SHER-E-KASHMIR INSTITUTE OF MEDICAL SCIENCES

DEPARTMENT OF GENERAL SURGERY

INVESTIGATIONS AND MANAGEMENT OF OBSTRUCTIVE JAUNDICE SECONDARY TO STONE

DISEASE

MODERATOR: PROF FAZL Q PARRYPRESENTER: IFRAH AHMAD QAZI

DEFINITION Jaundice – derivative of ‘ Jaune’ meaning yellow

Yellowish discolouration of skin ,sclera, mucous membrane

Clinically detected at bilirubin levels > 3.5 g/dl

BILIRUBIN METABOLISM

Heme

Biliverdin

Unconjugated bilirubin

Conjugated bilirubin

Urobilinogen

Stercobilin

Globin

Heme oxygenase

Biliverdin reductase

UDPGT

Intestinal bacteria

LIVER

INTESTINE

KIDNEYUrinary Urobilinogen

CLASSIFICATION

Prehepatic jaundice

Hepatic jaundice

Post hepatic jaundice/ Obstructive jaundice/ Surgical jaundice

OBSTRUCTIVE JAUNDICE Obstructive jaundice is interruption to the drainage of bile

in the biliary system

Symptoms

Yellowish discolouration Clay coloured stools Tea coloured urine Pain abdomen Fever Pruritis

Signs

Scratch marks Hepatomegaly Distended palpable GB Abdominal distension Dilated abdominal veins Edema

CAUSES OF OBSTRUCTIVE JAUNDICE INTRALUMINAL CAUSES

CBD stones ( most common)

Parasites ( Ascariasis)

TRANSMURAL CAUSES

Cholangiocarcinoma

Choledochal Cyst

Strictures

EXTRALUMINAL CAUSES

Ca head of pancreas

Periampullary tumour

Lymph node

Mirrizi Syndrome

Accidental ligation of CBD

EFFECTS OF OBSTRUCTIVE JAUNDICE

Alteration in:

Systemic and renal hemodynamics

Hepatic function ( protein synthesis, reticuloendothelial function,hepatic metabolism)

Hemostatic mechanism

Immune function

Wound healing

MANAGEMENTObjectives

To establish cause.

To plan appropriate intervention.

To prevent complications.

To prevent recurrence.

INVESTIGATIONS

Biochemical test

Imaging Studies

BIOCHEMICAL TESTSThese tests can be used to:

Detect the presence of liver disease

Distinguish between various types of liver disorders

Gauge the extent of liver damage

Follow the response to the treatment

Shortcomings :

Normal in a patient with serious liver disease

Abnormal in a patient with no liver disease

Rarely suggest a diagnosis

Measure only a limited no. of liver functions.

Thus no single test enables the clinician to accurately assess the liver’s total functional capacity

Battery of tests used.

The tests commonly employed include :

Bilirubin

Aminotransferases

Alkaline phosphatase

GGT

Coagulogram

Liver Function Test

Based on excretory and detoxification function

Serum Enzymes

Based on biosynthetic function

Serum Bilirubin Urine Bilirubin Globulin Coagulation

factorsAlbumin

Normal < 1 mg/dlUnconjugated

Conjugated (30%) *

*markedly ^ed in Obstructive

juandice

Half life 15-20 days

Serum levels not specific

for liver function

derangements

• Mostly synthesised

in liver• Vit K

dependent factors II, VII,

IX, X• PT/INR/aPTT

Serum Enzymes

ASPARTATE AMINOTRANSFERAS

EALANINE

AMINOTRASFERASEALKALINE

PHOSPATSASE5’

NUCEOTIDASE GGT

• Diagnosis of hepatocellular

injury• Mildly elevated

in obstructive jaundice

• Present in liver, bile duct, kidney,

bone and placenta• Normal level 20-

140 IU/L• > 3 fold ^ in

biliary obstruction• Not specific for

liver diseas

• ^ed in biliary obstruction

• Not ^ed in infancy, pregnancy, osteoblastic disease of bone

15-85 IU/L (men)

5-55 IU/L (women)

Increased in diseases of liver, biliary

tract and pancreas

BILIARY IMAGING Role in identification and detailed assessment of major bile duct

obstruction.

The questions to be addressed :

Is bile duct obstruction present?

What is the anatomical level of obstruction?

What is the cause of the obstruction?

IMAGING STUDIES

Transabdominal Ultrasonography Computed Tomography ERCP MRI / MRCP Endoscopic Ultrasonography PTC Intraoperative Cholangiography

TRANSABDOMINAL ULTRASONOGRAPHY

Initial investigation

Non-invasive, Painless, No radiation Exposure and provides real time images.

