Definition, aetiological, investigation and management

1. Seminar Outline
• General Overview
• Surgical Anatomy of the Gall Bladder and Biliary
System
• Common Pathologies involving Gall Bladder and
Biliary System
• Differentiating Types of Jaundice
• Clinical Features in Obstructive Jaundice
• Investigations in Obstructive Jaundice
• Management of Obstructive Jaundice

2. General Overview
• Normal serum bilirubin – 0.2-0.8 mg/dL
• Surgical jaundice – Any jaundice amenable /
correctable by surgical intervention
• Majority due to extrahepatic biliary
obstruction
• However not all obstructive jaundice is
surgical jaundice (hepatitis) and not all
surgical jaundice is due to obstruction
(congenital spherocytosis).

3. • Pear-shaped hollow structure with a normal
capacity of 35-50ml
• 7 – 10 cm in length, 2.5 – 5 cm in diameter
• Undersurface of liver, mainly at the junction of
left and right lobes of liver
Surgical Anatomy of the Gall Bladder and
Biliary System
Gall bladder

5. Anterior view Posterior view

6. Gall bladder
• Divided into 4 parts:
(i) Fundus
(ii) Body
(iii) Infundibulum
- Hartmann pouch
(iv) Neck
- s-shaped as it joins the
cystic duct

8. Blood supply
• Arterial blood supply - cystic artery which arises from
the right hepatic artery
• The flow of the arterial blood: aorta  celiac trunk
 common hepatic artery  right proper hepatic
artery  cystic artery

9. Venous drainage
• Cystic vein drains blood from the gallbladder
and, accompanying the cystic duct, usually
ends in the right branch of the portal vein
• Not present, blood drains via small
(cholecystohepatic) veins in the gall-bladder
bed directly to the parenchyma of the liver

10. Lymphatic drainage
• The lymph from the gallbladder drains to the
cystic lymph node, which is often enlarged when the
gallbladder is inflamed
• Mascagni’s or Lund’s node lies in the imaginary
hepatobiliary Calot’s triangle
• Often removed together with the inflamed gallbladder

11. Innervation
• Parasympathetic fibers the hepatic branch of
the vagus nerve
• Sympathetic fibers arise from celiac plexus
• Sensory innervation is provided by the right
phrenic nerve

12. Calot’s triangle (hepatobiliary triangle)
• 3 margins
- Medially - common
hepatic duct)
- Laterally - cystic duct
- Superiorly - inferior
margin of the liver

13. • 3 contents:
- Cystic artery
- Right hepatic artery
- Cystic lymph node (Lund’s node)
Calot’s triangle (hepatobiliary triangle)

14. Calot’s triangle (hepatobiliary triangle)
• Clinical significance:
 Dissected during cholecystectomy
 Contents must be identified for ligation

15. Hepatobiliary tree

17. Main functions of gall bladder
Bile reservoir
• Fasting
- resistance through sphincter is high
- bile diverted to gall bladder
• Food intake
1. Cholecystokinin (CCK) secretion stimulated by presence of fats
in duodenum
- stimulates gallbladder contractions & common bile duct
- bile flows into duodenum
2. Secretin secreted in response of acid in duodenum
- stimulates biliary duct cells to secrete bicarbonate and water
- increases bile volume
- increase flow to duodenum

18. Main functions of gall bladder
Concentration of bile
• Absorption of water, NaCl, and bicarbonate
• 5-10 times more concentrated
• Increase in proportion of bile salts, bile pigments, cholesterol,
and calcium
• Secretion of mucus

20. Common Pathologies involving Gall
Bladder and Biliary System
1. Congenital: Biliary atresia, choledochal cyst.
2. Inflammatory: Ascending cholangitis,
sclerosing cholangitis.
3. Obstructive: Cholelithiasis, Common bile
duct stones, biliary strictures
4. Neoplastic: cholangiocarcinomas, gall
bladder carcinoma
5. Extrinsic compression of common bile duct:
Lymph nodes or tumours.

22. Congenital Abnormalities of the Gall
Bladder and Bile Ducts

23. Extrahepatic Biliary Atresia
• Atresia: abnormal narrowing.
• Present approximately in 1:12000 live births
and affect males and females equally.
• The aetiology is unknown.
• Classes
– Class I: atresia restricted to the common bile
duct.
– Class II: atresia of the common bile duct.
– Class III: atresia of the right and left hepatic
ducts.

