Case: “A 46-year-old woman presents to your clinic after family members noted that her eyes were turning

yellow.
She notes that over the past 2 weeks, she has developed pruritus and clay-colored stools. She describes darkening
of his urine. She has on and off colicky pain at right upper quadrant of abdomen sometimes radiating to the back ,
but no weight loss as claimed. Vital signs are within normal limits. On examination, she appears jaundiced with
scleral icterus, and no palpable masses. He has no prior medical problems, non alcoholic , and works as a
beautician.

Pertinent Findings:

 46 y.o woman
 Eyes turning yellow
 2 weeks PTA she developed pruritus & clay colored stools
 Darkening of urine
 On and off colicky pain at RUQ and sometimes radiates to the back
 On P.E – she appears jaundiced, with scleral icterus

Clinical Impression:

Obstructive Jaundice secondary to Choledocholithiasis

 Choledocholithiasis should be suspected when patient present with gallstone-related disease, elevated liver enzymes
(especially bilirubin and alkaline phosphatase) and CBD diameter greater than 5 mm based on ultrasound.

Rule in:
RUQ pain – due to a stone obstructing the common bile duct which impact the outflow of both liver and
gallbladder
Jaundice - when serum bilirubin exceeds 3mg/dL
- due to hepatic outflow obstruction of bilirubin
- If bilirubin cannot be moved through the liver and bile ducts quickly enough, it builds up in
the blood and is deposited in the skin. The result is jaundice.

Dark urine with clay-colored stools- this occur when a blockage prevents bilirubin from being eliminated
in stool, causing more bilirubin to be eliminated in urine.

Pruritus – this is due blockage, so when there’s blockage , it causes to increase pressure in the bile
ducts and eventually will causes leakage of bile salts & acids and also cholesterol into the blood and
when it reaches the skin it will causes itchiness/pruritus

Diagnostic modalities:
 CBC
 Liver function tets
o The serum transaminases ALT and AST are sensitive indicators of hepatocellular damage
o So the plasma levels rise as hepatocyte membrane integrity is lost during hepatocellular injury
 Ultrasound- will show dilation of the common bile duct, presence of gallstones in the common bile duct.
o But the presence of a gallstone in the common bile duct can be difficult to appreciate on the RUQ
ultrasound. Because it has low sensitivity (only 15-40%) and this is because the detection of
Common bile duct stones is impeded by the presence of gas in the duodenum, possible reflection
and refraction of the sound beam by the curvature of the duct, and the location of the duct
beyond the optimal focal point of the transducer.
 ERCP and MRCP – both have higher sensitivities and specificities than ultrasound
 Gold standard for diagnosing choledocholithiasis
 ERCP(Endoscopic retrograde cholangiopancreatography) - not only diagnostic but also
therapeutic. It uses endoscopic techniques to diagnose choledocholithiasis which can
then be treated with endoscopic sphincterotomy and/or stone removal.
 involves passing an endoscope (a flexible viewing tube) through the mouth,
esophagus, and stomach into the duodenum. A thin tube is then inserted
through the endoscope into the biliary tract. Doctors inject a radiopaque
contrast agent through the tube into the biliary tract, and, at the same time,
x-rays are taken of the biliary tract and pancreatic duct.
 Complication: Pancreatitis- post-ERCP pancreatitis is believed to be multi-
factorial, involving a combination of chemical, hydrostatic, enzymatic,
mechanical, and thermal factors.
Bilirubin metabolism:

