Obstructive Jaundice

By
Dr Gedion G(MD, General Surgeon)
YHMC, Department of Surgery
Outline
• Objectives
• Anatomy and physiology of the liver and gallbladder.
• Jaundice
• Clinical presentation of a patient with obstructive jaundice.
• Investigations
• Management of obstructive jaundice.
Objectives
• Describe the physiology and anatomy of the liver and gallbladder.
• List the causes of jaundice.
• Describe the presentation of a patient with obstructive jaundice.
• Explain the investigation and management of obstructive jaundice.
The liver: Anatomy
• The liver is the largest abdominal organ, weighing approximately 1500 g.
• It extends from the fifth intercostal space to the right costal margin.
• It is triangular in shape, its apex reaching the left midclavicular line in the
fifth intercostal space.
• In the recumbent position, the liver is impalpable under cover of the ribs.
• The liver is attached to the undersurface of the diaphragm by suspensory
ligaments that enclose a ‘bare area’, the only part of its surface without a
peritoneal covering.
• Its inferior or visceral surface lies on the right kidney, duodenum, colon
and stomach.
The liver: Anatomy cont…
• Topographically, the liver parenchyma is smooth and provides few external
markings as clues to it underlying segmental anatomy.
• The leading edge of the falciform ligament running on the cranial surface contains
a remnant of the embryological umbilical vein.
• It acts as external guide to the plane between segments 2/3 and 4.
• On its visceral surface the porta hepatis contains the draining extrahepatic biliary
tree and dual vascular inflow (portal vein and hepatic artery) wrapped in a layer
of loose connective tissue that separate segment 4 anteriorly and caudate lobe
(segment 1) posteriorly.
• An imaginary line drawn over the cranial surface from the gallbladder to the
termination of the middle hepatic vein into the inferior vena cava acts a guide to
the principal plane separating the anatomical right and left hemilivers.
• A detailed knowledge of the liver segmental anatomy, as defined by the
distribution of its blood supply is important to the surgeon.
Segmental anatomy
• The portal vein, hepatic artery and draining biliary tree are wrapped in a fibrous
sheath and divide into right and left branches in the porta hepatis.
• Each hemiliver is further divided into sectors and segments by a combination of
branches of the vascular inflow and draining hepatic veins.
• The right hemiliver is divided into the right anterior and posterior sector (separated
by the right hepatic vein) and then segments 8/5 (anterior sector) and 6/7
(posterior sector) by branches of the right hemiliver inflow.
• On the left side, three segments (2, 3, 4) are formed by branches of the left
hemiliver inflow and drained by the left and middle hepatic vein.
• The caudate lobe (segment 1) lies across the inferior vena cava surrounded by the
right and left hemiliver and is supplied by the vascular inflow from both hemilivers
with corresponding biliary drainage.
Blood supply and function
• The liver normally receives 1500 mL of blood per minute and has a
dual blood supply, 75% coming from the portal vein and 25% from the
hepatic artery, which supplies 50% of the oxygen requirements.
• The main venous drainage of the liver is by the right, middle and left
hepatic veins, which enter the vena cava.
• In 25% of individuals, there is an inferior right hepatic vein.
• The venous drainage of the caudate lobe is by numerous small veins
(short hepatics) emptying directly into the vena cava.
Blood supply and function cont…
• The functional unit of the liver is the hepatic acinus.
• Sheets of liver cells (hepatocytes) one cell thick are separated by
interlacing sinusoids
• Blood flows from the peripheral portal tract into the hepatic acinus to
the central branch of the hepatic venous system.
• Bile is secreted by the liver cells and passes in the opposite direction
along the small canaliculi into interlobular bile ducts located in the
portal tracts.
Blood supply and function cont…
• The liver has an important role in nutrient metabolism and is responsible for storing
glucose as glycogen, or converting it to lactate for release into the systemic circulation.
