1. Obstructive Jaundice Surgical and Non Surgical Treatment
Prepared by: Dr. Fuad BinGadeem
Under Supervision of :
Ass.Prof. Dr Mahmoud Makki

2. Definition
Jaundice came from the French word “jaune” which means yellow.
Yellowish discoloration of sclera, skin mucous membranes due to increased serum bilirubin level. Typically can be detected if serum bilirubin level above 3 mg/dl (51.3 μmol/L.
Obstructive jaundice is interruption to the drainage of bile in the biliary system

3. Classifications: Prehepatic Hepatic Posthepatic (Obstructive)
Intraluminal- Transmural- Extramural
Common- Infrequent- Rare
Complete (type 1)- Intermittent (Type 2)- Chronic incomplete (Type 3)- Segmental obstruction (Type 4)
Etiology (congenital, inflammatory, traumatic, neoplastic, parasitic etc.)

4. Obstructive Jaundice Alteration in: Systemic and renal hemodynamics
Hepatic function ( protein synthesis, reticuloendothelial function,hepatic metabolism)
Hemostatic mechanism
Gastointestinal barrier
Immune function
Wound healing

5. Managment Objectives:
To identify pts who need relief of obstruction To establish cause, to plan appropriate intervention, prevent complications, prevent recurrence.

6. S&S for urgent surgical interventions:
Abdominal pain (70%)
Jaundice (60%)
Tea colored urine/ pale stool
Altered mental status (10-20%)
Hypotension (30%)
Fever, persistent (90%)
RUQ tenderness

7. Imaging Studies Ultrasound CT scan, Spiral CT scan MRI, MRCP
Digital substraction angiography
Cholangiography ERCP, PTC
IDUS
PET

8. Ultrasonography 1st choice in O.J. Non invasive, cheep, bed side
Size of bile duct, level of obstruction, identify the cause in some cases, liver parenchyma,
Limitation: obese, Exessive bovel gases, retroduodenal and intraduodenal CBD

9. CT scan of Abdomen Very useful for assessment of malignancy
Intrahepatic biliary dilatations,
Level of obstruction
Spiral CT allows : relationship vascular and bile duct anatomy at the hilum

10. MRCP Non invasive Useful when ERCP contraindicated
No intravenous contrast
Purely diagnostic
C/I pt with pacemaker, cerebral aneurism clips, other metal implants

11. ERCP Diagnostic and therapeutic
Find out obstruction especially in the lower part of biliary passage
Invassive
Cannot reliabily distinguish betweenbenign and malignant features
Opportunity to take tissue sample
Endoprosthesis

12. ERCP Diagnostic and therapeutic
Find out obstruction especially in the lower part of biliary passage
Invassive
Cannot reliabily distinguish betweenbenign and malignant features
Opportunity to take tissue sample
Endoprosthesis

13. PTC Diagnostic and therapeutic
Best suited for leisions proximal to the bifurcation of hepatic duct
Invasive
Complications similar to ERCP

14. Endoscopic Ultrasound
Assessment bile duct and proximal pancreatic pathology
Recently IDUS in ERCP

15. Laparoscopic cholangiography

16. Treatment

17. Conservative 1 Fluid and electrolytes Urine output monitoring
Correction of coagulation defects
Prevention of infection
Prevention of hepatorenal syndrome
Nutrition

18. Conservative 2
Bile acid binding resins, Cholestyramine (4g) or cholestipol (5g) disolved in wter or juice × TDS
Individualized regime for replacement of vitamines A, D, E and K as needed.
Antihistamine for pruritus
Naloxone or nalmefene has improved pruritus
Discontinuation of medications that cause or exacerbate cholestasis

19. Surgical Options By Pass Surgeries Roux-en-y hepaticojejunostomy
Roux-en-y Choledochojejunostomy
Roux-en-y Cholecystojejunostomy
Choledochoduodenestomy
Whipple’s operation
Pylorus Preserving Pancreaticoduedenectomy
Choledochotomy + T-tube drainage
Transduodenal sphincterotomy and sphinteroplasty

20. Roux-en-Y Hepaticojejunostomy

21. Roux-en-Y Choledochojejunostomy

22. Cholecystojejunostomy

23. Whipple’s Operation

24. Pylorus Preserving Pancreaticoduedenectomy

25. Open Exploration of CBD

26. T- tube

27. ERCP with Sphincterotomy

28. Transcystic CBD Exploration

29. Indications for Open CBD Exploration
Multiple stones > 5
Stones > 1 cm
Multiple intrahepatic stones
Distal bile duct sticture
Failure of ERCP
Recurrence of CBDS after sphinterotomy

30. CBD Exploration- Surgical Options:
CBD exploration with T-tube decompression
Choledochoduodenostomy
Transduodenal sphincterotomy and sphinteroplasty
Roux-en-Y choledochojejunostomy

31. Criteria for Irresectability
Extra hepatic metastasis
Extrahepatic organ invasion
Peripheral hepatic metastasis remote from primary tumor
Major vascular involvement

32. Palliative Procedures
Interventional Endoscopy: Endoscopic stenting
Radiology: Chemo radiation, Intralumial brachitherapy
Photo Dynamic Therapy
High intensity intraductal ultrasound
Palliative surgery: Cholecystojejunostomy, choledochojejunostomy, Hepatojejunostomy +/- gasrtojejunostomy,

33. Thank you for Attention!