Management of Obstructive Jaundice

Dr. Al-Mumtin, Ahmed

Introduction

• Definition of Jaundice.

• Jaundice vs Hyperbilirubinaemia.

• Systemic Approach.

• Based on Billirubin metabolism classification.

• Pre-hepatic, hepatic and post-hepatic.

• Differentials.

• Conjugated, and Unconjugated Hyperbilirubinaemia.

Obstructive Jaundice

• Intrahepatic.

• Extrahepatic.

Principally

• Conjugated hyperbilirubinaemia due to :

• Impaired bile formation (hepatocytes)

• Impaired bile flow (bile ducts/ductules)

Intrahepatic Cholestasis✴Viral Hepatitis:

• Fibrosing cholestatic hepatitis.• Hep. B &C Hep.A, EBV, CMV

✴Alcoholic Hepatitis✴Drug toxicity

• Pure cholestasis- Anabolic & contraceptive steroids

• Cholestatic hepatitis- chlorpromazine, erythromycin, Amoxiclav

• Chronic cholestasis- chlorpromazine & prochloperazine

✴Primary Biliary cirrhosis✴Primary Sclerosing cholangitis✴Vanishing Bile duct Syndrome

• Chronic rejection of liver transplant

• Sarcoidosis• Drugs

✴ Non hepatobiliary Sepsis✴ Benign post-operative cholestasis✴ Para neoplastic Syndrome✴ Veno-occlusive disease✴ GVHD ✴ Inherited

• Progressive familial intrahepatic cholestasis

• Benign recurrent cholestasis ✴ Cholestasis of pregnancy ✴ Total Parenteral Nutrition ✴ Infiltrative diseases

• TB• Lymphoma• Amyloidosis

✴ Infections• Malaria• Leptospirosis

Extrahepatic

Benjamin Classification of Obstructive Jaundice

1983• Type 1: complete obstruction.

• Tumours.

• Ligation/clipping of CBD

• Cholangiocarcinoma

• type 2: Intermittant obstruction.

• Choledocholithiasis

• periampullary carcinoma

• duodenal diverticulae

• papillomas of bile duct

• choledochal cyst.

• Type 3: chronic incomplete obstruction.

• Strictures (congenital, iatrogenic, sclerosing, post-radiotherapy)

• stenosed biliary-enteric anastomosis

• chronic pancreatitis

• CF

• Stenosis of sphincter of oddi.

• Type 4: segmental Obstruction.

• Traumatic or iatrogenic

• sclerosing cholangitis

• cholangiocarcinoma

• Clinically-

• Pruritus,

• Fatigue,

• Xanthomas,

• Hepatic Osteodystrophy: back pain from osteoporosis,

• Pale stools, or steatorrhea

• Evidence of fat-soluble vitamin deficiency.

• Enlarged liver with a firm smooth non-tender edge.

• Histologically- • Bile plugs

(bilirubinostasis),

• Feathery degeneration of hepatocytes (cholate stasis),

• Small-bile-duct destruction,

• Peri cholangitis,

• Portal edema,

• Bile lakes and infarcts (typically with extrahepatic obstruction),

• Finally , biliary cirrhosis.

Choledocholithiasis

Choledocholithiasis

• Definition.

• 5 to 20 percent of patients have choledocholithiasis at the time of cholecystectomy.

• Primary vs secondary cholidocholithiasis.

Clinically• Biliary pain.

• Cholestatic Jaundice.

• Uncomplicated cholidocholithiasis.

• Asymptomatic

• RUQ pain.

• Nausea and vomiting.

Clinically

• Physical exam:

• RUQ, Epigastric tenderness.

• Jaundice.

• Courvoisier’s sign.

Laboratory Tests

• ALT, AST elevation, 64% sensitive.

• Increased Bilirubin; 69% sensitive, 88% specific.

• ALP is 57% sensitive, 86% specific.

• GGT elevation 84% sensitive.

Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.AU Abboud PA, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV

SO Gastrointest Endosc. 1996;44(4):450.

• Complicated cholidocholithiasis.

• Two major complications:

• Pancreatitis.

• Nausea, vomiting, high levels of amylase and lipase.

• Acute Cholangitis

• Charcot’s triad, Renauld’s pentad.

• Long standing complications

Imaging

• Transabdominal U/S.

• Sensitivity is 20-90%.

• Dilated CBD is suggestive of choledocholithiasis.

• A “Cutoff” 6 mm may miss cases.

A transverse ultrasound in the region of the porta hepatis shows multiple

shadowing stones (arrows) within a dilated distal

common bile duct.

Imaging• EUS and MRCP

• EUS vs ERCP

• MRCP vs ERCP

• MRCP vs EUS.

• EUS for stones < 6 mm and sludge not detected by MRCP.

Imaging

• EUS and MRCP

Imaging• Intraoperative cholangiogram:

• 59-100 % sensitive, 93-100%

• Operator dependant.

• Proponents and Opponents.

• Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. AU Gurusamy KS, Giljaca V, Takwoingi Y, Higgie D, Poropat G,Štimac D, Davidson BR SO Cochrane Database Syst Rev. 2015;2:CD010339.

Imaging

• Computed Tomography:

• 93% sensitive, 100% specific.

ERCP

• Diagnostic and therapeutic.

• High sensitivity and specificity.

• Invasive.

• Technical expertise is needed.

• Prone to complications

Sclerosing cholangitis Multiple CBD Stones Ascariasis in CBD

Bile duct obstruction from chronic pancreatitis

Biliary stricture, secondary to

Cholangiocarcinoma

PTC

• Percutaneous transhepatic cholangiography.

