1. CONCERNED
Obstructive jaundice
INVESTIGATIONS

2. definition
 Biliary obstruction refers to the blockage of any
duct that carries bile from the liver to the
gallbladder or from the gallbladder to the small
intestine.
 This can occur at various levels within the biliary
system.
 The major signs and symptoms of biliary
obstruction result directly from the failure of bile to
reach its proper destination.
 Accumulation of bilirubin in the bloodstream and
subsequent deposition in the skin causes jaundice
 Conjunctival icterus is generally more sensitive
 Jaundice may not be clinically recognizable until
levels are at least 2 mg/dL

3.  Urine bilirubin is normally absent.
 When it is present, only conjugated bilirubin
is passed into the urine.
 This may be evidenced by dark-colored
urine seen in patients with obstructive
jaundice or jaundice due to hepatocellular
injury..
 The lack of bilirubin in the intestinal tract is
responsible for the pale stools typically
associated with biliary obstruction.
 The cause of pruritus associated with biliary
obstruction is due to accumulation of bile
salts in the skin.

4. CAUSES
Intrahepatic extrahepatic
intraductal extraductal
 Cirrhosis
 Hepatitis
 Drugs
 Neoplasm
 Stone disease
 Biliary stricture
 Parsites
 PSC
 Aids related
cholangiopathy
 Biliary TB
 Secondary
to neoplasm
 Pancreatitis
 Cystic duct
stones

5. Evaluation of obstructive jaundice begins with careful
history & physical examination
JAUNDICE- hallmark of obstruction
Pruritis, fever, weight loss, color of feces & urine
Previous h/o pancreatitis, ulcerative colitis, hepatitis, or
cholangitis
INTERMITTENT JAUNDICE- stone related disease
ampullary Ca
papillary cholangioCa
Prior h/o biliary surgery s/o stricture possibility
Late jaundice after pancreaticoduodenectomy s/o
recurrent disease
technical anastomotic failure
iatrogenic stricture if radiation is administered

6. Medical causes of jaundice :
Hepatitis
Cirrhosis
Alcohol
Hemolysis
Impaired uptake or conjugation of
bilirubin
Drugs

7. drugs
cholestasis
gallstone
Acute
cholestatic
injury
Hepatocellular
necrosis
• Anabolic
steroids
• chlorpromazine
• Thiazide
diuretics
• amoxyclav
• Acetaminophen
• isoniazid
 Typically, drug-induced jaundice appears early with
associated pruritus, but the patient's well-being shows
little alteration.
 Generally, symptoms subside promptly when the
offending drug is removed

8. Other physical findings are:
Lymphadenopathy
Evidence of nutritional deprivation
A palpable non tender GB in a jaundiced pt.
s/o malignant obstruction CURVOISIER’S LAW
Signs of cirrhosis or portal HTN as ascites,
spleenomegaly
 Cirrhosis is characterized by generalized
disorganization of hepatic architecture with
nodule formation and scarring on the
parenchyma.
 Cirrhosis may be a result of intrinsic liver
disease or secondary to biliary obstruction

9. Goals
of investigations
Determine
level of
obstruction
Severity of
jaundice
Ductal
dilatation
jaundice
Cause of
obstruction

10. investigations
LFT
GGT
PT
Hepatitis serology
Antimitochondrial antibody
Urine bilirubin
Imaging studies

11. Imaging studies
 USG
 CT
 MRCP
 ERCP
 Endoscopic ultrasound (EUS)
 Percutaneous transhepatic
cholangiogram (PTC)

12. Tests for liver functioning
Based on
detoxification
& excretory
function
Enzymes
indicating
liver injury
Measure
biosynthetic
function
Damage to
hepatocytes
cholestasis
Serum
bilirubin
Urine
bilirunin
Blood
ammonia
Aspartate
aminotransferase
Alanine
aminotransferase
Alkaline
phosphatase
5 nucleotidase
GGT
Serum albumin
Serum globulin
Coagulation
factors