24. • Clinical feature
– About 1/3 of the patients are jaundice at birth.
– More commonly, jaundice present by the end of first week and deepens progressively.
– Associated with
• Bile stained meconium
• Pale stool
• Dark urine
• Severe pruritis
• Clubbing
• Skin xanthomas

25. Choledochal Cyst
• Congenital dilatations of the intra/extrahepatic biliary system.
• Classification

26. • Clinical Feature
– Jaundice
– Fever
– Abdominal pain
• Physical examination
– Right upper quadrant mass
• Investigation
– Ultrasonography
• confirm presence of an abnormal cyst
– MRI
• Reveal the anatomy. Particularly on the relationship between lower end of the
bile duct and pancreatic duct.
– CT scan
• useful for delineating the extent of the intra/extrahepatic dilatations.
• Treatment
– Radical excision of the cyst with reconstruction of the biliary tract

27. Cholelithiasis (Gall Stones)
• Most common biliary pathology
• Gall stones
– Cholesterol stones
– Pigment stones
• Brown pigment stones
• Black pigment stones
– Mixed stones

28. Cholesterol Stones
• Cholesterol is secreted from the canalicular membrane in phospholipid vesicles.
• Insoluble in water.
• Risk factors
– Obesity
– High calorie diet
– Abnormal gastric emptying

29. Pigment Stones
• Black pigment stones
1. Insoluble bilirubin
2. Pigment polymer
3. Mixed with calcium phosphatase and calcium carbonate
– Associated with hemolysis
• Hereditary spherocytosis
• Sickle cell anemia
• Brown pigment stones
1. Calcium bilirubinate
2. Calcium palmitate
3. Calcium stearate
4. Cholesterol
– Formed in bile duct, formation of stones is associated with
• Bile stasis
• Infected bile

31. Clinical features
• Location : RUQ/ epigastric pain
• Character: Colicky but more often dull and constant
– Associated symptoms:
– Dyspepsia
– Flatulence
– Food intolerance ( fatty food )
– Altered bowel habits
• Progression: Biliary Colic
– Severe RUQ pain
– Nuasea/Vomiting
– Pain radiates to the chest
– Pain during midnight

35. Complication
• In the gall bladder
• Biliary colic
• Acute cholecystitis
• Chronic cholecystitis
• Empyema of the gall
bladder
• Mucocele
• In the bile ducts
• Biliary obstruction
• Acute cholangitis
• Acute pancreatitis
• In the intestine
• Intestinal obstruction
• Gall stones ileus
Differential
diagnosis
• Common
– Acute appendicitis
– Perforated gastric ulcer
– Acute pancreatitis
• Uncommon
– Acute pyelonephritis
– Myocardial infarction
– Pneumonia

36. Cholecystitis
• Inflammation of the gall bladder that occurs
most commonly because of an obstruction
of the cystic duct from cholelithiasis.
Calculous cholecystitis Acalculous cholecystitis
• Obstruction of the cystic duct from
cholelithiasis
• Risk factors
• Increasing age
• Obesity
• Drugs
• Pregnancy
• Associated with
• Biliary stasis
• Debilitation
• Major surgery
• Severe trauma
• Sepsis
• Long-term total parenteral nutrition
• Prolonged fasting
• Diabetes mellitus

37. • Clinical Features
– Acute upper abdominal pain
– Begins in the epigastric region and then localized to the RUQ
– Colicky in nature
– Associated with fever
– May radiate to the shoulder or scapula
• On examination
– Tachycardia
– RUQ tenderness
– Guarding and rebound tenderness
– Jaundice (not very common)
• Complication
– Perforation
– Gangrene
– Peritonitis

38. Cholangitis
• Is an infection of the biliary tract.
• Pathophysiology
1. Choledocholithiasis is the most common cause of
biliary tract obstruction resulting in cholangitis
2. Biliary tract manipulations/ stents
3. Hepatobiliary malignancies
• Clinical presentations
– Fever with chills and rigor
– RUQ pain
– Jaundice cCharchot
triad

39. Sclerosing Cholangitis
• Idiopathic fibrosing inflammatory condition of the
biliary tree affecting both intra/extrahepatic ducts.
• Strongly associated with inflammatory bowel disease,
especially ulcerative colitis.
• May associated with
– Hypergammaglobulinaemia
– Elevated markers such as
– Smooth muscle antibody
– Anti-nuclear factors
• Majority patients are between 30-60 years of age.