 the bilirubin metabolism begins with the red blood cells, which have a lifespan of approximately 120
days and after they complete their life cycle, they are destroyed in organs like the spleen and the
liver which contain numerous macrophages.
 So it releases the hemoglobin within the red blood cell
 Then hemoglobin is then split into the heme component and globin component
 The globin is further converted into the amino acids and utilized in the body.
 The heme component is then converted into the iron and the biliverdin and this reaction is catalyzed by
the enzyme heme oxygenase in the next step.
 The biliverdin is converted into the yellow compound the bilirubin and this reaction is catalyzed by the
enzyme biliverdin reductase
 this bilirubin is still the unconjugated form which is not the water soluble form.
 So it requires albumin for its transport to the liver
 So in the liver, the bilirubin is converted into the conjugated form, which is the water soluble form of the
bilirubin and this reaction takes place by the combination of glucuronic acid with unconjugated bilirubin.
 And then it will be transported through the biliary channels into the duodenum and through the
duodenum it reaches the colon
 in the colon, the bilirubin is acted upon by number of microorganisms and is converted into urobilinogen
and stercobilinogen
 So majority of these compounds are excreted in the feces in the form of stercobilin which causes the
yellow color to the feces,
 But 10 to 15% of these compounds are reabsorbed into the blood and some part of that reaches the liver
and this is known as the enterohepatic circulation
 while a few percentage of the reabsorbed compounds reach the kidney and they are excreted in the urine
in the form of urobilin which also contributes to the yellow color of urine

Questions to ask the patient:

 Alcoholic liver disease and Fatty liver disease

o We can ask the patient, was there history of chronic alcohol consumption….or is she alcoholic to
rule out alcoholic liver disease… ( such as Liver cirrhosis or alcoholic hepatitis )
o We can ask this by saying, ma’am
  In the past year, do you sometimes drink alcoholic beverages, like beer, wine, or hard
liquor?
 How much alcohol do you typically drink?
 How often do you drink alcohol per week?
 Do you ever drink more than 6 drinks on any one occasion?

 Viral Hepatitis
o We can also focus on the review of systems, we can ask if the pain is associated with fever or
viral symptoms so that we can rule out viral hepatitis.
o since hepatitis is a common cause of jaundice, so we can ask about conditions that increase the
risk of hepatitis such as living or travelling to an area where hepatitis is widespread, having
hemodialysis or having had a blood transfusion before 1992. Or having sex with someone who
has hepatitis.
o We can also ask if she had poor appetite and nausea and vomiting to rule out Viral hepa
 Ask by saying ma’am before you experience your symptoms such as pain, do you still
like to eat ? or and now you have abdominal pain do you still want to ear??
 Drug-induced liver injury-
o we can ask the patient about medications, if she was taking any drugs such as rifampicin,
chlorpromazine (used to treat tetanus & hiccups)
o drugs that typically cause liver injury 3 to 12 months after starting (isoniazid, flutamide) and
others for which the liver injury arises or becomes clinically evident after years of use
(minocycline, amiodarone, nitrofurantoin).
 Liver cirrhosis
o We can ask or evaluate for the fluid accumulation in the legs or edema
o Or we can ask if she experience mental confusion – this is due to increase in ammonia
o We can ask if the patient or evaluate for any bruising, spider angiomas. Or evaluate for
hepatomegaly and ascites.
 Chronic Pancreatitis
o We can ask the patient about history of acute pancreatitis that comes back or does not get better
to rule out chronic pancreatitis
o Or ask about symptoms like abdominal pain that get worse upon eating or drinking alcohol
o Or symptoms like diarrhea , nausea and vomiting , weight loss
 Cholangiocarcinoma (bile duct cancer)
o We can ask the patient about family history of Cholangiocarcinoma
o Aside from family history, we can ask about symptoms like fatigue,fever,night sweats or losing
weight without trying.
 Biliary stricture-
o We can ask the patient if she had history of gallbladder removal surgery or cholecystectomy to
rule out Biliary stricture since this can be one of the main cause for biliary stricture to occur
 o During cholecystectomy damage to the bile ducts can happen.so A bile duct can get cut, burned,
or pinched. As a result of an injury, the bile duct will not be able to work right, leaking bile into
the abdomen or blocking the normal flow of bile from the liver.
 AIDS cholangiopathy
o a syndrome of biliary obstruction and liver damage due to infection-related strictures of the
biliary tract.
o Maybe we can ask about history of HIV/AIDS infection to rule out AIDS cholangiopathy
o We can ask about fever or weight loss