Operator dependent , Visualisation may be difficult in Obese patients, ascites, or distended bowel

71-80% accuracy for identifying cause of obstruction

The extrahepatic bile ducts are well visualized by ultrasound, except for the infraduodenal portion.

Ultrasonography visualizes CBD

stones in only about 50% of cases

Dilatation of the CBD to a diameter greater than 6 mm is seen in about 75% of cases

COMPUTED TOMOGRAPHY Integral part in diagnosis of obstructive jaundice.

Sensitivity of CT in detection of CBD stones is about 22 %

Investigation of choice

suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of the pancreas

CT CHOLANGIOGRAPHY

Involves IV contrast agents excreted preferentially by the liver

Excretion and subsequent passage of a contrast agent, provides a functional dimension not obtained with conventional magnetic resonance cholangiography.

Demonstration of bile leaks, biliary communication with cysts and segmental obstruction

CT-IVC shows a small stone within the opacified distal common bile duct

CECT carcinoma of the pancreatic head.

MRI/MRCP

Non invasive

Investigation of choice for detecting biliary pathology.

No intravenous contrast

Purely diagnostic

C/I pt with pacemaker, cerebral aneurism clips, other metal implants

CONTD..

MRCP uses T2-weighted imaging with parameters designed to afford best view of bile duct

Bile has a long T2 relaxation time and hence a high signal intensity, so that bile ducts are easily distinguished from vessels on heavily T2-weighted images

Fast, effective, non-invasive way to image biliary tract

Demonstrates ductal dilatation and strictures with 95% sensitivity

Sensitivity for stone visualization - 75-95%, better than CT or US

CHOLEDOCHOLITHIASIS

MRC (MR cholangiography) Bile: Very bright signal Ductal stones: Decreased signal

intensity foci

Low-signal filling defects within increased signal intensity bile

MRCP in a case of PSC showing a long stricture( arrow)

MRCP showing dilated hepatic ducts with tumour causinga blockage at the confluence

ERCP Provides dynamic information during contrast

medium introduction and drainage CBD Stones

Sensitivity 90-95 % Specificity 92-98 %

Offers the option of intervention

Stone extraction Sphincterotomy Placement of biliary stent

Advantages :

Diagnostic and therapeutic Find out obstruction especially in the lower part of biliary

passage Opportunity to take tissue sample

Disadvantages :

Invasive

Bleeding, pancreatitis, cholangitis, perforation( 10 %)

ERCP showing multiplecalculi (filling defects) withincystic and common bile ducts

ERCP following endoscopicpapillotomy shows a wire basket being used to fragment, snare and extract biliary calculi

ENDOSCOPIC ULTRASOUND Detailed imaging of organs in close

proximity to the digestive tract.

Sensitivity (94%) and specificity (95%) --diagnosis of choledocholithiasis

Tissue sampling by EUS-guided fine needle aspiration (EUS-FNA)

EUS and EUS-FNA are sensitive (overall 73 %) -cholangiocarcinoma and very specific (97%) in predicting unresectability

High detection rates (96%-100%) and staging accuracy of EUS with respect to duodenal or CBD wall involvement, invasion of the pancreas and portal vein, and spread to regional lymph nodes.

More accurate than CT and MRI in tumor staging of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%).

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY Preferred technique

proximal obstruction ERCP not possible

Option of tissue biopsy Intervention with drain or stent

Largely replaced by non-invasive techniques like MRCP

Role in post Bilio-enteric anastamotic strictures

INTRAOPERATIVE CHOLANGIOGRAPHY Mirizzi described the procedure in 1937 Most commonly used during elective cholecystectomy

assess retained stones and to provide clarification of the biliary anatomy.

Diagnosis : Choledocholithiasis Biliary Injury (earlier recognition and correction of biliary

injury )

TREATMENT

CONSERVATIVE Fluid and electrolytes

Urine output monitoring

Correction of coagulation defects

Prevention of infection

Nutrition ( enteral nutrition preferred)

FLUID AND ELECTROLYTE THERAPY AND URINE OUTPUT MONITORING Dehydration occurs in obstructive jaundice:

Recurrent vomitting Decreased intake Fever

Prevention of dehydration

Liberal fluid therapy with correction of electrolytes

CORRECTION OF COAGULATION DEFECTS

Coagulopathy due to: Decreased absoption of Vit K Liver injury

Assessment by Prothrombin time / INR.

Inj Vit K 10 mg i/v OD for three days ( in elective procedures)

Trasfuse FFPs ( in emergency situation)

PREVENTION OF INFECTION

Cholangitis and sepsis :

Gram negative org ( E.coli, K. pneumonae, P. mirabilis,etc) Anaerobes

Cephalosporins ( second and third generations) Floroquinolones Metronidazole

SURGICAL MANAGEMENT

Definitive treatment of the obstructive jaundice.