40. • Common symptoms
– RUQ discomfort
– Jaundice
– Pruritis
– Weight loss
– Fever
– Fatigue
• Investigations
– Liver function test
• Elevated serum alkaline phosphatase
• Elevated gamma-glutamyl transferase
• Elevated aminotransferase
– Ultrasonography
– Cholangiography
– Endoscopic retrograde cholangiopancreatography
• Demonstrating stricture and beading of the bile ducts.
• Treatment
– Vitamin K
– Steroids
– Immunosuppressant
• Surgery
– Endoscopic stenting
Liver biopsy is helpful
in confirming the
diagnosis by excluding
cirrhosis

41. Stricture of the Bile Duct
• Causes
– Congenital
• Biliary atresia
– Bile duct injury during surgery
• Cholecystrectomy
• Choledochostomy
• Gastrectomy
• Hepatic resection
• Transplantation
– Inflammation
• Stones
• Cholangitis
• Pancreatitis
• Sclerosing cholangitis
– Trauma
– Idiopathic

44. Stones in the Bile Ducts
• Aetiology
– May occur many years after a cholecystrectomy.
– Infection of the biliary tree
• Clinical features
– Fever
– RUQ pain
– Jaundice
.
Courvoisier’s law
States that in obstruction
of the common bile duct
due to a stone, distention
of the gall bladder seldom
occurs. In fact, it is usually
shrunken

47. Tumors of the Bile Duct
Benign
• Papilloma and Adenoma
– Most common benign neoplasm arises from the
glandular epithelium lining of the bile ducts.
• Papillomatosis
– Rare conditions
– Presence of multiple mucus secreting tumors of the
biliary epithelium.
– Patient often presents with obstructive jaundice.
– Tumors have malignant potential and must be
resected if possible.

48. Malignant
• Carcinoma can arise from any parts in the biliary tree, from common bile
duct to small intrahepatic ducts.
• Usually is adenocarcinoma ( cholangiocarcinoma ) which predominantly
located in the extrahepatic biliary system.
• Slow growing tumor which invade locally and metastasise to local lymph
nodes.
• Incidence
– Rare malignancy
– Overall annual incidence is 1:100000 with 2/3 of the patients being older than
65 years old.
• Association
– History of ulcerative colitis
– Sclerosing cholangitis
– Cholecdochal cyst
• Clinical features
– Jaundice
– Abdominal pain
– Early satiety
– Weight loss

49. • Investigation
– Biochemical investigation
• Elevated bilirubin
• Elevated phosphatase
• Elevated gamma-glutamyl transaminase
– Tumor Marker : CA 19-9
– Ultrasonography and CT scan
• Detect the level of obstruction
• Loco regional extent of disease
• Presence of metastasis
– Percutaneous transhepatic cholangiography
– Percutaneous drainage for cytology
• Treatment
– Resection
• Prognosis
– Median survival is 18 months
– 20% of the patient survive 5 years post resection
– Adjuvant chemotherapy and radiotherapy has limited role.

51. Carcinoma of the Gall Bladder
• Rare disease
• Affect elder patient, 60-70 years old.
• Unknown aetiology
– Associated with calcification of the gall bladder
• Pathology
– Adenocarcinoma
– Tumors are nodular and infiltrative
– Thickening of gall bladder wall
• Tumor spread by
– Direct extension into the liver
– Involvement of the perihilar lymphatics
– Neural plexuses
• Clinical features
– Jaundice
– Anorexia
– Weight loss
– Palpable mass

52. • Investigation
– Non specific investigations
• Anemia
• Leucocytosis
• Elevated ESR
• Elevated C-reactive protein
• Elevated CA 19-9 (80%)
– Diagnosis
• Ultrasonography and defined by multidetector row CT scan
• Percutaneous biopsy confirming the histological changes.
• Treatment
– Radical resection
• Prognosis
– Median survival less than 6 years

54. Tumors of the Bile Duct Gall Bladder CA
Rare
Present with Jaundice and weight loss
Diagnosis by ultrasonography and CT scan
Surgical excision is only possible in 5% of
the patients
Poor prognosis
Rare
Present as benign biliary disease(gall
stones)
Surgical excision is less than 10% of the
patients
Poor prognosis

55. Types of jaundice
1) Pre-hepatic jaundice
- disruption happens before bilirubin has been transported from the blood to
the liver
- caused by conditions such as sickle cell anaemia and haemolytic anaemia
2) Intra-hepatic jaundice (hepatocellular jaundice)
- disruption happens inside the liver
- caused by conditions such as Gilbert's syndrome and liver cirrhosis
3) Post-hepatic jaundice (obstructive jaundice)
- disruption prevents the bile (and the bilirubin inside it) from draining out of
the gallbladder and into the digestive system
- caused by conditions such as cholelithiasis (gallstones) or tumours