13. Features Hepato cellular injury cholestasis
Alanine
aminotransferase
10–40(U/L) in males
7–35 U/L in females
>10 URL , persists for
weeks in most forms
Transient increase to
>10URL with complete
obstruction falls
quickly
ALP (20 to 140 IU/L) <3 URL in most forms >3URL, may be normal
in early obstruction
GGT (0-30 IU/L) <5URL >5URL, may be lower
in early obstruction
Bilirubin 0.1-1.2
Direct , 0.1-0.4 mg/dL (<
7 μmol/L); Indirect, 0.2-
0.7 mg/dL (< 12 μmol/L)
50-80% direct 50-80% direct
PT (10 to 14 seconds) Normal or slightly
increased , no
response to vit-k
Normal maybe
incresead with
prolonged obstruction
uaually respond to vit-k
Imaging studies Normal ducts Abnormal ducts with
complete obstruction

14. Imaging studies may be used to look for
presence of dilated biliary ducts
However bile duct obstruction without
dilatation may occur when there is :
Recent obstruction
Chronic low grade obstruction
Intermittent obstruction
Primary sclerosing cholangitis
Suspicion of obstruction should prompt
cholangiography even when ducts are of
normal caliber
Some may present with dilated ducts without
obstruction if there was previous obstruction
Percutaneous liver biopsy may be required in
some cases to exclude hepatitis

15. Causes based on
level of
obstruction
Proximal
obstruction Distal
obstruction
Biliary Extrinsic Biliary Extrinsic
•cholangioCa.
•Choledocholithiasis
•GB cancer
•Biliay stricture
•Malignant
masquerade
•Mirrizzi syndrome
•Sclerosing cholangitis
•Hepatic neoplasm
•Extra hepatic
mass
•lymphadenopathy
•cholangioCa
•Choledocholithiasis
•Choledochal cyst
•Biliary stricture
•Periampullary
neoplasm
•Pancreatitis
•Pancreatic cyst

16. Imaging studies Usg
 initial test of choice in biliary obstruction
 Determine
 level of biliary dilatation in 92% cases
 Cause of obstruction in 71%cases
 Limited in distal biliary tree by overlying bowe gas
 Upper limits of normal diameter of
 CBD-8mm
 CHD-6mm
CT
 95% accurate in determining level & cause of an obstruction
 Segmental or lobar atrophy of liver from portal vein or duct
obstruction best visualised

17. DIRECT CHOLANGIOGRAPHY
Done via percutaneous transhepatic
cholangiography (PTC) & endoscopic
retrograde
cholangiopancreaticography(ERCP)
Provides most anatomical detail of biliary
tree
Enables inspection for :
• Filling defects
• Stenoses
• Occlusion
• Masses

18. ERCP is preferred for distal duct obstruction ,
PTC for proximal
Both ERCP & PTC have similar accuracy in
diagnosing jaundice
GB isn’t visualized by direct cholangiography
& better examined with USG
mrcp
Provides detail of liver parenchyma, biliary
tree, pancreas, & vasculature & identify
anatomical variants
Noninvasive
Averts risk of pancreatitis, bleeding,
perforation

19. Can be employed when ERCP/PTC is
contraindicated or when they are failed
Can be used when there is biliary enteric
anastomosis
MRCP enables visualization of biliary tree
both above & below the level of obstruction
When therapeutic intervention is required
ERCP or PTC is preferred
MRCP 95% sensitive in detecting
obstruction
Inaccurate in assessing grade of
obstruction
Strictures can’t be well characterized

20. Endoscopic ultrasound (EUS)
 combines endoscopy and USG to provide remarkably
detailed images of the pancreas and biliary tree.
 EUS has been reported to have up to a 98%
diagnostic accuracy in patients with obstructive
jaundice.
This makes ERCP unnecessary in patients who are
found not to have extrahepatic obstruction.
 In addition, those patients who may require operative
biliary drainage are reliably identified and similarly
need not undergo ERCP for further evaluation.
 EUS provides highly detailed imaging of the pancreas.
 EUS is more portable than ERCP or MRCP
EUS-FNA

21. Choledocholithiasis
• May be asymptomatic
or present with
jaundice, cholangitis,
or pancreatitis
• Direct
cholangiography is the
gold standard
investigation appear as
filling defects
• ERCP film showing
choledocholithiasis

22. MRCP Showing choledocholithiasis

23. MRCP is also highly
accurate
 MRCP sensitivity
88-92%, specificity
91-98% in detecting
choledocholithiasis

24. USG showing choledocholithiasis
Not reliable in
visualizing duct
stones due to
sound wave
distortion from
valves of heister
56% sensitive,
68%specific in
detecting
choledocholithiasis

25. Intraductal stones appear as target sign on ct
CT. 75-88% sensitive, 97%specific for choledocholithiasis
79%sensitive, 100% specific for gallstones

