Jaundice

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Jaundice

• Dr. Ahmed Kensarah

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Introduction

• Surgical obstructive jaundice (jaundice due to
  intra- or extra-hepatic organic obstruction to
  biliary outflow) can present problems in
  diagnosis and management. This is so because,
  there is a hard core of jaundiced patients in
  whom it is very difficult to distinguish between
  organic obstruction and medical causes of
  jaundice, particularly intrahepatic cholestasis.
  Even serial liver function tests are often
  inconclusive in differentiating However, it is
  mandatory to determine pre-operatively the
  existence, the nature and the site of obstruction
  in the surgical cases because an ill chosen
  therapeutic approach can be dangerous.

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Material and Methods

• Twenty-six consecutive cases of obstructive
  jaundice were diagnosed and treated in one
  full-time surgical unit over a period of 3 years
  from 1976 to 1979. Of these, 14 cases had
  malignancy and 12 cases belonged to the
  non-malignant group. A11 the patients were above
  40 years of age and the male female ratio was
  1.91.The patients were subjected to a detailed
  clinical examination particularly with reference
  to the enlargement of liver, spleen and gall
  bladder. They also had urine examination,
  hemogram and, serum chemistry including liver
  function tests.

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Material and Methods (cont.)

• Australia antigen examination was done in 15
  cases. Citrate clearance test' was done in 12
  patients. All the patients had plain X-ray of
  abdomen and upper GI Barium series. Oral
  cholecystography was done in 7 patients whose
  serum bilirubin was less than 3 mg,-.
  Percutaneous transhepatic cholangiography (PTC)
  was done in 9 patients. Liver scan using 99mTc
  phytate was done in 13 cases. Selective hepatic
  angiography was done pre-operatively in 2
  patients.

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Material and Methods (cont.)

• The patients were prepared for surgery with
  injectable Vitamin K to correct the prothrombin
  time they were given fresh blood transfusions if
  the prothrombin time did not improve. In order to
  avert possible post-operative renal failure, all
  patients were treated with correction of
  dehydration, intravenous Mannitol and intravenous
  Frusemide pre-operatively.

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Material and Methods (cont.)

• PTCD-Percutaneous Transhepatic Cholangiography
  with drainage.
• The patients were treated with various surgical
  procedures as shown in Table 1. Some of the
  patients had more than one surgical procedures
  mentioned in the table. Curative surgery was
  attempted in benign conditions and in early
  malignancies. In the advanced malignancies
  surgery was mainly palliative.Whenever bile
  could be obtained either during P.T.C. or during
  laparotomy (20 cases), it was subjected to
  bacteriological examination.

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Material and Methods (cont.)

• Intra-operative cholangiography was done in 3
  cases and it showed the sites of obstruction.
  Tube cholangiography was done post-operatively in
  11 cases either through the cholecystostomy tube
  or through a splint kept in the biliary tree.

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Results (cont.)

• The patient with hepatoma of the liver and one
  patient with carcinoma of the gall bladder
  infiltrating into the liver had hard enlarged
  liver. There were 6 cases who illustrated an
  exception to Courvoisiers law.Of these, 4 were
  patients with cholelithiasis and a palpable gall
  bladder of these, 2 had an associated malignancy
  of the biliary tract. The remaining 2 exceptions
  were patients with malignant obstruction of the
  lower end of the common bile duct (CBD), in whom
  the gall bladder was not palpable in one of
  them, this was due to an associated carcinoma of
  the right hepatic duct involving the cystic duct.

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Results (cont.)

• Nineteen out of the 26 patients had serum albumin
  level of less than 3 gms per cent. The average
  total serum bilirubin was 10.4 mg, the highest
  being 35.5 mg and the lowest being 1.6 mg. The
  SGPT' was elevated (more than 40 Reitman and
  Frankel units/ml) in 11 patients it was more
  than 1G0 Reitman and Frankel Units /ml in 10
  patients. The alkaline phosphatase was elevated
  (more than 30 K.A. units) in 19 patients it was
  normal in 7 patients. The prothrombin time was
  elevated (more than 16, seconds) in all patients.
  Citrate clearance was abnormal in all the
  patients.

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Results (cont.)

• Plain X-ray abdomen showed enlarged liver shadows
  in 8 patients and radio opaque gall stones in 5
  patients. Barium meal examination of the G.I.
  tract showed chronic gastritis with duodenal
  ulcer in 1 case of gall stones, indentation of
  duodenum by enlarged common bile duct in 3
  patients, inverted three' (8) appearance in
  periampullary malignancy (1 case), widening of
  duodenal C in 2 cases of carcinoma of head of
  pancreas and displacement of the stomach by
  enlarged liver in 1 case of hepatoma of the
  liver.Oral cholecystography showed filling
  defects suggestive of stones in 2 patients and
  failure of visualisation of the gall bladder in 4
  patients it was normal in 1 patient whose serum
  bilirubin was 1.6 mg.

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Results (cont.)

