History

 Age-
 Gender- Pancreatic malignancies more in males
 Ca Gallbladder more common in the Gangetic belt
 Jaundice
o Onset
 Where did the patient notice yellowish discolouration?
 Any prodromal symptoms?
o Duration
o Progression- Painless and progressively deepening jaundice is characteristic of any
malignant cause of OJ (Dr. Kate)
 Why deeper jaundice? Because it is a more prolonged and progressive
process.
o Associated with abdominal pain? More suggestive of benign causes
o Any jaundice free period?
 Remittent jaundice- waxing and waning type. Never reaches the baseline.
Seen in Periampullary carcinoma because of sloughing of tumour mass
 Intermittent jaundice- jaundice free period. Seen in cholelithiasis because
the duct dilates after the stone gets lodged and thus slips proximally causing
relief of the jaundice. Then it gets lodged back and the jaundice returns.
(Ball valve)
o Previous episodes of jaundice
o Colour of stools- clay coloured stools is s/o OJ- due to absence of urobilinogen in the
stool. Silvery stools are seen in periampullary carcinoma (Thomas sign) because
when light shines on clay coloured stools+ minimal blood, it appears silver
o Colour of urine- yellowish discolouration is s/o OJ- due to presence of conjugated
bilirubin in urine
o Itching- due to deposition of bile salts in the skin which causes the release of
Histamine. Classically seen in OJ
 Abdominal pain
o Site, Onset, Character, Radiation, Associated symptoms, time, exacerbating/relieving
factors, severity
o Abdominal pain is more suggestive of benign cause.
o Pancreatic pain
 Epigastric, radiating to the back, relieved on lying forward, aggravated on
lying down (because the retroperitoneum is stretched causing nerve
irritation)
o Characteristic benign pain
 Biliary colic- severe cramping pain, 2 hours after food, in the right
hypochondrium, radiating to the shoulder, lasts for 15-30 min and goes up
to 6 hours. Characteristic of cholecystitis. It is not a typical colic (intermittent
severe pain)???
 Site- Just below the RCM in cholecystitis
 Radiation- Right shoulder or inferior angle of right scapula in cholecystitis
 Flatulent dyspepsia- often seen in patients with gallbladder disease. Feeling
of fullness after food, belching and heartburn.
 Qualitative dyspepsia- dislike for fatty foods characterises gallbladder
disease
o However, abdominal pain (dull aching) can also be seen in malignant OJ in the
following settings
 Cholestatic hepatomegaly
  Distended pancreatic duct (? Subclinical pancreatitis)
 Cholangitis
 Nerve involvement
 Ulceration causing bleeding
 Malaena
o Ca head of pancreas ulcerating into duodenum
o Ca stomach with porta hepatis nodes
o Fresh bleeding PR- Rectal malignancy with liver secondaries
 Vomiting
o History suggestive of GOO- Ca head of pancreas causing duodenal obstruction, Ca
stomach with porta nodes, Duodenal primary with secondary in liver
 Note: Ca head of pancreas infiltrating into the duodenum will cause back pain because of
retroperitoneal infiltration
 Constipation- can be seen in biliary disorders. Reason?
 Abdominal distension- most common presentation of secondaries
 Mass abdomen history
o Ca gall bladder, Liver mets, Ca stomach
o Ca head of pancreas does not present with a palpable lump because 15 cm
enlargement is required whereas obstructive jaundice develops at 4 cm enlargement
itself (Dr. Kate)
 History of fever, altered sensorium- cholangitis
o Cholangitis is almost never seen in malignant disease because the obstruction is
gradual and progressive