26. In suspected cases of cholangitis due
to choledocholithiasis evaluation
should begin with USG to define level of
obstruction
Emergent drinage by ERCP, PTC or
operation may be required in who don’t
improve with resuscitation & antibiotics

27. Biliary strictures

28.  Long, smooth tapered
strictures are usually
benign
 MC cause is iatrogenic
injury following
cholecystectomy or less
frequently rt. Upper
quadrant surgery
 Other causes are:
• pancreatitis
• Radiation
• Inflammation due to
stone disease
• PSC

29. Level of
stricture
Proximal duct
stricture
Mid bile duct
stricture
Low ductal
stricture
cholangioCa.
Malignant
masquerade
GB cancer
cholangioCa.
Mirizzi
syndrome
Periampullary
neoplasm
Pancreatitis
Cholelithiasis

30. ERCP films
showing stricture
and further
dilatation of
stricture
•PTC is used
for proximal
ductal disease
whereas ERCP
for distal
•MRCP provides
same
information

31. Primary sclerosing cholangitis
OProgressive fibrosis of biliary of
unknown etiology
OFound in association with
ulcerative colitis
OMC in men
OPSC is best diagnosed by
ERCP

32. Primary sclerosing cholangitis
USG picture of
PSC showing
thickening of the
wall of the bile
duct

33. CT film showing mild bile duct dilatation with a
discontinuous pattern.

34. Discontinuous dilatation
Bile wall thickening at the level of the porta hepatis
Lymphadenopathy

35. intrahepatic bile duct dilatation with strictures
and only mild dilatation, the first diagnosis we
think of is primary sclerosing cholangitis (PSC).

36. Choledochal cyst
choledochocele extrahepatic and
intrahepatic disease
saccular or fusiform
dilatations of CBD
 MC type is fusiform dilatation of EHBD
 Presents with jaundice, pain and mass
 Manifests in childhood & usually involves lower bile duct

37. Carolis disease:
congenital
condition of
dilatation of intra
hepatic ducts
may be diagnosed
with CT, USG, PTC,
ERCP
ERCP: severe intra hepatic dilatation
without any obstruction

38. Caroli’s disease
 The hallmark of Caroli disease is intrahepatic duct dilatation.
 The dilatation can be very large and saccular as seen in the case on the left or it can be
very linear.

39. central dot sign and the segmental involvement
(portal vein that is surrounded by dilated bile ducts)

40. Cholangiocarcinoma
 Often discovered as a result of obstructive
jaundice
 Papillary variant produces intermittent
jaundice
 USG is the preferred initial test
 Detects hilar tumors
 Predicts extent of bile duct involvement in
87% cases

41.  Duct dilatation
 Ill-defined mass
 Lobar atrophy
 Vascular invasion

42.  Duplex USG may be accurate in determining extent of disease & vascular involvement
 MRCP is also one of the best investigation available
 Determine resectability of tumour through visualisation of tumor extension along the
biliary tract

43.  Combination of MRCP and duplex USG is
sufficient for diagnosis & staging
CT may be used instead of MRCP but direct
cholangiography may be preferred
 Features determing resectability:
• Vascular involvement,
• local extension,
• liver metastasis,
• liver lobe atrophy,
• extent of intraductal disease

44. CECT scan is showing a hypoattenuating irregular large cholangiocarcinoma
(arrow) with peripheral rim enhancement (arrowheads) in left lobe

45. Gallbladder carcinoma
 When a
gallbladder cancer
is discovered
preoperatively
MRCP & usg are
required for
diagnosis &
staging
 CT may be used
instead of MRCP

47. PERIAMPULLARY NEOPLASMS
Distal bile duct obstruction is seen with:
• Periampullary neoplasm
• Pancreatitis
• Pseudocyst
• Biliary stricture
Periampullary neoplasms include
• Cholangiocarcinoma
• Pancreatic adenocarcinoma
• Duodenal adenocarcinoma
• Ampullary adenocarcinoma
• Lymphoma or mets

48. USG demonstrates distal nature of
obstruction and is the intial test of choice
Helical CT is best over all for assessing
periampullary lesions & determing
resectability
On occasion MRCP is needed to define the
mass
ERCP is not typically required
Routine preoperative bilairy drinage with a
stent should be avoided as it is associated
with higher incidence of post-op infections