• Amino acids are utilised for hepatic and plasma protein synthesis or catabolised to
urea.
• The liver has a central role in the metabolism of lipids, bilirubin and bile salts, drugs
and alcohol.
• It is the principal organ for storage of a number of minerals and vitamins, and is
responsible for the production of the coagulation factors I, V, XI, the vitamin K-
dependent factors II, VII, IX and X as well as proteins C and S and antithrombin.
• The liver is also the largest reticuloendothelial organ in the body and its Kupffer cells
play a role in the removal of damaged red blood cells, bacteria, viruses and endotoxin,
much of which enter the body from the gut.
Jaundice
• Jaundice is caused by an increase in the level of circulating bilirubin
and becomes obvious in the skin and sclera when levels exceed 50
μmol/L.
• It may result from excessive destruction of red cells (haemolytic
jaundice), from failure to remove bilirubin from the bloodstream
(hepatocellular jaundice), or from obstruction to the flow of bile from
the liver (cholestatic or obstructive jaundice).
• Congenital nonhaemolytic hyperbilirubinaemia (Gilbert’s syndrome) is
a relatively rare cause of jaundice due to defective bilirubin transport;
the jaundice is usually mild and transient, and the prognosis is
excellent.
Jaundice cont…
• To the surgeon, the most important type of haemolytic jaundice is that
caused by hereditary spherocytosis, in which splenectomy may be
necessary (Chapter 15).
• Haemolytic jaundice may also occur after blood transfusion and after
operative or accidental trauma, when haematoma formation produces a
pigment load that exceeds hepatic excretory capacity.
• Hepatocellular jaundice is usually a medical rather than a surgical
condition, although its recognition in patients presenting with abdominal
pain is important, as surgical intervention may aggravate the hepatocellular
injury.
• Cholestatic jaundice due to intrahepatic obstruction of bile canaliculi may
be a feature of acute and chronic liver disease.
Jaundice cont…
• Examples include drugs such as antibiotics, antituberculosis and HIV therapies.
• This form of jaundice must be differentiated from that due to extrahepatic obstruction, the
causes of which have the most surgical relevance.
• Extrahepatic obstruction most commonly results from gallstones or cancer of the head of the
pancreas.
• Other causes can be broken down into lesions of the lumen, lesions of the wall or extrinsic
compression.
• Examples of luminal causes include parasitic infection or medically placed stents.
• Examples of lesions of the wall include primary neoplastic lesions such as cholangio or
ampullary carcinoma, inflammatory lesions such as primary sclerosing cholangitis,
postsurgical strictures or autoimmune disease or congenital lesions such as choledochal cysts.
• Extrinsic compression can result from neoplastic lesions such as metastatic nodal disease,
inflammatory pseudocysts or chronic pancreatitis.
Diagnosis: History and clinical examination
• An accurate, rapid diagnosis of the cause of jaundice allows prompt institution of
appropriate treatment.
• The age, sex, occupation, social habits, drug and alcohol intake, history of injections
or infusions, and general demeanour of the patient must be considered.
• A history of intermittent pain, fluctuant jaundice and dyspepsia suggests calculous
obstruction of the common bile duct, whereas a history of weight loss and
relentless progressive jaundice favours a diagnosis of neoplasia.
• Obstructive jaundice is likely if there is a history of passage of dark urine and pale
stools, and if the patient complains of pruritus (owing to an inability to secrete bile
salts into the obstructed biliary system).
• Hepatocellular jaundice is likely if there are stigmata of chronic liver disease, such as
palmar erythema, spider naevi, testicular atrophy and gynaecomastia.
Diagnosis: Biochemical and haematological
investigations
• The abdomen must be examined for evidence of hepatomegaly or
gallbladder distension (not usually found with gallstones), and for signs of
portal hypertension such as splenomegaly, ascites and large collateral veins
(caput medusae) in the abdominal wall.
