work-up

Significant Elevation of: NV

Total Bilirubin 10 mg 0.3 – 1.0 mg/dL

B1 2 mg < 0.2 mg/dL

B2 8 mg < 0.8 mg/dL

Alkaline 500 U/L 20-70 U/L

phosphatase
CA 19-9 350 U/mL < 37 U/mL
 Differentiating Jaundice
Pre-hepatic Intrahepatic Obstructive

Plasma  B1  both  B2
Bilirubin
Urine bilirubin  Often absent 

Stercobilin & , dark /N, pale/N , pale

fecal color
Plasma N  
Alkaline
Phosphatase
 Differentiating Jaundice
Pre-hepatic Intrahepatic Obstructive

Plasma  B1  both  B2
Bilirubin
Urine bilirubin  Often absent 

Stercobilin & , dark /N, pale/N , pale

fecal color
Plasma N  
Alkaline
Phosphatase
 Lab Work-up

 Others:
 Prothrombin time Prolonged
 Serum amylase Elevated
 Transaminases Elevated
 Obstructive Jaundice

Gradual obstruction of CBD

(weeks or months)

Without assoc. Sx
Jaundice Pruritus of biliary colic
or cholangitis
 Differential Diagnosis

Painless Jaundice

Biliary Obstruction
Choledocholithiasis
2o to malignancy

Periampullary Hilar
Tumors Cholangiocarcinoma
 Choledocholithiasis

Clinical Picture
 May be silent
 Often discovered incidentally
 May cause obstruction
 Complete
 Incomplete
 May manifest with cholangitis or gall
bladder pancreatitis
 Choledocholithiasis
 PE: may be normal
 Mild epigastric or RUQ pain
 Jaundice
 Completely impacted stones:
Severe progressive jaundice

 Lab Workup
  serum bilirubin
  alkaline phosphatase
  transaminases
 Choledocholithiasis

 Assoc. with chronic calculous cholecystitis

 PAIN
 Absence of a palpable GB
 Courvoisier’s Law
 Presence of a palpably enlarged GB
suggests biliary obstruction secondary to an
underlying malignancy rather than a
calculous disease.
Choledocholithiasis
Imaging Studies
 Differential Diagnosis

Painless Jaundice


Choledocholithiasis
Biliary Obstruction
2o to malignancy

Periampullary Hilar
Tumors Cholangiocarcinoma
 Periampullary Tumors

 Ampulla of Vater
 Distal common bile duct
 Duodenum
 Head of the Pancreas
 Periampullary Tumors

Clinical Picture
 Painless progressive jaundice
 Pruritus
 Acholic stool
 Tea-colored urine
 Weight loss (Average 10 kg)
 Mild RUQ pain
 Anorexia
 Fatigue
 Periampullary Tumors

 PE is usually normal
 Palpable GB (Courvoisier’s Law)

 Lab Workup
  alkaline phosphatase
  total bilirubin & B2
 Hilar Cholangiocarcinoma

 Klatskin’s tumor
Clinical Picture:
 Painless jaundice
 Pruritus
 Mild RUQ pain
 Anorexia
 Weight loss
 Acholic stools
 Hilar Cholangiocarcinoma

 PE is usually normal
 Hepatomegaly
 Collapsed GB

 Lab Workup
  alkaline phosphatase
  gammaglutaryltransferase
 Treatment

Resectable?