Interpretation of history
 Features suggestive of obstructive jaundice- jaundice, itching, clay coloured stools, high
coloured urine
 Features suggestive of malignancy- important malignancies to consider are
o Ca head of pancreas,
o Cholangiocarcinoma
o Ca Gallbladder- causes obstructive jaundice by CBD infiltration, liver secondaries,
CBD compression
o Periampullary malignancies (located within 2 cm of the ampulla) are Ca head of
pancreas, Duodenal ca, lower CBD malignancy, ampullary tumour from ampulla of
vater.
o Other causes- Klatskin tumour, Lymph node, Hepatoma, Secondaries
 Painless, progressive jaundice
 Silvery stools in periampullary carcinoma
 Longer duration of history??
 Elderly male (However, North Indian female- Ca GB)
 Features suggestive of benign disease
o Painful
o Short duration (like 7-10 days)??
o Important benign causes of OJ
 Choledocholithiasis-
 Primary CBD stones are rare
 Secondary to Gallstones- most common site of impaction is the
supraduodenal part of CBD (parts are Supraduodenal,
Retroduodenal, Retropancreatic, Intraduodenal)
 Strictures- Congenital, post infectious, instrumentation
  Choledochal cyst
 Mirizzi syndrome
Examination

General Examination
 Patient is conscious, oriented to place, time, person
 Signs of liver cell failure- which one will cause liver cell failure?
 Scratch marks- importance- interventional procedure may be required to palliate itching.
 Icterus- seen in the sclera through the upper bulbar conjunctiva- because it is more
convenient to see. Check the hands as well.
o Lemon yellow colour: Bilirubin is 5-10. More likely due to stone
o Deep yellow- malignant obstructive cause
o In remittent jaundice, there is a false positive icterus in the sclera because the
bilirubin stays in the sclera for some time. But it disappears from the palms.
o If the patient has pallor and icterus, check for pallor in the palm crease (loss), nails,
under surface of tongue
 Oedema- hypoalbuminaemia
 Peripheral manifestations of GI malignancy (comment only if present)
o Acanthosis nigricans
o Superficial migratory thrombophlebitis (Trousseau sign)
o Irish node- Left axillary node
o Lesser-Trelat sign- multiple outcrops of seborrheic keratoses
Local Examination
 Inspection
o Abdomen contour- flat/distended/scaphoid
o Flanks- full or free. Flank is the area from subcostal area to iliac crest. Check them
from the foot side of the patient.
o Movement of all quadrants with respiration
o Umbilicus
 Position- Normal position is middle of the line joining xiphoid process and
symphysis pubis
 Tanyol’s sign- umbilicus is displaced upwards by a pelvic swelling
and downwards by ascites
 Inverted/everted- everted in ascites
 Nodules
 Caput medusae
o Skin- scars, dilated veins
o Visible mass
 Site, size, extent
 Movement with respiration
 Change with head/leg raising
o Visible peristalsis
o Inguinal region- swelling/cough impulse
o External genitalia
o Spine
o Supraclavicular region
 Palpation
o Local rise in temperature
o Tenderness
o Palpable mass
  Site, size, extent, margins, surface, consistency
 Mobility
o Palpable organomegaly
 Liver- tenderness, size, border, surface, consistency
 Spleen
 Gall bladder
 Tense, globular swelling projecting downwards and forwards from
below the liver just lateral to the outer border of the right rectus
muscle below the tip of the 9th rib.
 Moves freely with respiration and its outer limit is continuous with
the liver, cannot insinuate fingers above the mass. Upper border of
liver goes into costal margin
 Can be moved slightly from side to side
 Palpable in
o Mucocele, empyema
o Ca head of pancreas, gallbladder malignancy
 Courvoisier’s Law: “In a patient with OJ, palpable gallbladder is
seldom due to stone disease”
o Calculous jaundice is not associated with gallbladder
enlargement due to fibrosis because of previous
inflammation
o Exceptions
 Double impaction of stone- one in the cystic duct
and the other in the CBD (the stone in the cystic
duct causes mucocele and GB enlargement while
the stone in the CBD causes jaundice)
 Gallbladder mucocele or empyema (usually due to a
stone in the cystic duct)
 Oriental cholangiohepatitis (Clonorchiasis)- in this
condition, ductal stones are formed secondary to
the infestation
 Pancreatic calculus obstructing the ampulla of vater
o Impalpable gallbladder in malignancy-
 Involvement of nodes in the porta- so it doesn’t get
filled at all (gallbladder gets filled retrograde)
 Malignancy above the level of cystic duct
 Large hepatomegaly in liver secondaries
 Intrahepatic gallbladder
 Low insertion of cystic duct
 (Dr. Kate- hepatomegaly with gallbladder
malignancy and agenesis of gallbladder)
o Supraclavicular region
o External genitalia
 Percussion
o Percussion over mass
o Liver span
o Traube’s space percussion
o Fluid thrill
o Shifting dullness
 Auscultation
Diagnosis- it’s a case of Benign/Malignant obstructive jaundice mostly of _____ etiology.
If malignant then always tell differentials in following order
 1st Ca head of pancreas
 2nd Ca periampullary
 3rd Distal CBD carcinoma
 4th Duodenal Carcinoma
Investigations
 Liver function tests
o Direct bilirubin greater than 15-40% is OJ. (?>20%))
o ALP- Normal is 150-200
o PT-INR: Raised because of defect of absorption of fat soluble vitamins which causes
decreased synthesis of Vitamin K dependent clotting factors. If raised, correct with
Vit K.
 Total protein
 Albumin
o Synthetic function of the liver
o Indicates nutritional status
o 3 g/dL is the albumin cutoff for surgeries in JIPMER
 Tumour markers (tell later)
o CA 19-9
o More useful for follow up- if two serial titres show progressive increase then it is
likely that the tumour has recurred
 Ultrasound
o Intrahepatic biliary radical dilation (IHBRD)
o CBD diameter (Normally 7-8 mm)
o Liver secondaries
o Gall bladder status
o Peripancreatic nodes
o Free fluid abdomen
o Omental deposits- not so good at picking up
 Endoscopy
o Visualise if there is any obstruction, mass, ulceration and to take a biopsy
o First end viewing, then side viewing endoscopy. There may be some luminal
obstruction that won’t be visualised by side-viewing scope that would otherwise be
pierced. The ampulla itself is located medially and can only be visualised by side-
viewing scope.