• Haemolytic jaundice is suggested if there are high circulating levels of
unconjugated bilirubin but no bilirubin in the urine.
• Serum concentrations of liver enzymes are normal in these circumstances
and the appropriate haematological investigations should be done.
• In jaundice due to biliary obstruction, the circulating bilirubin is conjugated
by the liver and rendered water-soluble; it can then be excreted in the urine
and gives it a dark colour.
Diagnosis: Biochemical and haematological
investigations cont..
• As bile cannot pass into the gastrointestinal tract, the stool becomes pale and
urobilinogen is absent from the urine.
• Obstruction increases the formation of alkaline phosphatase from the cells lining
the biliary canaliculi, producing raised serum levels.
• It is believed that bile acids may act to solubilise membranes and thus promote
the release of alkaline phosphatase.
• The increased levels correlate with the severity of luminal obstruction and are
used as a better estimate of bile flow patency postoperatively even when bilirubin
levels have normalised.
• This rise precedes that of bilirubin and its fall is more gradual once obstruction is
relieved. Serum transaminase and lactic dehydrogenase levels may rise in
obstruction.
Diagnosis: Biochemical and haematological
investigations cont…
• Conversely, swelling of the parenchyma in hepatocellular jaundice
frequently produces an element of intrahepatic biliary obstruction
and a modest rise in serum alkaline phosphatase concentration.
• Full blood count and coagulation screen should be undertaken as a
matter of routine and viral status should be determined.
• Anaemia may signify occult blood loss, and a low white cell or platelet
count may indicate hypersplenism due to portal hypertension.
• Prolongation of the prothrombin time may be present in both
hepatocellular and cholestatic jaundice.
Radiological investigations
• Ultrasonography
• In skilled hands, this key investigation is safe, noninvasive and reliable using ultrasound
wave echoes reflected from tissues at various depths
• It is used to define whether the patient has bile duct dilatation or gallbladder distension
due to obstruction.
• Obstructive or surgical jaundice is diagnosed by the presence of dilated intrahepatic biliary
radicles that the sonologist can follow distally to determine the level of obstruction.
• The cause of obstruction may also become clear.
• Ultrasonography will also detect gallstones (seen as a hyperechoic lesion casting a classic
‘acoustic shadow’)
• For the same reason, stones in a dilated common bile duct may not always be seen clearly.
Radiological investigations cont…
• Magnetic resonance imaging (MRI)
• Magnetic resonance cholangiopancreatography (MRCP) has largely replaced other
forms of invasive radiological imaging of the bile duct and pancreas.
• MRI has the advantage that it does not introduce infection into an obstructed biliary
system or the pancreatic duct.
• The T2-weighted MRI scans are reconstructed by software to show the entire biliary
tree with luminal stones or obstruction seen as filling defects amidst the biliary
secretions, seen as white in the absence of any contrast.
• MRCP is performed without contrast and therefore is only useful for assessment of
stones.
• To fully stage hepatic, biliary or pancreatic tumours invading the biliary tree, contrast
is required to obtain arterial, portal venous and delayed hepatobiliary phases.
Radiological investigations cont…
• Endoscopic retrograde cholangiopancreatography (ERCP)
• ERCP is now restricted to therapeutic indications.
• It outlines the biliary and pancreatic systems by injecting contrast through a cannula
inserted into the papilla of Vater
• It gives more detailed information than ultrasonography and allows endoscopic
extraction of common bile duct stones, biopsy of periampullary tumours, and relief of
obstructive jaundice by stent insertion.
• Distal obstructions are more amenable for stenting than proximal or hilar obstructions.
• Stenting should be performed only in the presence of uncontrolled sepsis or for
malignant lesions when an operation is considered inappropriate.
• The investigation may be complicated by acute pancreatitis, and prophylactic antibiotics
should be administered
Radiological investigations cont…
• Percutaneous transhepatic cholangiography (PTC)
• PTC is restricted to a therapeutic role for proximal biliary lesions or when ERCP has failed
for distal lesions or cannot be used due to anatomical considerations.