56. Pre-hepatic Hepatic Post-hepatic
Excessive amount of
bilirubin is presented
to the liver due to
excessive haemolysis
Impaired cellular
uptake, defective
conjugation or
abnormal secretion
of bilirubin by the
liver cell
Impaired excretion
due to mechanical
obstruction to bile
flow
Elevated
unconjugated
bilirubin in serum
Both conjugated and
unconjugated
bilirubin may be
elevated in serum
Elevated conjugated
bilirubin in serum
Types of Jaundice

57. Type Pre-hepatic Hepatic Post-hepatic
Urine colour Normal Dark Dark
Stool colour Normal Normal Acholic
(Putty-coloured /
greyish-yellow)
Pruritus No No Yes
Types of Jaundice

58. Pre-hepatic Hepatic Post-hepatic
Haemolytic
Anaemia, Sickle-cell
Anaemia
Hepatitis, cirrhosis,
hepatocellular
diseases etc.
Gallstone,
malignancy,
inflammation
Types of Jaundice

59. Types of Jaundice
Other types of jaundice:
• Pathologic Jaundice
- when jaundice presents a health risk
- in adults / children
- may be pre-hepatic / hepatic / post-hepatic
• Gilbert Syndrome
- harmless hereditary condition
- results in mild jaundice
- due to low levels of bilirubin-processing enzymes in their
livers
- does not require further medical treatment

61. Differentiating Types of Jaundice

62. Clinical Features in Obstructive
Jaundice
Consider:
- Patients' ages and
associated conditions
- Presence or absence of pain
- Location and characteristics
of the pain
- Acuteness of the symptoms
- Presence of systemic
symptoms (eg, fever, weight
loss)
- Symptoms of gastric stasis
(eg, early satiety, vomiting, belching)
- History of anaemia
- Previous malignancy
- Known gallstone disease
- Gastrointestinal bleeding
- Hepatitis
- Previous biliary surgery
- Diabetes or diarrhoea of
recent onset
Commonly - pale stools, dark urine, jaundice & pruritus
Explore use of any alcohol,
drugs, and medications.

63. History
•Family history of jaundice with anaemia (haemolysis ) -
Hereditary spherocytosis
• Gilbert’s Familial non-hemolytic hyperbilirubinemia
•Back Pain: 25% of patients with carcinoma pancreas (relieved
by sitting
•Whitish clay-colored stools: suggestive of Obstructive Jaundice
•Melena: Periampullary carcinoma ( silver paint stool )
•Charcot’s triad: Intermittent jaundice, pain, intermittent fever

64. •History of infections , drug abuse, tattoos, blood transfusion
(Hepatitis B )
•Past History of biliary surgery (Post-operative stricture )
•History of omphalitis (inflammation of the navel)
Infection of Umblicus  incomplete obliterations of umbilical
vein  jaundice
•History of drugs : Chloropromazine, Methyltestosterone

65. Examination
• Yellow discoloration: sclera , skin , nail bed,
posterior part of the hard palate, under surface
of the tongue
• Presence of scratch mark- in the lower limbs,
chest and abdomen (accumulation of bile salts)
• Migratory thrombophlebitis (Trosseau’s sign
seen in carcinoma pancreas)
• Stigmata of liver disease – spider angioma,
ascites, collateral veins on the abdomen and
splenomegaly
• Distended gall bladder
• Look for supraclavicular nodal enlargement

66. INVESTIGATION OF OBSTRUCTIVE
JAUNDICE
HEE YAN HAN BMS 14091168

67. Investigations in Obstructive Jaundice
General
• Full Blood Count – Anaemia, signs of infection,
haemoglobulinopathy
• Serum electrolyte, urea & creatinine
• Liver function test
- Bilirubin (Direct  - obstruction)
- Raised serum albumin ( A/G Ratio)
• Urinalysis – Bilirubin, urobilinogen
• Faecal occult blood test (Carcinoma of ampulla of pancreas)
• Coagulation profile – PT, PTT, INR
• Hepatitis serology (HbsAg, HCV)

70. Imaging
• Plain radiographs – little value
• Abdominal ultrasonography – 1st-line imaging in
jaundice
- detect liver abnormalities, hepatosplenomegaly and
gallstones
- identify extrahepatic causes of biliary obstruction
- Identify intrahepatic disease e.g. malignancy
Diagram 1: Ultrasound image showing choledocholithiasis.

71. • Endoscopic ultrasound (EUS) – detailed
imaging of pancreas and biliary tree, tissue
sampling via fine needle aspiration (EUS-FNA)
• Computed tomography (CT) scan - more
accurate than US to determine specific cause
& level of obstruction
Diagram 2: CT scan showing carcinoma of head of pancreas.