 CT Abdomen
 Most preferred method- Triple phase, contrast enhanced, thin slice,
helical CT with three-dimensional reconstruction
 Pancreas protocol for contrast
o Arterial phase- first 30 seconds after the contrast injection-
coeliac axis, SMA, peripancreatic arteries
o Pancreatic phase- Attenuation difference between tumour
and the normal pancreas (after arterial phase and before
venous phase)
o Portal venous phase- enhancement of SMV, Splenic and
portal veins
 Poorly defined, hypodense mass (Pseudocyst is hyperdense)
  Double duct sign (can be visible in all imaging modalities)- with
increasing size, the tumours of the pancreatic head may block bile
drainage in both the CBD and the Pancreatic duct, leading to dilation
of both structures
 Assessment of resectability
 Detection of distant metastases
 Unresectable head of pancreas lesions
o Solid tumour contact with SMA>180°
o Solid tumour contact with Coeliac axis >180°
o Solid tumour contact with the first jejunal SMA branch
o Unreconstructable SMV or portal vein
o Distant metastases
o Metastases to lymph nodes beyond the field of resection

 ERCP
o Indications
 Absolute- Cholangitis with sepsis, Pre chemo for palliation
 Other indications- If bilirubin is vey high (like >30)- tissue healing delayed,
anastomotic leak, then it can be relieved by Pre-op ERCP stenting. Also if
BUN, Creat is high, Hepatorenal syndrome
 Plastic stent is preferred- can be shit out. Metallic stent preferred in long
standing (palliation)
o Complications
 Infection
 Trauma
 Cholangitis
 Pancreatitis
 Other investigations not commonly done
o Barium meal
 Ampullary growth- Rose thorn appearance of medial border of duodenum
 Filling defect in the region of ampulla giving rise to an “inverted 3
appearance”
o CT Angiography
o PTC- Percutaneous Transhepatic Cholangiography- Not preferred, but PTC followed
by PTBD is an alternative to relieve jaundice
Possibilites

