ETIOLOGY OF

OBSTRUCTIVE JAUNDICE

PRAYWIN
B BATCH – 4TH UNIT
 CAUSES OF OBSTRUCTIVE JAUNDICE:
EXTRA LUMINAL

INTRA LUMINAL
• Malignant • Congenital • Choledocholithiasis
• Parasitic disease

MURAL
• Benign

• Inflammatory

• Neoplastic

• Traumatic
PERI AMPULLARY CA:

 Tumour arising at / near ampulla.

INCLUDES :
 CA head of Pancreas
 Ampullary variety
 Distal CBD Cholangiocarcinoma
 Duodenal Adenocarcinoma
CLINICAL FEATURES:
 CARCINOMA OF PANCREAS
 Constitutes 2-3% of all cancer.
 It is the 6th leading cause of death in UK ; incidence is
10 cases per 1,00,000 population per year.
PATHOLOGY:

• >85% - Ductal Adenocarcinoma

• More commonly – Head of Pancreas
• Multiple genes are somatically mutated
• KRAS (M/C)
• CDKN2A
• SMAD4
• TP53
RISK FACTORS:
 AGE (65 – 75 years)
 MALE
 African American
 Diabetes mellitus
 Strong Family history
 CIGARETTE SMOKING
 PEUTZ-JEGHERS SYNDROME (STK 11 gene mutation) ->100%
 HEREDITARY PANCREATITIS (PRSS1 & SPINK1 gene mutation )
 Familial Atypical mole & Multiple melanoma syndrome(CDKN2A)
 Cystic Fibrosis(CFTR)
 Familial breast-ovarian cancer syndrome
 LYNCH SYNDROME (MLH1)
CLINICAL FEATURES:
 Painless Jaundice (m/c presentation) - pruritis, dark urine ,pale stool
with steatorrhoea.
 Weight loss
 On examination – palpable liver & GB
 Left supraclavicular LN
 Periumbilical LN
 Highly invasive – Retroperitoneal Infiltration
CARCINOMA OF GALL BLADDER:

 Incidence-American Indians ,North Indians

 Common- 6th -7th decade
 Female > Males
 90% GB Cancer –fundus/body of GB.
 Pattern of Growth – Infiltrating & Exophytic
RISK FACTORS:
 Gall stones(90%) –stones >3cm
 Porcelain Gall bladder(5%)
 Abnormal pancreaticobiliary duct Jn (APBDJ)
 Adenomatous GB polyp
CLINICAL FEATURES:
 Patient – asymptomatic
 Symptoms –advanced stage
 Jaundice – late feature
 palpable mass –late sign.
PORTA HEPATIS NODES:
 12th station -Hepatoduodenal ligament
 12a – along Hepatic artery
 12b – along Bile duct
 12p – along Portal vein
 Malignant involvement
CHRONIC PANCREATITIS:
 Progressive inflammatory disease
 Irreversible destruction of pancreatic tissue
 Inflammation – CBD Stricture
CAUSES – TIGAR-O
 T -Toxins
 I – Idiopathic
 G – Genetic / Hereditary (SPINK-1 & PRSS Gene)
 A – Autoimmune( IgG4 )
 R – Recurrent
 O - Obstruction
CLINICAL FEATURES:
 Pain
 Exocrine insufficiency
 Endocrine insufficiency
 Mild jaundice
 Weight loss
BILIARY ATRESIA
 Progressive Inflammatory obliteration –extrahepatic and intrahepatic
bile duct.
 1 Per 12,000 live birth.
 Males=females
CLASSIFICATION:
ANOMALIES:
 Cardiac lesion
 Polysplenia
 Situs inversus
 Absent IVC
 Preduodenal portal vein

CLINICAL FEATURES:
 Jaundice at birth
 Pruritis
 Pale stool , dark urine
 Liver failure
 LFT :raised ALP & bilirubin
CHOLEDOCHAL CYST:

 Cystic dilation of biliary system.

 Increased risk of Cholangiocarcinoma.
 Females > males
CLASSIFICATION:
 Todani /Modified Alonsa –Lej classification

TYPE 5 –Caroli’s disease

Type 3 - Choledochocele
CLINICAL FEATURES:
 Jaundice
 Abd Pain
 RUQ Mass on examination
 60% cases are diagnosed before 10 yrs age
PRIMARY SCLEROSING CHOLANGITIS:
 Progressive fibrous stricture of extra and intrahepatic bile duct.
 30 to 60 yrs
 Males > Females
 ETIOLOGY-Idiopathic likely Autoimmune
 Associated –Hypergammaglobulinemia
 Elevated-smooth muscle antibodies & antinuclear factor
 Associated with UC
 Abnormal raised LFT
CLINICAL FEATURES:
 Jaundice
 RUQ Discomfort
 Pruritis
 Fatigue
 Weight loss
BILE DUCT STRICTURE:
CAUSES :
 Cholecystectomy (M/C)
 Chronic pancreatitis
 Sclerosing cholangitis
 Mirizzi Syndrome
CHOLANGIOCARCINOMA:
 Involves bile duct
 Incidence – 1-1.5 Per 1,00,000 ; Peak-8th decade
 Males > Females
RISK FACTORS:
 PSC (20 folds )
 Hep C
 Asiatic cholangiohepatis
 Choledochal cyst
 Caroli’s disease
 APBDJ
 Chemical-Thorium dioxide,Vinyl chloride,Dioxin
CLINICAL FEATURES:
 Early symptoms-Abd pain ,early satiety ,anorexia, weight loss
 Jaundice , pruritis
 Palpable gallbladder
CLASSIFICATION- BISMUTH – CORLETTE:

Type 2- Klatskin tumour

PARASITIC DISEASES:
BILIARY ASCARIASIS:
 Complications-strictures , suppurative cholangitis , liver abscess ,
empyema of GB.
ASIATIC CHOLANGIOHEPATIS:
 Bile duct – fibrous thickening
 Complications-cholangiocarcinoma , biliary pain ,cholangitis, cirrhosis.
 SUMMARY :

• Malignant • Congenital • Choledocholithiasis

EXTRA LUMINAL

INTRA LUMINAL
-carcinoma gall -biliary atresia • Parasitic disease
bladder
-Peri Ampullary CA -
-porta hepatis choledochal cyst
nodes - • Inflammatory

MURAL
carcinoma pancreas -primary sclerosing
• Benign cholangitis
-chronic pancreatitis • Neoplastic
-cholangiocarcinoma
• Traumatic
-post operative biliary
stricture