 Primary Sclerosing Cholangitis(PSC) – itchiness and jaundice

o This is a disease that attacks the bile ducts which causes it to become scarred. And slowly narrow
until the bile backs up into the liver and starts to damage it
o So we can ask the patient about family history of Primary Sclerosing Cholangitis. And also fever ,
we can ask about if the condition is associated with fever since this can cause fever due to
infection of the bile ducts
 Pancreatic Cancer (rule in jaundice, dark urine,pruritus)
o Cancer that blocks the liver’s bile duct causes jaundice
o We can ask the patient if she had any loss of appetite and weight loss to rule out pancreatic
cancer. Or a family history of pancreatic cancer
 Acute Fatty liver
 Cholelithiasis
o We can ask the patient if the abdominal pain comes and goes," typically after eating a large, fatty
meal and if it is associated with nausea and vomiting to rule out Cholelithiasis
o Cholithiasis can be diagnosed using a right upper quadrant ultrasound that will show hyperechoic
stony formations with a posterior acoustic shadow.
 Cholangitis (infection of the bile ducts) due to blockage in a bile duct/biliary tree
o Rule out because symptoms usually associated with Charcot’s Triad which includes fever, right
upper quadrant pain, and jaundice
 Hyperbilirubinemia secondary to sepsis
o We can ask if it is associated with fever to rule out hyperbilirubinemia secondary to sepsis, since
o Sepsis causes cytokine release during the body’s attempt to fight infection. These cytokines, also
the reason for inflammation during sepsis, so this could also disrupt our body’s ability to regulate
bilirubin.
o Our bodies therefore cannot process bilirubin normally, leading to a buildup of bilirubin, which
turns the skin a yellow color, also known as jaundice.
 Unconjugated hyperbilirubinemia secondary to Hemolytic disorders
o Ask about family history of hemolytic anemia
o Ask about if you have noticed blood in your urine (hematuria)
 Unconjugated hyperbilirubinemia secondary to Gilbert syndrome
o Ask about family history of Gilbert syndrome
 Choledochal cyst
o – RULE out coz no mass present
o A classic triad of abdominal pain, jaundice, and a palpable right upper quadrant abdominal mass
Questions

When a patient presents with a skin discoloration suggestive of jaundice, the first step is to confirm that icterus is
indeed present.

-mucous membranes of the mouth, the palms, the soles, and the sclerae should be examined in natural light

How do you confirm that icterus is present?

o We can do Physical examination, so icterus is best appreciated when sclera is inspected under
natural light
o So In fair-skinned individuals, a yellow tinge to the skin may be obvious.
o In dark-skinned individuals, examination of the mucous membranes below the tongue can
demonstrate jaundice.
o But laboratory tests usually serve to confirm the jaundice
o We can test for fractionated bilirubin
o Complete blood count
o Alanine transaminase
o Aspartate transaminase
o Gamma gltutamyl transferase
o Prothrombin time
o Albumin and total protein

1. History and PE
o A. After confirmation, what history directed questions that will differentiate whether jaundice is
from direct or indirect hyperbilirubinemia?
 So in history we can ask a detailed alcohol and drug use history which can help identify
intrahepatic disorders such as alcoholic liver disease, viral hepatitis, chronic liver
disease, or drug-induced liver injury which can cause direct hyperbilirubinemia.
  A focused review of systems is also important. For example, we can ask about fever and
viral symptoms can precede acute viral hepatitis, fever can be associated with
underlying sepsis, and weight loss can be associated with underlying malignancy.
 So in indirect hyperbilirubinemia, Indirect bilirubin usually increased in blood loss or
blood disorders such as hemolytic anemia so we can ask about family history of this
disorder and also hereditary disorder also such as Gilberts syndrome.
 Also we can also ask history of fatigue, dizziness.

1.B Once the presence of direct hyperbilirubinemia is confirmed, what’s the next step ?
 We could do Laboratory studies like
 Bilirubin levels
o This is used either alone or as part of a liver panel to detect an increased level in the blood to
help determine the cause of jaundice and/or help diagnose conditions such as liver
disease, hemolytic anemia, and blockage of the bile ducts.
o So 1st an initial test measures the total bilirubin levels, If the total bilirubin level is increased, then
test for the direct bilirubin.
o the direct bilirubin test provides an estimate of the amount of conjugated bilirubin present.
o Then Subtracting the direct bilirubin level from the total bilirubin level helps estimate the
“indirect” level of unconjugated bilirubin.
 CBC to screen for hemolysis
 Serum AST and ALT – to assess liver function
o The purpose of an ALT test is to help assess the health of the liver. Damage to cells in the liver
can cause ALT to leak into the blood, so an ALT test can help detect liver problems.
o Because AST levels in the blood can rise when cells are damaged, elevated AST can reflect health
conditions, including liver diseases like cirrhosis or hepatitis.