1. Ca Head of Pancreas
 CA 19-9 levels- to check for follow up (colorectal and gastric carcinomas also have
elevated CA 19-9)
 Role of biopsy
o Trucut and other biopsies are usually not advisable as they may cause
bleeding, infection and negative biopsy does not rule out malignancy
o So, biopsy is usually not done in resectable tumours. It can be done in
inoperable cases to start chemo- to give a diagnosis
 ERCP
o Not commonly done in operable cases
o Double duct sign- also can be seen on CT and USG. Due to simultaneous
dilation of CBD and pancreatic duct. Seen in periampullary tumours and
chronic pancreatitis
o Scrambled egg appearance- not in head of pancreas
 o Pancreatic duct encasement
 Staging Laparoscopy- done in high risk cases
o Tumours >3cm
o Significant elevation of CA 19-9 (>100 U/ml)
o Body and tail tumours
 Criteria for resection (SRB)
o Tumour size <3cm
o Periampullary tumours
o Growth not adherent to portal system
 Borderline resectable tumours- those which involve the vessels- SMV, PV, SMA,
Hepatic artery
 Treatment- Whipple’s procedure (Pancreatico-duodenectomy)
o First described by Kausch, but first successfully performed by Whipple
o Structures removed- Tumour with the head and neck including uncinate
process of the pancreas, Duodenum, distal stomach, 10-15 cm jejunum,
lower end of CBD, gallbladder, peripancreatic, pericholedochal,
paraduodenal, perihepatic nodes
o Structures supplied by the gastroduodenal artery are removed
o Why is gallbladder removed (not supplied by gastroduodenal artery)?
Because the ampulla and sphincter of oddi are removed, retrograde flow of
bowel contents will occur causing infection
o Anastomosis
 Pancreaticojejunostomy- Pancreatic duct to jejunum. If this is not
possible, then body of pancreas to jejunum (dunking)
 Hepaticojejunostomy- Proximal CBD to jejunum
 Gastrojejunostomy- site to site
 Why this order? When pancreatic juice is there, bile should not be
there because the pancreatic enzymes can get activated.
o Complications
 Post op pancreatic fistula (leakage)
 Amylase rich fluid in the surgical drain
 Mostly heal with conservative management
 Haemorrhage- Post pancreatic haemorrhage (PPH)- Endoscopy/CT in
intraluminal vs. extraluminal
 Delayed gastric emptying (m/c complication) because the pylorus is
removed and X nerve can be damaged. Presents as need for
prolonged nasogastric tube and inability to tolerate oral feeds.
Prevented by PPPD- Pylorus preserving pancreaticoduodenectomy.
 Biliary leak- bile leak from the choledochojejunal anastomosis. Bile
will appear in the drainage fluid.
o Total pancreatectomy?
 Advantages
 Removes any growth that involves the body as well
 Pancreatic carcinomas can be multicentric
 Post whipple’s, there is a chance of local recurrence
 Pancreaticojejunal anastomosis leak causes morbidity and
this can be avoided
 Disadvantages
 Slight increase in mortality
 Need for lifelong supplementation of insulin and pancreatic
enzymes
 o Post surgery- Gemcitabine based chemotherapy for high grade malignancies
or positive margins
 Palliative surgeries if growth is inoperable on exploration
 Palliation of symptoms if metastatic

