Obstructive jaundice

• The LFT- how I approach it

  1. Step 1: Total bilirubin and conjugated bilirubin levels

  2. Step 2: Ductal enzymes (ALP and GGT)

  3. Step 3: Hepatocellular enzymes (ALT and AST)

  4. Step 4: Albumin
• Ratio >0.7

  Obstructive jaundice
• Ratio <0.3

  Non-obstructive jaundice
• Ductal enzymes (ALP and GGT) always more than AST and ALT
• Chronic OJ results in hepatocellular damage
• RED FLAGS!

  • Acute cholangitis
  • Pruritis
  • Coagulopathy
  • (Worsening renal function)
• Acute cholangitis

  1. Cholangitis originates as a bacterial infection in the biliary tree

  2. Systemic cholangitis is a life-threatening condition

  3. There are three pre-requisites for cholangitis to occur: Biliary obstruction, Bacteria in the bile, Increased pressure in the biliary tree
• Charcot's triad

  • Right upper quadrant pain
  • Systemic inflammation: Fever and/or shaking chills (rigors)
  • Cholestasis ie: Jaundice
• Raynaud's Pentad

  • Hypotension
  • Confusion
  • Charcot's triad
• Severity assessment

  Grade I-III (Tokyo guidelines)
• Management of acute cholangitis

  1. Fluid resuscitation

  2. Broad-spectrum antibiotics

  3. Biliary drainage depending on cause and severity of cholangitis
• Pruritis


  An irritating condition that arouses the desire to scratch to provide temporary relief
• Pruritis is not associated with a specific level of bilirubin
• Pruritis results in sleep deprivation, depression, decreased quality of life
• Theories as to origin of pruritis

  • Bile salt deposition in skin
  • Histamine release
  • Serotonin
  • Steroids
• Coagulopathy


  Due to decreased excretion of bile salts – no absorption of fat soluble vitamins, ADEK. Depletion of vitamin K leads to depletion of the clotting factors 2, 5, 7, 9 and 10. This in turn leads to an increase in the INR.
• Coagulopathy is hardly ever associated with clinically significant hemorrhage but it is important because it may need to be corrected prior to any intervention, such as an ERCP.
• Worsening renal dysfunction

  Renal impairment is common in cholestatic jaundice. Due to changes in hydrostatic pressure, patients suffer from chronic intravascular volume depletion with subsequent decreased renal perfusion and lower glomerular filtration rates.
• Worsening renal dysfunction is often a component of superimposed sepsis due to cholangitis, which may aggravate renal impairment.
• OJ Classification

  • Persistent versus fluctuant (Pattern)
  • Proximal versus distal (Level of obstruction)
  • Intraductal versus intramural versus extraluminal (Etiology)
• Persistent OJ


  Jaundice doesn't improve without clinical intervention. Causes include strictures and malignancy.
• Fluctuant OJ

  Jaundice relieves spontaneously only to recur, cycle repeats itself. Causes include choledocholithiasis and peri-ampullary lesions e.g. ampullary polyps.
• Proximal versus distal refers to the level of obstruction in the biliary tree.
• Causes of OJ

  • Intraductal: gallstones, parasites and foreign objects
  • Intramural: cholangiocarcinoma, iatrogenic strictures, primary sclerosing cholangitis, chronic pancreatitis
  • Extraluminal: lymphoma, tuberculosis, lymph node metastases
• How to come to a diagnosis?

  Careful history, physical examination, and initial laboratory studies. A differential diagnosis is formulated based on those results and additional testing is performed to narrow the diagnostic possibilities.
• History

  • Use of medications, herbal medications, dietary supplements, and recreational drugs
  • Alcohol use
  • Hepatitis risk factors
  • History of abdominal operations, including gallbladder surgery
  • History of inherited disorders, including liver diseases and hemolytic disorders
  • HIV status
• Associated symptoms

  • A history of fever, particularly associated with chills or right upper quadrant pain
  • History of gallstones/biliary colic
  • History of prior biliary surgery
  • Symptoms of anorexia, malaise, weight loss
  • Right upper quadrant pain suggests extrahepatic biliary obstruction
  • Acholic stools
  • Dark urine
  • Pruritis
• Clinical Examination

  • General examination: Scleral jaundice, lymph nodes
  • Abdominal: Courvoisier law - Palpable gallbladder in the presence of painless jaundice, Advanced hepatopancreatico biliary malignancies – may have Sister-Mary Joseph node or Virchow-Troisier's node, ascites
• Laboratory Tests

  • LFT
  • Full blood count: White cell count, Platelets
  • U&E: Urea and creatinine, Hyponatremia
  • INR
  • C-reactive protein
• Radiology

  • Abdominal ultrasound
  • Abdominal CT scan (ensure correct request contrast and phases)
  • MRCP/ MRI
• Abdominal ultrasound

  First investigation. Confirms obstructed (dilated) biliary tree. May give indication of the level of the obstruction. May show the cause e.g. choledocholithiasis. Lacks sensitivity though to assess distal biliary tree and head of pancreas.
• Abdominal CT scan


  Request CT contrast and phases according to suspected diagnosis. Most common triphasic CT scan or a pancreas protocol CT scan. Useful if suspect an underlying malignancy. Gives good anatomical definition as to the level of the obstruction. Useful for staging malignancy and planning treatment.
• MRCP/ MRI

  Diagnostic modality. Provides detailed information of biliary tree and pancreatic ducts.
• Therapy

  • Endoscopic
  • Radiologically guided
  • Surgical
  • Palliation (Drainage not possible)
• Endoscopic retrograde cholangiopancreatography (ERCP)


  Endoscopic biliary tree access through the Ampulla of Vater. ERCP is a very useful intervention with multiple therapeutic advantages. Use with caution in proximal strictures. 6% Complication rate, therefore select patients carefully. NOT A DIAGNOSTIC TOOL: has been replaced by MRCP.
• Percutaneous transhepatic biliary drainage (PTBD)


  Biliary tree is accessed in a prograde fashion under ultrasound guidance. A cholangiogram catheter is placed. Reserved for: proximal strictures, bile duct injuries, ERCP not available, failed ERCP, px too sick to undergo an ERCP, anatomical factors that preclude an ERCP. Associated with significant complications, incl. bleeding and biliary leak.
• Surgical drainage

  Often included in the definitive surgery for the underlying cause. May include: Biliary bypass by choledochojejunostomy, hepaticojejunostomy, choledochoduodenostomy or cholecystojejunostomy. Placement of T-tube cholangiogram catheter.
• Palliation (Medical management of OJ)

  1. Ursodeoxycholic acid: especially effective in intrahepatic cholestasis of pregnancy. Given as 200mg TDS po.

  2. Anion exchange resins: cholestyramine. S/E are a problem: px compliance, reduced bioavailability of chronic meds

  3. Opioid anatagonists: μ-receptor antagnonists eg: naloxone
• Skin care in OJ: avoid the skin becoming dry. Good hydration, Lotions kept in the fridge, loose clothing, short fingernails.
• Jaundice is not a diagnosis, but a clinical sign of a disease process.