o However, because AST is found in other parts of the body, it can be elevated in the blood as a
result of cell damage outside the liver.
o For this reason, the doctor may look at the levels of both AST and the enzyme alanine
aminotransferase (ALT) side by side. ALT is more concentrated in the liver, so if AST is high while
ALT is normal, it can be a sign of a problem outside the liver. In other cases, though, having a
much higher level of AST than ALT can be a sign of alcohol-induced damage to the liver.
 Alkaline phosphatase and GGT
 Serum ALP – so if this is elevated or if obstruction is suspected then imaging should be obtained
 Gamma glutamyl transpeptidases – results may help differentiate a hepatic source of the elevated ALP
from bone or other causes.
o To evaluate for a possible liver disease or bile duct disease or to differentiate between liver and
bone disease as a cause of elevated alkaline phosphatase
 We could also do Imaging studies
o Ultrasonography
 to exclude biliary obstruction and to evaluate the liver parenchyma for
possible cirrhosis,
 This also provides good visualization of the gallbladder, bile ducts, and cystic lesions,
and it can detect parenchymal liver disease, such as cirrhosis or infiltration, and signs
of portal hypertension
o CT scanning
 offers the following advantages:

 Better resolution than ultrasonography

 And Provides good evaluation of the entire bile duct
 And can also define the anatomy better than ultrasonography, especially if contrast
agents are used
 Better for evaluating suspected malignancies, especially with evaluation of the arterial
phase
o MRI
 produces images comparable in quality to CT scans without patient exposure to ionizing
radiation
 provides anatomic details of the liver, gallbladder, and pancreas
 MRI with magnetic resonance cholangiopancreatography (MRCP) -focused, noninvasive
test for the diagnosis of biliary tract and pancreatic disease -detect choledocholithiasis
o Endoscopic Retrograde Cholangiopancreatography
 - direct visualization of the ampullary region
 - direct access to the distal common bile duct for cholangiography or
choledochoscopy. - diagnostic and therapeutic for choledocholithiasis,
obstructive jaundice, biliary strictures, or cholangitis

o Endoscopic Choledochoscopy
 small fiber-optic cameras that can be threaded through endoscopes used for
endoscopic retrograde cholangiopancreatography (ERCP)
 direct visualization of the biliary and pancreatic ducts
 therapeutic applications that include biliary stone lithotripsy and directed stone
extraction in high-risk surgical patients
 direct visualization and sampling of concerning lesions in order to evaluate for
malignancy
o Endoscopic Ultrasound
 a specialized 30° endoscope with either a radial or linear ultrasound transducer
at its tip
 noninvasive imaging of the bile ducts and adjacent structures
 identify choledocholithiasis
 evaluation of the retroduodenal potion of the bile duct
 fine-needle aspiration (FNA) of tumors or lymph nodes, therapeutic injections,
or drainage procedures can be performed
 o Percutaneous Transhepatic Cholangiography
 performed by accessing the intrahepatic bile ducts percutaneously with a small
needle under fluoroscopic guidance
 Once the position in a bile duct has been confirmed, a guidewire is inserted and
a catheter is passed over the wire
 tissue sampling, biliary drain insertions, or stent placements performed
 potential risks for PTC, are mainly bleeding, cholangitis, bile leak, and other
catheter-related problems.

1.C How do you examine the abdomen?

