1. THE JAUNDICED PATIENT
BY
DR.SEFEEN SAIF ATTYA
SOHAG TEACHING HOSPITAL

3. JAUNDICE
 Jaundice is a syndrome ,the hallmark of which
is yellowish discoloration of body tissues
produced by an excess of circulating bilirubin
(conjugated or unconjugated)
 Normal serum bilirubin is ranging from 0.1-1
mg % and jaundice is detected clinically in
the sclera of the eye when the level rises above
2.5 mg%
 It is most evident in tissues which have a high
elastic tissue content (skin –sclera of the eye –
blood vessels)

4. BILIRUBIN METABOLISM
 Bilirubin is formed from haem (a compound of iron and
protoporphyrin) , Haem comes from breakdown of mature red cells
in the reticuloendothelial system
 This unconjugated bilirubin which is water insoluble is toxic and
transported attached to plasma proteins to the liver cells
 In the hepatic cells it is conjugated into water soluble bilirubin
(conjugated bilirubin)
 Conjugated bilirubin is excreted into the bile canaliculi
Disturbance of the flow of bile led to stagnation and retention of
conjugated bilirubin (cholestasis)which may occur in the
intrahepatic bile ducts (intrahepatic cholestasis)or in the extrahepatic
bile ducts (extrahepatic cholestasis)

5. Mechanisms of jaundice
)1(Excess bilirubin production
)2(impaired uptake and transport of bilirubin by the hepatocytes
)3(failure of conjugation
)4(Impaired secretion of conjugated bilirubin into the bile canaliculi
)5(Impaired bile flow subsequent to secretion by the hepatocyte
Thus there are 3 categories of jaundice
Haemolytic jaundice)1(
Hepatocellular jaundice)2-4(
)Obstruvtive jaundice)5

6. Classification of Jaundice
Defect in bilirubin metabolism Predominant hyperbilirubinemia Examples
Increased production Unconjugated Congenital hemoglobinopathies,
hemolysis, multiple transfusions,
sepsis, burns
Impaired hepatocyte uptake Unconjugated Gilbert’s disease, drug induced
Reduced conjugation Unconjugated Neonatal jaundice, Crigler–
Najjar syndrome
Impaired transport and excretion Conjugated Hepatitis, cirrhosis, Dubin–Johnson
syndrome, Rotor syndrome
Biliary obstruction Conjugated Choledocholithiasis, benign strictures,
chronic pancreatitis, sclerosing
cholangitis, periampullary cancer,
cholangiocarcinoma

7. The term cholestatic jaundice may be
intrahepatic (hepatic disease impairing
transport of conjugated bilirubin from the
hepatocyte to bile canaliculi and intrahepatic
ducts)
or Extrahepatic (from large bile duct
obstruction)
The later is referred to as surgical jaundice

8. JAUNDICE DUE TO INCREASED BILIRUBIN LOAD
(HAEMOLYTIC JAUNDICE-UNCONJUGATED HYPERBILIRUBINAEMIA(
Hereditary spherocytosis
Sickle cell anaemia
Thalassaemia
acquired haemolytic anaemia
Incompatible blood transfusion
Severe sepsis
drugs

9. DISTURBED BILIRUBIN UPTAKE &
CONJUGATION
Grigler –najjar familial non-haemolytic
jaundice
Familial neonatal hyperbilirubinaemia
Gilbert’s familial non haemolytic
hyperbilirubinaemia
Viral hepatitis
Hepato-toxins
cirrhosis

10. DISTURBED BILIRUBIN EXCRETION
(CHOLESTASIS(
A- intrahepatic cholestasis
Cirrhosis
Vira hepatitis
Drugs(chlorpromasine- oral contraceptives)
Dubin-johnson familial conjugated
hyperbilirubinaemia
Primary biliary cirrhosis(chronic non-
suppurative destructive cholangitis)

11. B-EXTRAHEPATIC CHOLESTASIS
1-INSIDE DUCT
Ductal stones
F.B.(broken T-tube)
Parasites (hydated liver fluke, round worm)
Titanium clips internalization
2-IN DUCT WALL
Congenetal atresia
traumatic stricture
Sclerosing cholangitis
Bile duct tumours
3-OUTSIDE WALL
Cancer head pancreas
cacer ampulla of vater
Pacreatitis
Porta hepatis metastasis

12. INVESTIGATION OF THE
JAUNDICED PATIENT
Parenchymal(hepatoc
ytes(
ALT AST
canalicular(biliary) ALP, 5'NT, GGT
synythetic Function and
metabolism
INR, bilirubin, albumin
A- LABOLATORY TESTS

13. B- Imaging studies
NON-INVASIVE METHODS
1-ULTRASOUND
 Ultrasonography is both sensitive and specific in
detecting gallbladder stones and dilatation of bile ducts.
Ultrasound usually misses stones in the common duct.
When ultrasound shows dilated bile ducts, THC will
nearly always be technically successful.