• Access to the biliary system is achieved by a slim flexible needle passed into the liver
under ultrasound and fluoroscopic guidance.
• Injecting contrast while withdrawing the needle under fluoroscopic guidance achieves
access to the dilated intrahepatic biliary radicles.
• Complications of PTC include bleeding, bile leakage, bacteraemia and renal dysfunction.
• Hence coagulation status must be checked, antibiotic cover should be given and the
patient should be well hydrated prior to the procedure.
• The procedure is considered unsafe in the presence of ascites, bleeding disorders and
hepatic hydatidosis.
Radiological investigations cont…
• Computed tomography (CT)
• Contrast enhanced CT can be used to identify and stage hepatic, bile duct and
pancreatic tumours in jaundiced patients.
• It is also used to diagnose acute pancreatitis (in cases where there is doubt) and assess
viability of pancreatic tissue in severe pancreatitis.
• Other radiological investigations
• Positron emission tomography (PET-CT) has found an increasing role in staging
hepatobiliary and pancreatic (HBP) malignancy.
• Isotopic liver scanning has been superseded by ultrasonography and CT.
• Selective angiography has been largely superseded by CT and MRI assessment of
vascular anatomy but may be used for embolisation of tumours or haemorrhagic
complications of HBP disease.
Radiological investigations cont…
• Liver biopsy
• Liver biopsy may be considered in patients with unexplained jaundice, in whom an
obstructing lesion has been excluded radiologically.
• ‘Targeted’ liver biopsy can be conducted under ultrasound or CT guidance.
• Prothrombin time, platelet count and hepatitis B surface antigen (HBsAg) status must
always be determined, and clotting abnormalities should be corrected before biopsy is
undertaken.
• Ascites remains an absolute contraindication to perform any type of liver puncture.
• Laparoscopy
• Laparoscopy under general anaesthesia may be used in the evaluation of liver disease.
• In selected patients with malignancy of the liver, pancreas and biliary tree, it may have a
role in the staging of the tumour to exclude peritoneal or hepatic dissemination.
Managing the patient with jaundice
• Given the important synthetic and excretory function of the liver, the
development of obstructive jaundice can lead to significant metabolic
derangement and disrupted haemostatic equilibrium.
• The most common abnormality is prolongation of the prothrombin time,
but this should readily correct within 36 hours with the administration of
parenteral vitamin K when jaundice is cholestatic.
• Prophylactic measures aimed at preventing venous thromboembolism
should therefore be considered.
• Patients with longstanding jaundice can become malnourished and
develop steatorrhoea particularly if combined with pancreatic duct
obstruction as seen with pancreatic head cancer.
Managing the patient with jaundice cont…
• Nutritional supplementation and pancreatic enzyme replacement
therapy may be indicated.
• Jaundiced patients are also at risk of renal dysfunction.
• Although the aetiology is not fully understood it is likely that an
enteric endotoxin crosses into the systemic circulation due to the
absence of enteric bile salts, leading to renal vasoconstriction.
• Further contributing factors include cardiovascular depression
secondary to jaundice resulting in peripheral vasodilatation.
Managing the patient with jaundice cont…
• When combined with hypovolaemia or septicaemia this can precipitate
acute renal failure and is associated with a high mortality.
• Ensuring patients are well hydrated, aggressive treatment of suspected
sepsis and early biliary decompression are all important preemptive
measures.
• Jaundiced patients are at increased risk of cholangitis and subsequent
septicaemia due to bacterial translocation (retrograde or
haemotogenous) into the biliary tree or by iatrogenic introduction
during interventional procedures.
• Resuscitation, antibiotic therapy and biliary drainage are key to
successful management outcome.
References

• Bailey & Love’s Short Practice of Surgery, 27th Ed.

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