Yes No

Good risk Poor risk Good risk Poor risk

Whipple’s Endoscopic drainage Bypass ERCP

Cholecystojejunostomy with
PPPD Gastrojejunostomy

Hepaticojejunostomy with
Gastrojejunostomy
 Outcomes in
Pancreaticoduodenectomy
 1-year mortality rate 57%
 3-year mortality rate 26%
 5-year mortality rate 21%

 Median survival rate: 15 months

 11 5-year survivors
 7 6-year survivors
 1 15-year survivor
 Outcomes in
Pancreaticoduodenectomy
 Strongest independent predictors of
favorable outcome
 Tumor DNA content,
 Tumor diameter,
 Status of resected lymph nodes,
 Margin status
 Use of postoperative combined modality
chemoradiation therapy
 References
 Brunicardi et. al. Schwartz's Principles of Surgery, 8/e. McGraw-Hill
Professional. 2004.
 Sabiston et. al. Sabiston Textbook of Surgery: The Biological Basis of
Modern Surgical Practice. W.B. Saunders Co. 2001.
 Greenfield, et. al. Essentials of Surgery: Scientific Principles & Practice.
Lippincott-Raven Publishers. 1997
 American Cancer Society. http://www.cancer.org
 Sosa et. al. Importance of hospital volume in the overall management of
pancreatic cancer. Ann Surg. 1998 Sep;228(3):429-38.
 Gordon et. al. Statewide regionalization of pancreaticoduodenectomy
and its effect on in-hospital mortality. Ann Surg. 1998 Jul;228(1):71-8.
 Body Mass Index (BMI)

BMI Weight Status

< 18.5 Underweight

18.5 – 24.9 Normal

25.0 – 29.9 Overweight

> 30.0 Obese

 Sites of Metastasis in Pancreatic CA
(Head)
 Regional Lymph Nodes 80%
 Juxtaregional Lymph Nodes 49%
 Liver 75%
 Lungs & Pleura 27%
 Adrenals & Stomach 14%
 No metastasis 14%
 TNM Classification for Staging of
Pancreatic CA
 T Categories of Cancer of the Pancreas

 T1: The cancer has not spread beyond the pancreas and is
smaller than 2 cm (about ¾ inch).
 T2: The cancer has not spread beyond the pancreas but is
larger than 2 cm (about ¾ inch).
 T3: The cancer has spread from the pancreas to surrounding
tissues near the pancreas but not blood vessels.
 T4: The cancer has extended further beyond the pancreas
into nearby large blood vessels.
 TNM Classification for Staging of
Pancreatic CA
 N Categories of Cancer of the Pancreas

 N0: Regional lymph nodes (lymph nodes near the pancreas)

are not involved.
 N1: Cancer has spread to regional lymph nodes.

 M Categories of Cancer of the Pancreas

 M1: Distant metastasis is present.

 TNM Classification for Staging of
Pancreatic CA
 Stage Grouping for Cancer of the Pancreas

 Stage IA (T1, N0, M0): The tumor is confined to the pancreas

and is less than 2 cm in size. It has not spread to nearby
lymph nodes or distant sites.
 Stage IB (T2, N0, M0): The tumor is confined to the pancreas
and is larger than 2 cm in size. It has not spread to nearby
lymph nodes or distant sites.
 Stage IIA (T3, N0, M0): The tumor is growing outside the
pancreas but not into large blood vessels. It has not spread
to nearby lymph nodes or distant sites.
 TNM Classification for Staging of
Pancreatic CA
 Stage Grouping for Cancer of the Pancreas

 Stage IIB (T1-3, N1, M0): The tumor is either confined to

the pancreas or growing outside the pancreas but not
into large blood vessels. It has spread to nearby lymph
nodes but not distant sites.
 Stage III (T4, Any N, M0): The tumor is growing outside
the pancreas into large blood vessels. It may or may not
have spread to nearby lymph nodes. It has not spread
to distant sites.
 Stage IV (Any T, Any N, M1): The cancer has spread to
distant sites.
 Symptoms of Pancreatic CA (Head)

 Weight Loss 92%

 Jaundice 82%
 Pain 72%
 Anorexia 64%
 Dark Urine 63%
 Light Stools 62%
 Nausea 45%
 Vomiting 37%
 Pruritus 24%
 Signs of Pancreatic CA (Head)

 Jaundice 87%
 Palpable Liver 83%
 Palpable Gallbladder 29%
 Tenderness 26%
 Ascites 14%
 Abdominal Mass 13%