 Palliative procedures
o Biliary bypass procedure (Triple procedure- Dr. Kate)
 Cholecystectomy is done first. Then Roux-en-Y Choledochojejunostomy,
Gastrojejunostomy and Jejunojejunostomy is done.
 Choledochojejunostomy is better than Cholecystojejunostomy because the
CCJ can get blocked by tumour infiltration/biliary sludge/inflammation
o ERCP with stenting
o Medical treatment of itching- refer discussion part
o Pain palliation
 According to the WHO pain palliation scale (refer Ca stomach document)
 Ethanol injection into the coeliac ganglion
2. Ca Gallbladder
 Risk factors- Gallstone disease, Porcelain Gallbladder, Gallbladder polyps, PSC
 Epidemiology- common in North India
 Treatment
 Assess for resectability- Conditions that preclude resection include liver
mets, peritoneal mets, malignant ascites, encasement of hepatic artery,
portal vein
 Early tumours can be treated with simple cholecystectomy
 Most tumours will require the following
 Extended cholecystectomy with en bloc resection of 2cm margin of
liver bed and any directly involved adjacent organ
 Portal or hepatoduodenal ligament lymphadenectomy
 Frozen section to assess margin in cystic duct. If there is involvement
of cystic duct then extrahepatic bile duct resection should be done
3. Ampullary carcinoma
o Anatomy
 Ampulla of Vater is formed by union of the Pancreatic duct and CBD
 Specifically located at the major duodenal papilla
 Sphincters related to Bile and Pancreatic ducts
 Sphincter Choledochus- terminal part of the bile duct is surrounded
just above its junction with the pancreatic duct by a ring of smooth
muscle called sphincter choledochus. Keeps the lower end of CBD
closed and allows bile to accumulate. When food enters the
duodenum, especially after a fatty meal, the sphincter opens and
bile stored in the GB is poured into the duodenum
  Sphincter Pancreaticus- Usually but not always present. Surrounds
the terminal pancreatic duct
 Sphincter of Oddi/Sphincter ampullae- Surrounds the Ampulla of
Vater

 The term Ampulla of Vater complex includes

Bilirubin physiology**
 One of the important functions of the liver is to secrete bile, usually between 600-1000
ml/day.
 Composition of bile: Water, Bile salts, Bilirubin, Cholesterol, Fatty acids, Lecithin, Electrolytes
(Na, K, Ca, Cl, HCO3-)
 Functions of bile
o Fat digestion and absorption by emulsification of fat particles and aiding in the
absorption through the intestinal mucosal membrane
o Bile helps in the excretion of metabolic products like bilirubin and cholesterol
 Pathway
o Haeme oxygenase forms biliverdin which is reduced to form unconjugated bilirubin
by biliverdin reductase
o UCB combines with albumin in the blood and is taken up by the hepatocytes
o In the hepatocytes, it is conjugated to glucuronic acid by uridine
glucuronyltransferase (UGT) to form CB (which is water soluble)
o CB is secreted into the intrahepatic bile ducts and is temporarily stored in the GB to
concentrate the contents
o CB then enters the duodenum via the common bile duct
o Intestinal bacteria convert CB to urobilinogen (UBG)
o Approx 20% of UBG is recycled to the liver and kidneys
o From the kidneys, it gets excreted in the urine where it gets spontaneously oxidised
to form urobilin which gives urine its colour
o The other 80% gets spontaneously oxidised to form stercobilin which is excreted in
the stool and responsible for the colour of stool
  Bile salts and enterohepatic circulation- read
Classification and causes of jaundice
 Prehepatic jaundice-
 Hepatic jaundice-
 Cholestatic jaundice
o Intrahepatic- Cholestatic phase of viral hepatitis, PSC, PBC, Infiltrative diseases
o Extrahepatic- Surgical causes
Cholestatic pruritus
 Causes- Intrahepatic cholestasis of pregnancy, Primary biliary cirrhosis, Primary sclerosing
cholangitis, Malignant obstructive jaundice, Chronic viral hepatitis
 Pathogenesis- multiple theories
o Bile acids- Elevated levels of bile acids in the skin act as pruritogens by releasing
histamine
o Endogenous opioids- endogenous opioid levels are elevated due to unknown
mechanisms in patients with chronic liver disease
o Lysophosphatidic acid and autotaxin. Autotaxin is an enzyme which produces LPA
 Pharmacotherapy options
o Bile acid sequestrants like Cholestyramine 4-16g/day: Binds anions including bile
acids in the gut lumen, thus preventing them from reaching the skin
o Antihistamines
o Ursodeoxycholic acid (UDCA) in pregnancy
o Opioid antagonists like Naltrexone
o Rifampicin- Potent agonist of the pregnane X receptor (PXR) which mediates
detoxification processes in the liver. It also reduces autotaxin expression
o Sertraline and other SSRIs
o Phenobarbital