 Wash your hands
 1st introduce yourself
 Ask for consent
 Explain the procedure
 Ask someone to accompany you during the procedure
 Then start the examination with inspection
 Let the knees be flexed to relax the abdomen
2. Imaging tests needed
 We can do
 Hepatobiliary ultrasound
o In acute cholecystitis -
 Transabdominal ultrasound
o noninvasive, painless, does not submit the patient to radiations
o advantages include:
 stone detection- which produce acoustic shadow
 polyps- may be calcified and reflect shadow
 also helps to indicate acute and chronic cholecystitis
 visualize extrahepatic bile ducts
 detect extrahepatic obstruction
 Ultrasonography
o Is commonly applied imaging modality used to evaluate abdominal symptoms.
o Is useful initial imaging test of the liver and biliary tree because it is inexpensive, widely
available and involves no radiation exposure. Will show stones in the gallbladder with
sensitivity and specificity of >90%.
 Computed Tomography
o Is to define the course and status of the extrahepatic biliary tree and adjacent
structures.
o Is the test of choice in evaluating the patient with suspected malignancy of the
gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of
the pancreas.
 o provide detailed morphologic information on the number, size, distribution, and
vascularity of liver lesions
 Magnetic Resonance Imaging
o provides anatomic details of the liver, gallbladder, and pancreas
o MRI with magnetic resonance cholangiopancreatography (MRCP) -focused, noninvasive
test for the diagnosis of biliary tract and pancreatic disease -detect choledocholithiasis
 Endoscopic Retrograde Cholangiopancreatography
o - direct visualization of the ampullary region
o - direct access to the distal common bile duct for cholangiography or choledochoscopy.
- diagnostic and therapeutic for choledocholithiasis, obstructive jaundice, biliary
strictures, or cholangitis

 Endoscopic Choledochoscopy
o small fiber-optic cameras that can be threaded through endoscopes used for endoscopic
retrograde cholangiopancreatography (ERCP)
o direct visualization of the biliary and pancreatic ducts
o therapeutic applications that include biliary stone lithotripsy and directed stone
extraction in high-risk surgical patients
o direct visualization and sampling of concerning lesions in order to evaluate for
malignancy
 Endoscopic Ultrasound
o a specialized 30° endoscope with either a radial or linear ultrasound transducer at its tip
o noninvasive imaging of the bile ducts and adjacent structures
o identify choledocholithiasis
o evaluation of the retroduodenal potion of the bile duct
o fine-needle aspiration (FNA) of tumors or lymph nodes, therapeutic injections, or
drainage procedures can be performed
 Percutaneous Transhepatic Cholangiography
o performed by accessing the intrahepatic bile ducts percutaneously with a small needle
under fluoroscopic guidance
o Once the position in a bile duct has been confirmed, a guidewire is inserted and a
catheter is passed over the wire
o tissue sampling, biliary drain insertions, or stent placements performed
o potential risks for PTC, are mainly bleeding, cholangitis, bile leak, and other catheter-
related problems.
 Goal of imaging
o Confirm if there is really presence of stone or obstruction
o Determine the location or level
o Identify the cause

3. Once post hepatic jaundice is established , what’s your next step?

o Post-hepatic, or obstructive jaundice, happens when bilirubin can’t be drained properly
into the bile ducts or digestive tract because of a blockage.
o Treatment for post-hepatic jaundice will address the cause.
o Guidelines : Open cholecystectomy by doing CBDE (CBD exploration)
 CBDE how to perform

o This includes:
 For CBD stone without cholangitis
o If you have gallstones and no symptoms, you can make certain lifestyle
changes.
o changing your diet to stop producing gallstones
o or proceed to surgery to remove gallstones or your gallbladder
entirely

o We could do ERCP plus sphincterotomy with stone extraction

o Or elective cholecystectomy to prevent recurrence (within 24-48 hrs
since there is passage of tone within that period)