14. ultrasound image demonstrate the normal gallbladder The thin wall of
the gallbladder is seen as a white ring surrounding bile, which appears
as a black fluid. The wall thickness should be less than 3 mm in adults.
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15. 2-SPIRAL C.T.
 Spiral C.T. with I.V. contrast enhancement
is essential in all patients with suspected
tumours
 I.V. superparamagnetic ferric oxide
(endorem) which yields even greater definition
 This shows liver tumours as white areas (no
kupffer cells) against a black background
(contrast in kupffer cells)

16. CT image demonstrates a large gallstone in
the gallbladder

17. 3-RADIONUCLIDE SCAN (HIDA SCAN)
 Technetium 99m-labeled derivatives of
iminodiacetic acid (IDA) are excreted in high
concentration in bile and produce excellent
gamma camera images.
 Following intravenous injection of the
radionuclide, imaging of the bile ducts and
gallbladder normally appears within 15–30
minutes.

18. 4-Magnetic Resonance Imaging
 Available since the mid-1990s, MRI provides
anatomic details of the liver, gallbladder, and
pancreas similar to those obtained from CT.
 Using MRI with newer techniques and contrast
materials, accurate anatomic images can be
obtained of the bile ducts and the pancreatic duct.
It has a sensitivity and specificity of 95 and 89%,
respectively, at detecting choledocholithiasis.

19. 5-MAGNITIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
Is completely non-invasive and does not require
injection of contrast
It is a specialized type of MRI that uses radio
waves and magnets to obtain pictures of the
bile ducts

20. INVASIVE METHODS
1-PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY
 PTC is performed by passing a fine needle through
the the hepatic parenchyma and into the lumen of a
bile duct. Water-soluble contrast material is injected,
and x-ray films are taken.
 The technical success is related to the degree of
dilatation of the intrahepatic bile ducts. THC is
especially valuable in demonstrating the biliary
anatomy in patients with lesions of the proximal bile
duct, or when ERCP has been unsuccessful.

21. These two radiographs demonstrate the skinny needle used to
puncture the bile duct during PTC.

22.  THC should not be done in patients with
cholangitis until the infection has been
controlled with antibiotics.
 Virtually all patients should be premedicated
with antibiotics regardless of whether they
have cholangitis or not
 septic shock has been produced by sudden
inoculation of organisms from bile into the
systemic circulation

23. 2-ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP(
 ERCP involves cannulating the sphincter of
Oddi under direct vision through a side-viewing
duodenoscope.
 Usually, it is possible to opacify the pancreatic
as well as the bile ducts.
 It is usually the preferred method of examining
the biliary tree in patients with presumed
choledocholithiasis or obstructing lesions in the
periampullary region.

25. The endoscope transmits dynamic images of the lumen of
the gut allowing the physician to carefully examine the
lining. During the procedure air is blown into the digestive
tract to expand mucosal folds making examination
thorough

26. The ERCP is usually performed in the radiology department under
fluoroscopic guidance. The patient is sedated, and the endoscope inserted
through the mouth into the duodenum. The physician looks for the major
duodenal papilla to insert the guide catheter to perform the retrograde
study of the biliary tree

28. This picture shows the catheter from the endoscope within
the papilla. This allows the physician to perform a
retrograde filling of the biliary tree.

