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Endoscopic management of obstructive jaundice
ENDOSCOPIC MANAGEMENT OF
The treatment of all patients with obstructive jaundice remained a domain
of surgeons until the early 1970's so much so that it had been designated
as "surgical jaundice". The cause of jaundice remained obscure till these
patients were operated, as the pre-operative work up of these patients
did not provide an accurate diagnosis. Moreover, patients not fit for
surgery were left to conservative management despite the fact that there
may have been an obstruction to the bile duct. The pancreatic and biliary
trees were considered unapproachable without surgery and per-operative
cholangiogram with its limitations used to be the only method to delineate
the pancreas. ERCP (Endoscopic Retrograde Pancreatico Cholangiography) has
not only made tremendous advancement in the diagnosis of patients with
obstructive jaundice but also to carry out various therapeutic procedures
to relieve the obstruction in the biliary system without surgical
The technique of ERCP was first introduced in 1970. It allows access to
the second part of duodenum, papilla of vater, bile duct and pancreatic
duct. It is a sophisticated technique that can be mastered by the trained
endoscopist. It is performed to define biliary obstruction and its nature
i.e. stone or stricture ‑ the two most common causes of obstructive
jaundice. The selective cannulation of the pancreatic biliary ductal
system can be done in 95% cases by an expert endoscopist trained in the
technique to perform an ERCP. The cannulation of the papilla requires the
use of a special side viewing duodenoscope and a Teflon 5F diameter
cannula. ERCP can be performed as an outpatient procedure provided the
patient's general condition is fit. Once the ampulla is cannulated the
contrast material is injected under fluoroscopy and serial radiographs
are taken as the dye fills the pancreatic biliary ductal system. ERCP is
far superior to ultrasound and C.T. scan for detection of stone or
stricture in the bile duct.
Papillotome cutting the sphincter
Endoscopic sphincterotomy (ES) has become the corner stone in the
management of obstructive biliary tract disease. It was first introduced
in Japan and Germany in 1977. It Is an endoscopic therapeutic modality
that incises the papilla and sphincter muscles surrounding the distal
common bile duct by electrodiathermy using a papillotome which Is used to
make a 0.5 to 1.5 cm incision. The sphincterotomes consist of a long
Teflon catheter and a cautery wire. The wire traverses the entire Teflon
tube and is exposed for a variable length of 2 to 3 cm near the tip of
sphincterotome. By applying traction on the proximal end of the wire, the
distal end of the catheter bends to assume a semilunar shape. When current
is applied, incision of the tissue in contact with wire takes place.
(a) Retained common bile duct stone following cholecystectomy with or
(b) Stone with gall bladder In situ in
high surgical risk patients
(c) Acute suppurative cholangitis with
(d) Gall stone pancreatitis
(e) Placement of nasobiliary catheter, biliary stents, dilatation of
biliary strictures and chemical dissolution of stones etc.
Stone extraction by dormia basket after sphincterotomy
(a) Significant coagulation defect
(b) Long stricture of distal common bile duct
ES FOR RETAINED CBD STONES
Despite intra-operative cholangiogaphy common bile duct stones are
overlooked in 1-14% of cases. More than 50% of these cases develop
complications so the removal is usually indicated. The surgical
re‑exploration of bile duct carries a higher morbidity and mortality than
that associated with endoscopic sphincterotomy.
ES WITH GALL BLADDER IN SITU
Wider application of endoscopic sphincterotomy has led to an increasing
proportion of patients with an intact gall bladder being treated for bile
duct stones. ES alone, for C8D stones in the elderly or other poor
surgical risk patients who have an intact gall bladder, is well accepted
though a similar management for younger, fit patients with symptomatic
stone is controversial. However, ES as a planned precholecystectomy
procedure is currently being evaluated.
ES IN SEVERE ACUTE CHOLANGITIS WITH CBD STONE
Emergency ES offers a safer method of biliary decompression (mortality
rate 4.7%) than emergency surgery (mortality 21.4%) in those patients
with cholangitis not responding to initial conservative measures.
SUCCESS RATE OF ES IN DELIVERING THE CBD STONE
With an adequate sphincterotomy most stones less than I cm pass
spontaneously. In about 25% cases a dormia (wire) basket or balloon
catheter is employed through the endoscope to extract the CBD stones. The
technical success of performing ES approaches 85‑90% and stone extraction
is achieved in 80-90%. The main reasons for failure are a large CBD stone
(>2cm), intrahepatic stones and a relatively small distal common bile
ENDOSCOPIC MANAGEMENT LARGE CBD STONE
Mechanical Lithotripsy : Large stones (> 2 cm) that cannot be removed, can
be pushed by mechanical lithotripsy (special wire basket) passed through
the endoscope. After crushing the CBD stone mechanically the stone
fragments are removed subsequently or pass spontaneously.
Electrohydraulic Lithotripsy : The basic principle is similar to that of
Extracorporeal Shock Wave Lithotripsy. A modified electrohydraulic
lithotripter probe has been designed which can be inserted into the CBD
through the endoscope. The lithotripter is placed in close proximity to
the stone and the shock waves generated break the stone.
Chemical Dissolution : The insertion of nasobiliary catheter through the
endoscope into the CBD, prevents stone impaction and enables subsequent
chemical dissolution by using various soIvents like, Monooctanoin, 1 %
EDT, methyl Terbutyl ether, etc.