Varies with the cause of obstruction and condition of patient.

Performed in physically fit and optimised patients.

CHOLEDOCHOLITHIASIS

Pre-op diagnosis of CBD stones

Lap(-)ERCP(-)

Lap(-)ERCP(+)

Lap(+)ERCP(+)

Lap(+)ERCP(-)

OC with CBDE

Transfer patient ERCP

LC

LC with CBDE

LC

ERCP

Intra-op diagnosis

of CBD stones

Lap(-)ERCP(-)

Lap(-)ERCP(+)

Lap(+)ERCP(+)

Lap(+)ERCP(-)

LC only

ERCP

LC with CBDE

ERCP ERCP with sphicterotomy f/b extraction

Dormia basket ( stone > 1cm) Balloon catheter

Success rate 80-90 %

Papilla and sphincter divided with a sphincterotome

ERCP with balloon sphincteroplasty ( 6-8 mm dia balloon)

High failure rates (22 %) and pancreatitis ( 3 fold of sphincteroromy)

In case of large stones > 1.5cm , impacted stones

Mechanical lithotripsy

Electrohydraulic lithotripsy

Laser lithotripsy

Extracorporeal shock wave lithotripsy

Large balloon dilatation

Mechanical Lithotripsy:

Most commonly used method of fragmentatation

Basket used to trap stone f/by crushing against the metal sheath

Success rate 80 to 90 %

Most important factors resulting in failure : Stone impaction Stone composition : hard calcified stones resist fragmentation

Intraductal Shock Wave Lithotripsy:

Done with the help of a flexible lithotripsy probe passed through the working channel of cholangioscope

Two types : Electrohydraulic lithotripsy Laser Lithotripsy

Impulses are fired on stone surface under cholangioscopic guidance

Success rate 80-95 %

Extracorporeal Shock Wave Lithotripsy:

Used in Patients with major medical comorbidities Technical difficulties in standard endoscopic stone extraction

Multiple session are needed

Stone targeting by either fluoroscopy or ultrasound

Complete clearance – 90%

Most patients require fragment extraction by endoscopy

Large balloon dilatation:

When other standard methods unsuccessful

10-20 mm diameter balloon used f/by basket/balloon extraction

Complications 7 – 33 % :

Cholangitis, pancreatitis, bleeding

ERCP WITH SPHINCTEROTOMY

LAPAROSCOPIC CBD EXPLORATION Transcystic approach Trasductal approach

Transcystic CBD Exploration

INDICATIONS OF TRANSDUCTAL APPROACH

Stones > 6 mm

Intrahepatic stones

Cystic duct diameter < 4mm

Cystic duct entrance either posterior or distal

MANAGEMENT OF CHOLEDOCHOTOMY

Primary closure

T-tube decompression

Choledochoduodenostomy

Transduodenal sphincterotomy

Roux-en-Y choledochojejunostomy

CBD EXPLORATION WITH T TUBE INSERTION

Indications :

Decompression of CBD in incomplete clearence Residual stones Postoperative biliary study

T tube cholangiogram is done usually after 7 to 10 days

Removed usually after 10 days if no residual stones seen

In case of residual stones , tube kept for 6 weeks

Burhenne technique can be stones to retrieve stones under flouroscopic guidance

COMPLICATIONS OF T- TUBE

Dislodgement

Bacteraemia

Fracture of tube

Bile leak and peritonitis at removal

TRANS DUODENAL SPHINCTEROTOMY

Indications :

Impacted stone in ampulla

Papillary stenosis

Multiple stones with nondilated duct

Ampulla localised by passing Fogarty catheter through CBD

Longitudinal duodenotomy made

Entrance to pancreatic duct identified

Absorbable sutures placed on each side of ampulla

Sphincterotomy started at 11 o’clock

Opening made wide enough for biliary dilator of size of CBD

Last ampullary suture placed at apex

Duodenotomy closed in transverse direction

CHOLEDOCHODUODENOSTOMY

Indications:

Recurrent stones requiring repeated interventions Impacted stones Ampullary stenosis Funnel syndrome

Side to side anastomosis most commonly used.

COMPLICATIONS OF CHOLEDOCHODUODENOSTOMY

Cholangitis

Sump syndrome

Wound infection

Anastomotic leaks

Intraabdominal abscess

CHOLEDOCHOJEJUNOSTOMY

Two methods : Loop choledochojejunostomy Roux en Y choledochojejunostomy

End – side anastomosis made Intestinal content reflux prevented by

Side to side jejunojenostomy in loop CDJ Using 60 cm afferent Roux en Y brought retrocolic in Roux en Y

CDJ

Anastomosis decompressed by T tube or transhepatic stents

THANK YOU FOR

ATTENTION..