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

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

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.)

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

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

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

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

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

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

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

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

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

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

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

Laparoscopic cholangiography

Treatment

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

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

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

Roux-en-Y Hepaticojejunostomy

Roux-en-Y Choledochojejunostomy

Cholecystojejunostomy

Whipple’s Operation

Pylorus Preserving Pancreaticoduedenectomy

Open Exploration of CBD

T- tube

ERCP with Sphincterotomy

Transcystic CBD Exploration

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

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

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

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

Thank you for Attention!