o Endoscopic Retrograde Cholangiopancreatography

o - direct visualization of the ampullary region
o - direct access to the distal common bile duct for cholangiography or
choledochoscopy. - diagnostic and therapeutic for choledocholithiasis,
obstructive jaundice, biliary strictures, or cholangitis
o For the management
o If you have gallstones and no symptoms, you can make certain lifestyle
changes.
o changing your diet to stop producing gallstones
o or proceed to surgery to remove gallstones or your gallbladder
entirely
o perform a laparoscopic gallbladder removal. This is a common surgery
that requires general anesthesia. The surgeon will usually make 3 or 4
incisions in your abdomen. They’ll then insert a small, lighted device
into one of the incisions and carefully remove your gallbladder.
o taking medications or treatments to dissolve gallstones
o Ultrasound - to confirm that you have gallstone disease. It can also
show abnormalities associated with acute cholecystitis.
o Abdominal CT scan: This imaging test takes pictures of your liver and
abdominal region.
o Blood tests: Your doctor may order blood tests that measure the
amount of bilirubin in your blood. The tests also help determine how
well your liver is functioning
 For CBD stone with Cholangitis
 cholangitis we need to resuscitate with IV fluid and may be require fresh frozen
plasma or Vitamin K for correction of coagulopathy, if present.
 Then we could also give parenteral antibiotics, initial should be piperacillin-
tazobactam , ticarcillin-clavulanate, ceftriaxone plus metronidazole or
ampicillin- sulbactam.
 And then we decompress upon stabilization by doing ERCP with
sphincterotomy, Percutaneous transhepatic cholangiography or PTC which
iinvolves passage of a thin needle into the liver under fluoroscopic guidance
and injection of contrast into the biliary tree
 o passage of a guide wire and cannula through the right flank incision.
o Usually done if ERCP fails to decompress the biliary system
o Helps to drain the bile proximal to the blockage
 Or decompress with T-tube if the above procedure is not possible
 For MALIGNANCY (bile duct cancer/ Cholangiocarcinoma)
 We can do imaging studies, such as CT Scan these can provide pictures &
provide detailed morphologic information on the number, size,
distribution, and vascularity of liver lesions
 And also imaging scans which can help to guide your surgeon’s movements to
remove a sample of tissue in what is called an imaging-assisted biopsy.
 Next do an endoscopic retrograde cholangiopancreatography (ERCP)
 During ERCP, your surgeon passes a long tube with a camera down your throat
and into the part of your gut where the bile ducts open. Your surgeon may
inject dye into the bile ducts. This helps the ducts show up clearly on an X-ray,
revealing any blockages.
 Next we proceed to surgery.
 surgery to remove bile ducts and parts of your liver and pancreas
 if a tumor is still confined to the bile ducts, you may only need to have the
ducts removed. If the cancer has spread beyond the ducts and into your liver,
part or all of the liver may have to be removed
 If your cancer has invaded nearby organs, a Whipple procedure may be done
 also known as a pancreaticoduodenectomy — is a complex operation to
remove the head of the pancreas, the first part of the small intestine
(duodenum), the gallbladder and the bile duct
 then we can do radiation or chemotherapy to destroy cancer cells
 For pancreatitis:
 rest & intravenous (IV) fluids or pain medication
 surgery to remove any causes of inflammation (like gallstones)
 For biliary atresia:
 the Kasai procedure to remove and replace ducts
 liver transplant
4. After thorough History And PE and imaging whats is your final diagnosis ?
o Obstructive Jaundice secondary to Choledocholithiasis
 These are stones in the common bile duct
 So we rule this in because of the age, scleral icterus, pruritus and clay colored
stools , dark color urine and on & off colicky pain at the RUQ and sometimes
radiates to the back.
 5. Complications

Complications include:

 Cholangitis
o This is an inflammation of the bile ducts
o It occurs when stones within the CBD causing either partial or completed obstruction of the CBD
o Usually Charcot’s triad is seen (fever, RUQ pain & jaundice)
o This condition can be serious and associated with sepsis, septic shock, and distant-organ dysfunction
o Systemic manifestations of this illness occur because ascending infections in the biliary tree can cause
activation of the Kupffer cells (hepatic macrophages) and produce
systemic proinflammatory responses and multiple-organ-dysfunction syndrome
o Nonsuppurative – most common and respond rapidly to antibiotics
o Suppurative – symptoms include mental confusion and septic shock this is due to pus that completely
obstruct the ducts & needs ERCP with endoscopic sphincterotomy
 Pancreatitis
o This is due to passage of gallstones through the common duct

o
 Biliary cirrhosis
o This is more common in cases of prolonged obstruction from stricture or neoplasm
ALGOS
USS findings:

 A thickened gallbladder wall, pericholecystic fluid, and local

tenderness with direct pressure by the ultrasound probe over
the fundus of the gallbladder (sonographic Murphy’s sign)
may indicate acute cholecystitis. When a stone obstructs the
neck of the gallbladder, the gallbladder may become very large,
but thin walled. A contracted, thick-walled gallbladder can be
indicative of chronic cholecystitis