COMPLICATIONS OF ES
A. ACUTE COMPLICATIONS
i. Heamorrhage: Usually ES is not association with much bleeding;
however, in about 2‑3% severe bleeding can occur. Urgent surgery may be
required to control the bleeding if coagulation current application is not
successful in controlling the bleeding.
ii. Perforation : The patient experiences sudden abdominal pain and
extravasation of the contrast is seen on the television screen. Since the
perforation is retroperitioneal the abdominal signs may not be very
striking. Treatment is conservative and most patients recover with
parenteral antibiotics and nasogastric suction.
iii. Cholangitis : There is no evidence that prophylactic antibiotics
prevent this complication although some workers recommend this step. It
infection occurs, the best treatment is a combination of ampicillin,
gentamicin and metronidazole, which achieve effective concentrations in
iv. Pancreatitis :The incidence of clinical pancreatitis ranges from 1.5
to 5.50A, although hyper amylasaemia invariably occurs.
v. Impaction of calculus and dormia basket This occurs when the
stone size is larger than the length of the sphincterotomy. The stone
cannot be dislodged from the basket and both get stuck in the CBD. The
best approach is to cut the basket wire below the handle and to withdraw
the endoscope and reintroduce it to enlarge the sphincterotomy. If this is
not possible, a nasobiliary tube is introduced and the patient is returned
to the ward with the basket in situ. Frequently the basket and the stone
pass out spontaneously after the oedema subsides. Failing this stone
dissolution can be attempted via the naso‑biliary tube or the patient is
taken for laparotomy.
B. LATE COMPLICATIONS
These complications occur in about 1-10% patients but are generally mild
and of not much importance. These are:
i) Stenosis of the sphincterotomy
ii) Cholangitis and cholecystitis
iii) New stone formation
PRE AND POST PROCEDURE MEASURES
1) The routine use of pre and postoperative antibiotics in patients
with obstruction to the pancreatico‑billary system remains controversial.
The usual drugs are broad spectrum antibiotics like ampicillin or
2) After the procedure the patient is kept fasting for 2 hours. The
vital signs are constantly checked and the patient is examined for signs
of free perforation. If everything is normal, the patient is allowed
liquid feeds followed by solids.
3) The patients are encouraged to' pass stools in a pan for the next 48
hours and to look for gallstones, If stones are definetely identified,
this may obviate the need for a repeat ERCP.
CAUSES OF FAILURE
In about 5-10% cases ES is unsuccessful even in the most experienced
hands. The various causes of failure are:
I) Operator's inexperience
ii) Anatomical abnormalities
iii) Large stone size
IV) Development of immediate complications necessitating the abandoning
of the procedure.
NASOBILIARY CATHETER DRAINAGE
Temporary or short term biliary decompression can be accomplished by
placing a Nasobiliary Catheter (NBC) above common bile duct stones or
strictures. It functions like a T-tube. NBC Is a long polyethylene tube,
one end of which is placed inside the biliary tree through an endoscope
while the other end exits through the nostril and connects to a bile
INDICATIONS FOR NASOBILIARY CATHETER DECOMPRESSION
a. Ascending cholangitis secondary to impaction of stone.
b. Ascending cholangitis with CBD stone and coagulopathy.
c. Pre-operative biliary decompression to decrease severe jaundice due
to extrahepatic biliary obstruction.
d. Biliary perfusion with stone dissolution agents.
e. Intraluminal irradiation therapy in selected cases of malignant
ENDOSCOPIC BILIARY STRICTURE DILATATION
Endoscopic dilatation of bile duct stenosis is technically feasible,
though often difficult. It may even provide long term relief. The
morbidity and mortality are less than those following transabdominal
surgery. The procedure can be repeated if stenosis recurs. After a
diagnostic ERCP, a small sphincterotomy is performed to facilitate the
manipulation through the ampulla.
Atraumatic slip guide wire is passed through the endoscope and
manipulated through the stricture under fluoroscopic control. Over this
guide wire is passed a tapered dilating catheter and removed after initial
dilatation leaving the guide wire in place. Then a polyethylene balloon
catheter is advanced over the guide wire and into the stricture. The
balloon is distended under pressure to break the fibrous tissue and
dilate the stricture. Once the stricture is adequately dilated, a large
caliber stent is endoscopically inserted over the guide wire and placed
across the stricture.
The stent generally needs to be replaced periodically (6 months to 1
year). It is removed only after the stricture remains adequately dilated.
The early results are promising and it will be interesting to see the long
term follow up results.
ENDOSCOPIC THERAPY OF BILIARY OBSTRUCTION DUE TO
The approach to bile duct obstruction due to malignant obstruction is
determined by the site of obstruction and the clinical manifestation.
Fig: Endoscopic dilatation of biliary stricture
Obstruction of distal bile duct : Carcinoma of the pancreas and
periampullary carcinoma are the most important causes of malignant distal
biliary obstruction. Surgical resection is not possible in majority of
the patients. Endoscopic stent placement is an important option for
selected patients. The technique of stent placement is similar to that
described for benign stricture. Seriously ill patients should be managed
with endoscopic sphincterotomy and placement of stents if feasible.
Obstruction,of fhe middle extrahepatic bile duct : Carcinoma of gall
bladder and cholangiocarcinorna cause obstruction of the middle
extrahepatic bile duct. The management is as in distal obstruction.
Obstruction of the left and l or right hepatic duct : For mechanical
reasons, malignant stenosis of the proximal bile ducts present difficult
technical problems for endoscopic management because the endoscopist has
relatively less mechanical control in maneovering guide wire and stents
through the stenosis. When both the left and right hepatic ducts are
involved, endoscopic decompression of both sides can be a formidable
Currently another method of palliation of bile duct malignancies by
endoscopic placement or iridium wire into the malignant biliary stricture
is being evaluated.
With the development of ultra‑slim (23mm) cholangioscopes which can be
passed over a guide wire through the channel of a conventional
duodenoscope, a direct cholangiopancreaticoscopy is possible. This could
be used to fragment impacted or large CBD stone under direct vision using
a dye laser. This may also help in placement of guide wires through
difficult biliary strictures.