• Abnormal anatomy not accessible to ERCP

• Failed ERCP• Diagnostic and

therapeutic.

Risk stratification

• Barkun AN, Barkun JS, Fried GM, et al. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. Ann Surg 1994;220:32-9

Diagnosis

Tse F, Barkun JS, Barkun AN. The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystec- tomy. Gastrointest Endosc

2004;60:437-48.

Next In management• The mainstay; Remove the stones.

• Early identifications of complications.

• Approach begins by the times choledocholithiasis is identified.

• Before or After cholecystectomy, ERCP.

• Intraoperatively; intra-op ERCP or CBD exploration (laparoscopic or open), or post-op ERCP.

• Hospital stay was significantly shorter in the LERV group; median 4 (2-19) days versus 5.5 (3-22) days, P = 0.0004

• No difference in morbidity and success of CBD clearance between the 2 groups

• Post-ERCP amylase value was found significantly lower in the LERV group: median 65 (16-1159) versus 91 (30-1846), P = 0.02

• Interim analysis of the results suggests the superiority of the LERV technique in terms of hospital stay and post-ERCP hyperamylasemia.

CBD Exploration• Traditionally; Diagnosed by intraoperative

cholangiography and treated by open CBD exploration.

• Advances in pre-op imaging and development of less invasive measures improved earlier diagnosis, and treatment.

• Potantial existence of CBD stones should be considered for all patients with symptomatic cholelithiasis.

Indication of CBD exploration

• Should be performed in all patients with confirmed CBD stones who are surgical candidates and have failed, or are not candidates for endoscopic therapy.

• PTC, electrohydraulic lithotripsy, and laser lithotripsy maybe useful in a small number of selected patients who are not candidates for surgery or endoscopic therapy.

Surgical Approach

• If identified on IOC:

• Laparoscopic exploration.

• Open exploration.

• Post-op ERCP.

Open vs Endoscopic Exploration

• SEARCH METHODS: We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

• Conclusion:• Open bile duct surgery seems superior to ERCP in achieving common bile

duct stone clearance based on the evidence available from the early endoscopy era.

• No significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options.

• No significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups.

TI Surgical versus endoscopic treatment of bile duct stones. AU Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA SO Cochrane Database Syst Rev. 2013;9:CD003327

Laparoscopic Exploration

• Laparoscopic transcystic exploration

• The preferred technique for Laparoscopic exploration.

• Provided:• CBD diameter <6 mm• Stone location distal to the

cystic duct/CBD junction• Cystic duct diameter >4 mm• Fewer than 6 to 8 stones

within the CBD• Stones smaller than 10 mm

Laparoscopic Exploration• Laparoscopic choledochotomy:

• More difficult technically.

• Indication: Failed laparoscopic transcystic exploration or for patients who are not candidates for the transcystic approach.

• Indications:

• Failed laparoscopic transcystic exploration or preoperative endoscopic stone extraction

• Narrow/tortuous cystic duct• Dilated CBD (6 to 10 mm)• Large stones (>10 mm)• Multiple stones• Stone location proximal to the cystic

duct/CBD junction.

• Primary closure of the choledochotomy with interrupted fine monofilament absorbable suture is safer than closure around a T-tube.

• Decreased operating time,

• Decreased postoperative and biliary complications, shorter time until return to work

• Decreased hospital costs.

TI Primary closure versus T-tube drainage after laparoscopic common bile duct stone exploration. AU Gurusamy KS, Samraj K SO Cochrane Database Syst

Rev. 2007;

When to do the Cholecystectomy?

Take Home• Obstructive jaundice is a huge spectrum of

differentials.

• Cause directed management is the key.

• Choledocholithiasis is the major entity in the surgical jaundice.

• Endoscopy and gastrointestinal specialised personnel is the cornerstone in management.

• Narrow window of surgery in the management.

Controversy Still Exists

• Shall we still admit patients with Choledocholithiasis in Surgical wards under Surgical specialties?

References

• Harrison’s Principles of Internal Medicine, 19th edition.• Goldman-Cecil Medicine, 24th edition• UpToDate (R)• Schwartz principles of surgery• Everhart JE, Khare M, Hill M, Maurer KR. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117:632.

• Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004; 239:28.

• Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg 1992; 163:53.

• Petelin JB. Laparoscopic common bile duct exploration. Surg Endosc 2003; 17:1705.• Neuhaus H, Feussner H, Ungeheuer A, et al. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy 1992; 24:745.

• Houdart R, Perniceni T, Darne B, et al. Predicting common bile duct lithiasis: determination and prospective validation of a model predicting low risk. Am J Surg 1995; 170:38.

• O'Neill CJ, Gillies DM, Gani JS. Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically. ANZ J Surg 2008; 78:487.

References

• Prat F, Meduri B, Ducot B, et al. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999; 229:362.

• Fitzgerald JE, White MJ, Lobo DN. Courvoisier's gallbladder: law or sign? World J Surg 2009; 33:886.

• Abboud PA, Malet PF, Berlin JA, et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996; 44:450.11Yang MH, Chen TH, Wang SE, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2008; 22:1620.

• Sox HC, Blatt MA, Higgins, MC, et al. Medical decision making, Butterworths, Boston 1988. p.67.

• ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1.

• Iranmanesh P, Frossard JL, Mugnier-Konrad B, et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial. JAMA 2014; 312:137.

• Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012; 5:CD009779.

• Freeman ML. Pancreatic stents for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1354.

Thank you!