72. • Magnetic resonance
cholangiopancreatography (MRCP) – test of
choice in obstructive jaundice
Figure 3 : MRCP shows GB malignancy causing
hilar obstruction with biliary stent in situ

73. • Endoscopic retrograde
cholangiopancreatography (ERCP) – diagnose
benign & extrahepatic obstruction, relieve
obstruction
Figure 4 : ERCP shows lower CBD
stricture with choledocholithiasis

74. • Percutaneous transhepatic cholangiography
(PTC) – evaluates suspected biliary obstruction
when ERCP is unsuccessful.
Figure 5 : PTC shows lower CBD
cholangiocarcinoma with proximal sludge

75. Liver Biopsy
• Laparoscopic / percutaneous
• To stage primary biliary cirrhosis
Laparotomy

76. Management of Obstructive Jaundice
Medical: Depends on underlying cause
Surgical: When indicated
Indications for surgery – Resectable
* Palliation if unresectable

77. Pre-Operative Management
• Proper diagnosis and assessment
• Injection vitamin K IM 10 mg for 5 days
• Fresh Frozen plasma ‐ 6 bottles or more
• Blood transfusion (if anaemic)
• Oral neomycin, lactulose
• IV Mannitol 100‐200 ml BD to prevent hepatorenal
syndrome
• Adequate hydration
• Repeated monitoring by doing prothrombin time, serum
electrolytes
• Antibiotics e.g. 3rd generation cephalosporins
• Calcium supplements e.g. IV Calcium chloride

78. Surgical Management Modalities
1) Triple Bypass
2) Whipple Procedure
3) ERCP / Stenting
4) CBD exploration (CBDE)
+
Choledochojejunostomy
(CDJ)
5) CBDE + T Tube
6) Percutaneous
transhepatic biliary
drainage + Palliative
7) Hepatojejunostomy

79. Percutaneous transhepatic biliary drainage

80. • Choledocholithiasis / cholecystolithiasis –
Cholecystectomy (Open / Laparoscopic)
• Carcinoma of head of pancreas
Early: Whipple procedure, Pancreaticoduodenectomy
+ Pancreaticojejunostomy + Gastrojejunostomy +
Cholecystojejunostomy
Late: Triple bypass surgery
• Cholangiocarcinoma - Hepaticojejunostomy
• Carcinoma of ampulla of Vater – Whipples
procedure
• Chronic pancreatitis – Subduodenal exploration,
sphincterectomy, stent insertion
• Liver transplantation

81. Whipple Procedure
• Pylorus-Preserving Pancreaticoduodenectomy
(PPPD)

82. Triple Bypass
• Consisting choledochojejunostomy
(cholecystojejunostomy), gastrojejunostomy,
and pancreaticojejunostomy

83. Cholecystectomy

84. Removed glallbladder Cholecystectomy scar after open surgery
Laparoscopic cholecystectomy scar

85. Post-Operative Care
• Monitoring with prothrombin time, bilirubin,
albumin,creatinine, electrolyte estimation
• FFP or blood transfusion
• Antibiotics
• Observe for septicaemia, haemorrhage,
pneumonia, pleural effusion, bile leak
• Care of T-tube and drains
• T‐tube cholangiography in 10‐14 days
• TPN, CVP line, nasogastric tube, urinary catheter

86. T Tube –drainage of bile leaks post-operatively

88. References
1. Blumgart L.H., Surgery of Liver and Biliary Tract
2. Bailey & Love, Short Practice of Surgery, 25th edition, 2008
3. Boyd, Surgical Pathology
4. Sheila Sherlock, Diseases of Liver and Biliary System
5. Rodney Maingot, Textbook of Adbominal Operations, 11th edition, 2007
6. Anderson A.R., Randomized trial of endoprosthesis versus operative bypass in
malignant obstructive jaundice
7. Trede M., The Surgical treatment of pancreatic carcinoma surgery
8. Sonnenfield, Byberg B., The effect of palliative biliodigestive operation for
unresectable pancreatic cancer
9. War-Shaw A.L., preoperative staging and assessment of resectability of
pancreatic cancer
10. Shapiro T.M., Adenocarcinoma of pancreas – a statistical analysis of biliary
bypass versus Whipple resection in good risk patients, Annals of Surgery
11. Christ D.W., Current status of pancreaticoduodenectomy for periampullary
hepatogastroenterology
12. Eastman M.C. Keene, The objective of palliative surgery in pancreatic cancer – a
retrospective study of 73 cases, Australian and NewZealand journal of surgery.
13 Cotton P, Leung J (Eds) Advanced Digestive Endoscopy: ERCP. Oxford:
Blackwell Publishing Ltd, pp. 1–8.