• PTC showed obstruction at the lower end of the
  CBD in 5 cases, 2 due to stones, 2 due to
  malignancy and one due to inflammatory stricture.
  PTC also helped to diagnose choledochal cyst in 2
  cases (which showed dilated CBD) and it showed
  dilated intrahepatic ducts filled with stones in
  2 cases.

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Results (cont.)

• Selective hepatic angiography showed an avascular
  area in the patient with intrahepatic choledochal
  cyst and in the patient with hepatoma, it
  outlined the vascular tumor.Hepatic scanning
  showed mild to moderate hepatomegaly in 12 cases.
  Two patients showed cold areas in the liver and
  another 2 in the region of the gall bladder
  invaginating into the liver substance suggesting
  a gall bladder mass. Sparse and scattered uptake
  by the liver suggestive of mild to moderate
  affection of liver function was seen in 9
  cases.Bacteriological examination of bile showed
  Staphylococcus (coagulase positive) in 3 cases,
  E. coli in 4, Klebsiella in 3, Proteus in 3,
  Pseudomonas in 1 and Salmonella typhi in 1. In 2
  cases, more than one organism was present. The
  bile was sterile in 6 patients.

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Results (cont.)

• The surgical procedures performed are outlined in
  Table 1. Percutaneous Transhepatic
  Cholangiography with drainage (PTCD) using a
  polyethylene PTCD set (commercially available)
  was done in 3 patients. This served as a
  palliative procedure to drain the bile. However,
  the maintainance of this tube was
  difficult.Cholecystostomy was done in 5
  patients. This was done under local anaesthesia
  whenever the patient's general condition and
  clotting was poor. In 2 patients it was done as
  the only (palliative) procedure.

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Results (cont.)

• The commonest procedure performed (15 cases) was
  a cholecystectomy, with exploration of the common
  bile duct together with removal of stones or
  dilatation of stricture. This was followed by
  sphincteroplasty and internal splintage with a
  sterile plastic tube. The duodenum had to be
  opened in most cases. The splintage tube would
  then be brought out through a high choledochotomy
  or sometimes through the liver to come out
  externally from the anterior abdominal wall.

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Results (cont.)

• The other end of the tube would lie in the
  duodenum across the obstruction and the
  sphincter, with a few side holes in that part
  which lay in the CBD. The lengths of the tubes
  and the sites of the holes were carefully
  measured as it was possible to change the tube if
  necessary in the postoperative period when the
  tract was established. This procedure was done in
  all cases of cholelithiasis with obstruction to
  CBD and also in many cases of malignant and
  inflammatory strictures of CBD.The
  histopathological confirmation of the cause of
  obstructive jaundice could be established in most
  cases on exploration. Eleven patients developed
  complications during the post-operative period
  biliary peritonitis in 2, wound infection in 6,
  G.I. bleeding in 2 and right subphrenic abscess
  in one.

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Discussion

• Obstructive lesions of the biliary system are
  difficult problems for the surgeon. Majority of
  the patients are old and poor surgical
  risks.Clinical symptoms are fairly typical
  although jaundice itself makes the patient seek
  surgical aid. Charcot's triad of intermittent
  fever, pain and jaundice is characteristic of
  ascending cholangitis and indicates biliary
  obstruction. Hepatomegaly is present in most
  cases of obstructive jaundice and is due to
  congestion and stretching out of intrahepatic
  biliary spaces. Long-standing biliary obstruction
  can also cause portal hypertension. This was seen
  in 2 of our patients who had palpable spleen. A
  palpable gall bladder usually indicates
  obstruction of the distal CBD, due to other
  causes than stone (Courvoisier's law). However,
  exceptions to Courvoisier's law are common,as
  seen in 6 patients in our series.

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Discussion (cont.)

• It is necessary to follow a standard system of
  investigations in order to arrive at a correct
  diagnosis of obstructive jaundice and also to
  assess fitness for surgery. An increased WBC
  count and ESR indicates severity of biliary
  sepsis. Bile salts and pigments in urine and
  absent urobilinogen also favour the diagnosis of
  obstructive jaundice. Serum albumin and
  prothrombin time are good indicators of liver
  function derangement. Serum bilirubin levels
  indicate severity of jaundice and high direct
  bilirubin rules out hemolytic jaundice. Mild
  elevation of SGPT levels are also seen in
  obstructive jaundice consistent with liver
  dysfunction. An elevated alkaline phosphatase
  (above 30 K.A. units) is ,always present in
  obstructive jaundice.

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Discussion (cont.)

• Plain X-ray of the abdomen may fail to show gall
  stones (4 out of 9 were radiolucent in our
  series). Barium series of the upper G.I. tract
  are very informative especially in peri-ampullary
  carcinoma (E appearance) and carcinoma of head of
  pancreas (widening of duodenal C). Oral
  cholecystography and intravenous cholangiography
  are of limited usefulness in obstructive
  jaundice.Hypotonic duodenography and endoscopic
  retrograde cholangiopancreaticography (ERCP) can
  also be of immense diagnostic value. These were
  not done in our series.

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Discussion (cont.)

