OBSTRUCTIVE JAUNDICE

ENDOSCOPIC MANAGEMENT
Jaundice
• Yellowish tint of skin and also of deep
tissues

• Skin : jaundiced: concentration rises

3x(1.5mg/dl plasma) the normal(0.5mg/dl
plasma)
• Differentials:

• “dirty sclera”

• Carotenemia: does
not involve the
sclera(blood levels
of bilirubin)
Bile formation
Biliary Anatomy
 Jaundice
• Most common causes • Increased destruction
of RBC

• Obstruction of bile
ducts
• Destruction of liver
cells
 Jaundice
• Hemolytic jaundice • Liver function is
normal

• Increased load of
bilirubin

• Increased free bile

(unconjugated) plasma
 Jaundice
• Obstructive jaundice • Obstruction of bile
ducts(CBD stones and
cancer)
• Damage to liver
cells(hepatitis)
• Rate of bilirubin
formation is normal
• Conjugated bile in
plasma
 Primary Objective:
• Clinically determine if • Total obstruction = no
the jaundice is of the bile into the intestines
obstructive type vs. = no urobilinogen in
hemolytic type urine = negative

• Clay colored stools

• Urine shaking = foam

- yellow.
• Conjugated • Urine is dark
hyperbilirubinemia
• Serum bilirubin is
greater 50%
conjugated
• unconjugated • Urine normal in color

• Serum bilirubin > 90%

B1
 Conjugated Hyperbilirubinemia
• Distinguish • intrinsic liver disease
conjugated – hepatitis
hyperbilirubinemia if:
• Obstructive causes –
biliary obstruction
 Conjugated hyperbilirubinemia
• Ultrasonography – non-invasive technique,
sensitive, cheap, readily available

• CTScan – non-invasive, expensive, not

readily available, to be used only when
clinically warranted
 Conjugated hyperbilirubinemia
• Ultrasonography • Dilatation of the
intrahepatic ducts
(obstruction)
• CT SCan • Exception: sclerosing
cholangitis: high
pressure but no ductal
dilatation, some cases
of choledocholithiasis
• Correlation: labs:
alkPO4
 Diagnostic evaluation
• Normal conditions:
IHD are not supposed
to be prominent by
UTZ

• Any dilatation would

need further
evaluation
 Most common causes of biliary
obstruction
• Biliary stones

• Benign/malignant strictures

• Congenital abnormalities

• Parasites
I. Cholelithiasis
• 1.GB stone • 2.CBD stone: secondary
stones

• ERCP – sphincterotomy
stone extraction (>1 cm
stone)

• > 2cm : lithotripsy /

stenting – bypass
obstruction – stone
dissolution or re extraction
 Cholecystolithiasis
• Doesn’t in itself cause • laparoscopic
jaundice cholecystectomy:
• Passage of secondary standard of therapy
stones into the CBD - • Less pain/ less number
jaundice out of work
• Mirizzi’s syndrome: • Easier/faster recovery
external compression • Cost effective
of CBD - jaundice
Laparoscopic cholecystectomy
• 4 port technique –
standard

• Minimally invasive

• “Safe” – comes with

experience

• Cost effective
• Titanium clips: inert
to human tissues
• Conversion rate: ~ 5%

• Morbidity/mortality
almost the same with
open technique
CBD stones
• Most common : • Laparoscopic CBD
secondary stone from exploration
GB stones
• LC + post-op/intra-
op/pre-op ERCP
 CBD Stones
• Jaundice

• Fever

• RUQ / abdominal pain

• Acute cholangitis • Infected bile because
of stasis

• Increased pressure in
the biliary tree due to
obstruction
 Acute Cholangitis
• Jaundice • Charcot’s Triad
• Fever
• Pain

• Hypotension • Reynold’s Pentad

• Changes in sensorium
 Triad of Charcot
• Only identified in 1/3 of all patients with
cholangitis

• High index of suspicion

• Not all with triad are having cholangitis:

pancreatitis, acute cholecystitis

• 75% cholangitis – resolve with antibiotics and

resuscitation
• Convert an emergency to a clinical situation that
can be managed endoscopically on an elective
basis

• Immediate endoscopic decompression is needed if

this is not achieved

• Surgical decompression: failure of endoscopic

means or unavailability of the technology

• Surgery: operative mortality of 20%

 Why endoscopic techniques?
• Diagnosis and • Many of the most
management of likely causes can be
jaundice managed by
endoscopic techniques
• Primary Obj: relief
from “jaundice”
• less invasive
• Normal cavities
 ERCP

Endoscopic retrograde cholangio-

pancreatography:

Diagnostic and Therapeutic

Endoscopic view
• Ampulla of Vater

• Minor papilla:
pancreatic duct
orifice
• Ductal dilatation:
CBD size (n=< 1 cm)

• CBD ~= scope
diameter (~ 1 cm)
• Jaundice after
laparoscopic
cholecystectomy –
retained stone

• Surgical complication
• Balloon extraction

• Basket extraction
 Complication of ERCP
• Pancreatitis

• Hemorrhage • Increased risk : acute

cholangitis
• Perforation
II. Benign Biliary stricture
• Post operative • Biliary dilatation
complication
• stenting
 Benign stricture

• Most common cause is

post operative
complication
Benign stricture
• Balloon dilatation of
the strictured area

• Temporizing
procedure

• Definitive surgical
option
III. Malignant obstruction
• Definitive : surgical • ERCP + stenting =
resection temporizing procedure

• Palliative: metallic
• Painless and slowly stenting
progressing jaundice

• Palpable GB
• Periampullary cancer
• CBD cancer
• Biliary stenting – to
relieve obstruction

• 3-6 months patency

rate

• Temporizing/
palliative procedure
Percutaneous techniques (PTBD)
• Rapid decompression • Used in a few cases as
of biliary obstruction adjunct with
endoscopy
• Invasive
procedure(IVR)

• Is an option if
endoscopic procedures
fail
 Two hand technique
• Percutaneous /
endoscopic techniques

• Benefits patients not

fit for surgery or when
initial endoscopic
technique fails

• Minimally invasive
 Unusual causes of Obstructive
Jaundice
• Parasitic: ascaris
• Medical + endoscopic
management

• Anti-helmintics: pyrantel
pamoate(repeat exam@ 2
weeks re-eradication)
• Mebendazole 100mg BID
x 3 days @ 2-3 weeks
 Endoscopic maneuvers in
relieving obstructive jaundice
• Summary: • Biliary
sphincterotomy +
advance techniques

• Biliary dilatation

• Stent placement
• Two hand techniques
 Summary
• Differentiate obstructive from hemolytic
jaundice

• Obstructive : Intrinsic liver disease vs.

biliary obstruction

• UTZ – intrahepatic duct dilatation

 Summary
• High index of suspicion : acute cholangitis
– increased complications

• First option: minimally invasive therapy

• Always wise to call for help from a

colleague – patient benefit and for medico-
legal purposes