Dr. Srinivas Asst. professor Dept.

of Surgery

Definition :
Is a condition characterized by Yellow discoloration of the skin , sclera & mucous membrane as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause.

Type I : complete obstruction

Tumors : Ca. head of Pancreas Ligation of the CBD Cholangio carcinoma Parenchymal Liver diseases

Type II : Intermittent obstruction Choledocholithiasis Periampullary tumor Duodenal diverticula Choledochal Cyst Papillomas of the bile duct Intra biliary parasites Hemobilia

Strictures of the CBD

Congenital Traumatic Sclerosing cholangitis Post radiotherapy

Stenosed biliary enteric anastamosis Cystic fibrosis Chronic pancreatitis Stenosis of the Sphincter of Oddi

ERCP showing distal common bile duct stricture with proximal dilation

TYPE IV : Segmental Obstruction

Traumatic Hepatodocholithiasis Sclerosing cholangitis

Cholangio carcinoma

 Systemic and renal hemodynamics Hepatic function

Protein synthesis, Reticulo-endothelial function Hepatic metabolism

Alterations in

Hemostatic mechanism Gastrointestinal barrier Immune function Wound healing

Coagulation system

Prolonged bile duct obstruction leads to significant defects in clotting factors Before surgery these defects should be corrected by Fresh frozen plasma and Vitamin K Even if there is no measurable coagulation dysfunction Vitamin K should be given to all patients with obstructive jaundice

Obstruction
Bilirubin

Hepatitis

Cirrhosis

Alk phos

/ /

ALT/AST
/
/

gGT

PT (INR)

What are reliable signs & symptoms (more than 90% certainty) that a patient with obstructive jaundice need urgent intervention ? Fever, persistent (90%) Abdominal pain (70%) Jaundice (60%) Tea-colored urine/pale stools Altered mental status (10-20%) Hypotension (30%) RUQ tenderness

Goal of Treatment

Obstructive Jaundice
Relief of Obstruction Prevent Complication

Prevent Recurrence

The role of Radiology

Are the ducts dilated
What is the level of obstruction What is the cause

What is the best therapeutic approach

Jaundice AXR Ultrasound

Dilated ducts Surgical Gall stones Pancreatic cancer

Undilated ducts Medical Hepatitis

Non-invasive
AXR US CT HIDA Scintigram MRI/MRCP

Invasive
ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy

CBD stones (Choledocholithiasis) vs. tumor

Clinical features favoring CBD stones:

Age < 45 Biliary colic Fever Transient spike in AST or amylase Painless jaundice Weight loss Palpable gallbladder Bilirubin > 10

Clinical features favoring cancer:

Unconjugated
production exceeds ability of liver to conjugate Ex. Hemolytic anemia's, hemoglobinopathie s, in-born errors of metab., transfusion rxn.

Conjugated
Can

produce but not excrete Intra- or extra hepatic obstruction Metabolic defect

Defined as stones in the CBD Patho physiology : intermittent obstruction of CBD Often asymptomatic Symptoms are indistinguishable from other causes of Biliary pain Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos.

ERCP
Primary

diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5%

Indications

Presence of multiple stones (more than 5) Stones > 1 cm

Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones after sphincterotomy

Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty

Roux-en-Y Choledocho jejunostomy

Congenital anomalies of the biliary tract that manifest as cystic dilatation of the extra hepatic and intra hepatic bile ducts Females are most commonly affected

ETIOLOGY : Congenital weakness of the bile duct wall Congenital obstruction of the bile ducts Reo virus association is seen in 78% of patients 40% of anomalies are seen at the junction of pancreatic and common bile ducts

Proposed by Todani & colleagues TYPE I : accounts for 80 90 % of cases exhibit segmental or diffuse fusiform dilatation of the CBD.

TYPE II : consists of a true Choledochal diverticulum

TYPE III : consists of dilatation of the intra duodenal portion of the CBD.

TYPE IV : multiple intra hepatic & extra hepatic cysts

TYPE V or CAROLIS disease : consists of single or multiple dilatation of the intra hepatic ductal system

Clinical features :

Disease often appears during first months of life 80% of pts. have cholestatic jaundice & acholic stools Vomiting , irritability & failure to thrive may occur Spontaneous perforation of a Choledochal cysts may occur Progressive hepatic injury due to biliary obstruction

DIAGNOSIS :

BEST established by USG Abdomen In Older children PTC or ERCP may help define the anatomy of the cyst.

Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree Biliary drainage is accomplished by Choledocho jejunostomy with a Roux en Y anastamosis Long term follow up is necessary because of complications like cholangitis , lithiasis , anastomotic stricture

90% are extra-hepatic 60s and 70s Highest incidence in Japan, Israel, and Native Americans Increased 3 fold in the last 30yrs in the USA M/F=3/2

Ulcerative Colitis Sclerosing Cholangitis Choledochal Cysts

Thorotrast Exposure Typhoid Carrier Adult Polycystic Kidney Disease

Hepatolithiasis
Liver Flukes

Papillomatosis of Bile Ducts

Right or left hepatic duct = 10% Bifurcation = 20% Proximal CBD = 30% Distal CBD = 30%

Jaundice Wt loss, anorexia, abdominal pain, fever US then CT (CTA?) Followed by ERCP, PTC or MRCP

CEA and CA 19-9 can be elevated

Suspicious mass on CT. Quadruple phase CT with 0.5 cm cuts through the liver and portal hepatitis. Consider CTA reconstruction.

Treatment

If adenoncarcinoma: look for primary with a chest CT and upper/lower endoscopy. Colon, pancreas, and stomach are common primary sites.

Extent of surgical therapy is determined by the location, hepatic function, and underlying cirrhosis. Anatomic resections have lowest recurrence rates. However non anatomic resection increases potential surgical candidates and improves survival Hepatic devascularization prior to resection is preferred

Ablative therapy gives good local control.

Klatskin tumor

Adeno carcinoma accounts for 95%

Arises from 4 different tissues of origin Head of pancreas Distal Bile duct Ampullary of Vater Periampullary duodenum

Prognosis for each of these are different.

Five year survival for pancreas: 18% Five year for ampulla: 36% Five year for distal bile duct: 34% Five year for duodenum: 33% Determination of tissue origin is important for prognosis, extent of resection.

Determination of tissue origin from FNA, endoscopic biopsy. Also from thin section CT scan, ERCP Determination of k-Ras also helps (95% of pancreatic cancer).

Loco regional spread results from lymphatic invasion and direct tumor spread to adjacent soft tissue. Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group. Duodenal has intermediate spread. Pancreas metastasizes 88% to multiple sites.

Standard Whipple pancreaticoduodenectomy thought to provide adequate tumor clearance in the case of non-pancreatic ampullary tumor, because tumor spread is localized. Biopsy proven paraduodenal LN is thought by most to preclude curative resection

Low risk patients had 5 year local control and survival of 100% and 80% respectively. High risk patients had 5 year local control and survival of 50% and 38%, respectively.

Based on these findings, some have proposed a course of preoperative chemoradiation to improve local disease control in these high risk patients.

Five basic techniques are used to resect pancreatic cancers Standard pancreaticoduodenectomy Pylorus preserving pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson)

Autopsy series show that 85% of patients will experience recurrence in operative field. 70% have metastases to liver. So need to address local control (radiation) and distant disease (chemotherapy). Most commonly used is 5 FU and this only has a 15-28% response on its own, but its a radio sensitizer, so it improves response to chemo.