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Extrahepatic

Cholestasis
Prof. Dr. Salih Pekmezci
IU Cerrahpaşa Medical Faculty
Department of General
Surgery
Definition

Cholestasis 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
– Murphy’s Sign
– Courvoisier’s Law
Physical examination
• Jaundice
• Scratch Marks
• Masses – Liver/Spleen
• Gall Bladder
– Murphy’s Sign
– Courvoisier’s 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 Hepatic Post-hepatic
Jaundice Jaundice Jaundice
Normal /
Total bilirubin Increased Increased
Increased
Normal Normal
Conjugated bilirubin Increased
/decreased /increased
Unconjugated Normal /
Increased Normal
bilirubin Increased
Normal / Decreased /
Urobilinogen Increased
Increased Negative
Urine Color Normal Dark Dark
Stool Color Normal Normal/pale Pale
Alkaline
Normal Increased Increased
phosphatase levels

Alanine transferase
and Aspartate Normal Increased Increased
transferase levels

Conjugated Bilirubin
Not Present Present 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
PeriampullaryTumor
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 Tm

Whipple procedure n:1000


Mean age: 63.4 (15-103) Malignant periampullary
tm: 652
n 5 year
Pancreatic head 405 survival
18%
tm (62.1%)
Ampulla Vateri tm 113 39%
(17.3%)
Distal CBD tm 95 22%
(14.5%)
Duodenum tm 39 52%
(5.98%)
Total 652
Cameron 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 başı kanserine göre daha iyidir
(%35-67’ye karşın %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


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