View Full Version : CALCULAR OBSTRUCTIVE JAUNDICE (Etiology-Pathology-Clinical picture-Investigations-Treatment)

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06-06-2008, 02:33 PM
m Aetiology: Stone in the biliary passage which may be:
1- Primarily formed in C.B.D.(80% of cases): many years after cholecystectomy or due to infection of the biliary tree or infestation by Ascaris lumbricoides or Clinorchis sinensis.
2- Migrating from the gall bladder.
m Pathology:
(I) At site of obstrction: stone which may impacted in
1- Supraduodenal portion of C.B.D. "common".
2- Retroduodenal portion of C.B.D. "2nd common".
3- Ampulla of vater.
4- Common hepatic duct [very rare].
(II) Above the site of obstruction:
a) Bile passages: Dilated with stasis & infection.
b) Gall bladder: Contracted in 80% of cases according to Courvoisier's law; {In case of obstructive jaundice, if the gall bladder is felt this is in favour of malignant obstruction and if not felt this is in favour of calcular obstruction}
But G.B. may be dilated when:
"Exceptions of the law".
1- Stone is 1ry formed in C.B.D ® with healthy G.B.
2- Cholesterol stone ® No infection.
3- Double impaction one in cystic & one in C.B.D.
4- Big stone in Hartmann's pouch obstructing common bile duct from outside and ® mucocele of G.B.
c) Liver:
1- If no infection ® Aseptic dilatation of intrahepatic biliary radicals ® hydro hepatosis ® enlarged firm grannular brownish liver ® later on ® biliary cirrhosis.
2- If there is infection ® pus in the bile passages and multiple abscesses in the wall ® fibrosis ® shrunken liver.
3- Failure of bile secretion ® white bile with bad prognosis.
4- Bile regurge into circulation ®high serum bile salts and cholebilirubin.
(III) Below the Site of Obstruction:
Bile cann't descend to intestine leads to decrease bile salts & stercobilinogen in stool and urobilinogen in urin.
The bile salts is Needed for:
1- Digestion of fat & its absorption.
2- Absorption of fat soluble vit. e.g."vit k".
3- Help in intestinal motility.
4- Inhibit bacterial growth and fermentation of stool. So the stool become pale, bulky, greazy and offensive.
mCl. Picture:
q Incidence: Common in 5 F.
q Symptoms: Charcot's triad: Intermittent pain, fever and jaundice.
In many cases the presence of stone give no complete obstruction of the common bile duct but give stasis ® infection (cholagitis) ® oedema (more obst.) ® pain, fever, jaundice ® (yellow discoloration of skin & mucous membrane). When infection and oedema subsides the pain, fever and jaundice will disappear.
q Signs:
Ÿ Marked itching due to deposition of bile salts in skin.
Ÿ Bradycardia due to effect on vagus nerve.
Ÿ Tenderness in Rt. hypochondrium.
Ÿ Murphy's sign & Boas sign +ve.
Ÿ Gall bladder is not felt (according Courvoisier's law).
I. Laboratory investigations:
a) Urine: dark due to ­ cholebilirubin.
b) Stool: Pale due to decrease stercobilin. Bulky and greasy due to increase fat content. Offensive due to high bacterial content.
c) Blood: Liver function tests shows increase in serum bilirubin. Direct bilirubin more, High alkaline phosphatase > 30 king Armstrong units.
II. Radiological investigations:
a) Plain x-ray: gall stones in appears only 15% of cases as the liver shadow hide the stone shadow in many cases.
b) Ultrasonography: The least invasive and it can detect stone in C.B.D. and dilated biliary tree. It can describe the pancreas and liver for further investigations if malignancy is suspected. Now, it is considered as the standard initial imaging technique for the biliary disease.
c) Magnetic Resonance Cholangio-pancreatography (MRCP). MRCP is considered now the standard technique to investigate the biliary system. Contrast is not necessary and with appropriate computing, a clear outline of the biliary tree and bile duct stone can be achieved. The technique will replace alternative diagnostic aids.

III. E.R.C.P.'Endoscopicretrogradeecholangio-pancreatography':
Injection of the dye directly to the common bile duct through endoscopic cannula in the duodenal papillae ® delineation of biliary tree and pancreatic duct. It can detect the level and nature of obstruction.
Through E.R.C.P. many therapeutic techniques can be done:
a) Impacted stone in the ampulla of Vater can be extracted using Dormia basket.
b) Endoscopic papillotomy may help stone extraction.
c) Stents can be inserted into the ampulla to maintain drainage when trial for stone extraction is failed
IV) Percutaneous Trans-hepatic Cholangiography,( P.T.C).:
Special needle is introduced into the liver, guided by ultrasonography or CT, till it reach a dilated intrahepatic biliary radicals. The dye is injected to delineate the biliary tree from above downward till the site of obstruction. If done at the same time with ERCP the cause of obstruction can be more accurately defined.
It can provide preoperative bile drainage and facilitate subsequent percutaneous choledochoscopy .
V) Computerised tomography (CT):
It is not a useful technique in investigating the biliary tree. Its only value is in the investigation of patients who may have a cancer of the gall bladder or bile ducts. It can define the tumour extent and presence of lymphadenopathy or metastases.
F N.B: Oral and I.V. cholecystography are contraindicated.
m Treatment:
] Preoperative Preparation of the Patient:
i. High carbohydrate diet to support the liver.
ii. Vit. K injection.
iii. I.V. Fluids glucose 25% + saline.
iv. Antibiotics.
As soon as resuscitation has taken place relief of obstruction is essential. This can be obtained either by minimally invasive techniques or by surgery.
] Minimally invasive techniques:
Endoscopic papillotomy is the preferred first technique with sphincterotomy and removal of the stones using a Dormia basket. If stone removal is impossible stent can be placed for drainage of bile.
If this technique failed PTC is done for more anatomical diagnosis and drainage of bile through the needle, then percutaenous choledochoscopy is done.
] Operation:
1- If the patient is with good general condition®choledecholithotomy (removal of the stone through C.B.D) and cholecystectomy (to prevent further stone formation).
2- If the patient is with bad general condition ® chdedecholithotomy alone is done.
Choledecholithotomy is done as follows:
1- Either supraduodenal or transduodenal approach.
2- The stone is removed.
3- T tube is inserted in the common bile duct.
· T tube is maleable rubbery tube which can be withdrawn after 10 days of operation with no pain.
· Surgery is now rarely used as most patients can be managed by minimally invasive techniques, followed by laparascopic cholecystectomy.
(III) Management of T tube:
It is clamped at the 10th day after op. If there is no pain, jaundice or bile leakage remove it. If there is pain & jaundice then do T tube cholangiography, stone may be found (missed stone).
m Management of residual stone:
It is the stone discovered within two years postoperative.
A- If T tube is present:
i) Flushing with heparinised saline. if failed
ii) Flushing with Monoctenium or Ether to dissolve stone. if failed
iii) ERCP and try to extract it by basket forceps. if failed
iv) Leave the T tube for 4 weeks till good fibrous tract will be formed through which basket forceps can extract the stone. if failed re-exploration is needed.
B- If there was no T tube ® Remove it by basket forceps, through ERCP or percutaneus choledochoscope and if failed ® Re-exploration (better avoided).
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