• PTC is an extremely useful investigation in the
  diagnosis of the nature and site of block in
  obstructive jaundice. An acceptably low
  complication rate has been reported in several
  recent series and with the new Chiba needle
  technique, the procedure has been widely accepted
  in the past few years. PTC is usually done just
  prior to exploration of the patient as several
  complications following PTC have been described.
  In our series only one patient developed biliary
  peritonitis following PTC. Other complications
  were not seen. Per-operative cholangiograms (3
  cases in our series) are reliable in 951 of cases
  and may be used on the table if the site of
  obstruction is not clear, to confirm that all
  stones have been removed and pre-operative PTC
  was not done.

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Discussion (cont.)

• Hepatic angiograms are useful in vascular tumors
  and space occupying lesions in the liver.99mTc
  Phytate liver scan is a useful non-invasive
  procedure which can outline cold areas in the
  liver and can give an idea of liver function.
  Rose Bengal liver scan (not done in our series)
  can indicate the site of obstruction.

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Discussion (cont.)

• Ultrasound scanning of the abdomen (not done in
  our series) is another useful non-invasive
  investigation in the diagnosis of obstructive
  jaundice. This method utilises physical and
  mechanical means of producing an image by
  reflected ultrasonic pulses created by
  stimulation of a piezoelectric transducer. The
  images are recorded' as dots of varying
  brightness (B mode studies or Beta scanning).
  Gall bladder dilatation in obstructive jaundice
  is easily demonstrable by B mode scanning and
  gall stones can also be recognised by the
  presence of strong internal echoes within the
  normally echo-free bile.

22
Discussion (cont.)

• Bacteriological examination of bile should be
  done in every case as sepsis is common in an
  obstructed biliary tree. Large number of
  pathogenic bacteria can be isolated from the bile
  in 50 of the cases requiring surgery on the
  biliary tract. Patients with biliary sepsis may
  develop clinical septicaemia before or after
  operation. This was seen in 5 patients in our
  series.

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Discussion (cont.)

• The commonest surgical procedure practised in our
  series and the procedure we advocate is a
  cholecystectomy with common bile duct
  exploration, dilatation, sphincteroplasty and
  internal splintage, with a tube by Rodney Smith's
  technique.We prefer to leave the splint in
  position for a minimum period of one year.
  Advantages of biliary splintage include obtaining
  bile for repeated cultures, regular washes of the
  biliary tree, cholangiograms, prevention of
  recurrence of obstruction, dilatation and for
  non3perative treatment of residual/recurrent
  stones. The longer the tube remains in situ, the
  better are the results.

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Discussion (cont.)

• Cholecystostomy is claimed to be a useful
  procedure for biliary drainage in moribund
  patients with severely impaired liver function.
  However, in our experience it has proved to be an
  unsuitable procedure for long term decompression
  as the oedematous cystic duct prevents adequate
  drainage.

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Discussion (cont.)

• Choledochal cysts can be treated in several
  ways.We have treated one case of fusiform
  Choledochal cyst of CBD successfully by
  choledochoduodenostomy with a splint across the
  anastomosis which was removed after one year.
  Biliary enteric anastomosis (gall bladder or CBD
  with duodenum or jejunum) are frequently employed
  for bypassing lower CBD obstruction.However, an
  internal anastomosis has the disadvantage of
  getting blocked, leaking into the peritoneal
  cavity and a high incidence of ascending
  cholangitis.

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Discussion (cont.)

• Most of the malignancies presented late when
  inoperable in our series, hence radical surgery
  was not done (except in 2 cases). Major resection
  of the nature of Whipples' operation
  (pancreatico-duodenectomy has been described
  with good results in early cases. We had one case
  each of Whipple's operation and hemihepatectomy.
  Both succumbed in the postoperative period.

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Discussion (cont.)

• The high incidence of complications, increased
  mortality and morbidity could be explained by
  advanced age, poor cardiac/ pulmonary/hepatic,/ren
  al function and associated biliary sepsis.
  Tolerance to major surgical procedures is poor.
  Surgery of obstructive jaundice therefore
  continues to be a challenge.

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34
Introduction

• Condition where blockage of the flow of bile from
  the liver causes overspill of bile products into
  the blood and incomplete bile excretion from the
  body. More detailed information about the
  symptoms, causes, and treatments of Obstructive
  Jaundice is available below.

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What are the causes of Jaundice?

• Some of the possible causes of Obstructive
  Jaundice include
• Gallstones - most common cause
• Pancreatic cancer
• Hepatitis
• Drugs/medications
• Interstitial liver diseases

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What are the symptoms of Obstructive Jaundice ?

• Some of the symptoms of Obstructive Jaundice
  include
• Dark coloured urine
• Pale stools
• Yellow colouration of skin and eyes
• Itchy skin
• Fever

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What treatments are available for Obstructive
Jaundice ?

• Surgical removal of obstruction - generally
  keyhole (laparascopic) surgery or ERCP
• Cease drugs suspected to be causing liver
  inflammation - e.g. steroids, sulfonylureas
• Antibiotics
• Liver transplantation