29. This picture shows the major duodenal
papilla before the endoscope is inserted.

30. 3-Endoscopic ultrasonography (EUS(
With the considerable advances in transducer
technology and related image-processing software
,EUS has been shown to be extremely useful for
the diagnosis and staging of bile duct and
proximal pancreatic pathology
A more recent development is intraductal
ultrasonography (IDUS( where a fine transducer
probe is introduced in the bile or pancreatic duct
at ERCP

33. 4-Laparoscopy with laparoscopic contact US
This provides the most senitive and reliable
assessment ,staging of hepatic ,biliary and
pancreatic cancers

34. C- LIVER BIOPSY
 Should not be done until a bleeding tendency
has been excluded
 The procedure is hazardous in the presence
of ascites
 Hydatid disease of the liver must be excluded
as accidental puncture can spread the disease
throughout the peritonial cavity or give rise to
anaphylactic shock

35. SURGICAL JAUNDICESURGICAL JAUNDICE
1-Gallstones and ductal calculi
2-Pancreatic disease
3-biliary malignancy
4-hepatic malignancy
5-benign bile duct strictures

36. 1-GALLSTONES & DUCTAL CALCULI
Gallstones are very common worldwide ,the prevalence is
18% with a female preponderance (2-1(
The currentaly accepted classification recognizes 3 main
types of gallstones
A-cholesterol stones: essentially metabolic stones that form in
the gall bladder
B-black pigment stones : form in the gall bladder and consist
of bilirubin pigments with a varrying amount of cholesterol
C- brown pigment stones :form in the bile ducts (primary
ductal stones( ,they are amorphous soft stones that consist of
calcium bilirubinate and palmitate bound in a matrix of
organic material

37. DUCTAL CALCULI
 Ductal calculi can result from migration of gallstones
through a patent cystic duct (secondary ductal calculi –
black pigment calculi( or formed de novo in the ducts
(primary ductal calculi-brown pigment stones(
 Ductal calculi may form around foreign bodies within
the lumen of the common bile duct ,a common
example of this nowadays is caused by the
internalization of titanium metal clips used to secure
the medial end of the cystic duct stump during
laparoscopic cholecystectomy ,the patient present
several months after an uneventful L.C.with jaundice
and /or cholangitis

38. ERCP demonstrates stones in the common bile duct on
the left radiograph, and cystic duct on the right radiograph

39. CLINICAL TERMS TO DESCRIBE DUCTAL CALCULI
UNSUSPECTED STONES
Are those discovered accidentally when routine
intraoperative cholangiography is performed
,these stones are usually small and floating and
the C.B.D. is of normal caliber
MISSED STONES
Are stones missed after intervention (surgical or
endoscopic) that fails to achieve complete ductal
clerance
Ductal calculi that diagnosed within 2 years of the
intervention are described as missed stones

40. RECURRENT STONES
Present at least 2 years after the first intervention
These tend to be primary ductal stones (brown
pigment stones)and are almost always
associated with dilatation of the C.B.D.

41. MANAGEMENT
1-GALLSTONES AND DUCTAL CALCULI
 Cholecystectomy is only indicated for symptomatic
gallstones and their copmlications (acute
cholecystitis,acute pacreatitis ,jaundice due to ductal
calculi)
 There is now firm evidence from several prospecive
randomized trials that “early” cholecystectomy for
acute cholecystitis (operation within the same hospital
admission )is superior to “delayed” cholecystectomy
(2-3 month after resolution of the attack )provided the
patient is fit for surgery and anaesthesia

42. operative cholangiogram. The catheter is inserted into the cystic duct
and contrast media injected as radiographs are taken. The entire distal
biliary tree is demonstrated without stone or dilation of the ducts. This
confirms that stones are limited to the gallbladder, which was removed

43. The benefits of early cholecystectomy include
 Reduced overall morbidity
 Reduced hospital stay
 Prevention of further attacks that may occur in
patients managed by yhe delayed
cholecystectomy policy
Unfit patients should be treated conservatively in
the first instance with the expectation that acute
cholecystitis will resolve in 80% of cases

44. If this conservative treatment fails or in cases
with empyema of the G.B. an ulrasound
laparoscopically guided cholecystostomy or
microcholecystostomy (under u/s guidance )
will tide the patient over the critical illness

45. The current treatment for patients with
concomitant ductal stones is preoperative
endoscopic stone extraction followed by
cholecystectomy preferably during the same
hospital admission
Single stage L.C. and ductal stone clerance either
by the transcystic route (stones <6mm )or by
laparoscopic supraduodenal direct C.B.D.
exploration (large stones) is prefered in some
centres instead of the two-stage approach

46. A large cholesterol stone (white arrow) is released
from a wire basket into the duodenum

47. sphincterectomy (blue arrow) was performed to
allow a stone to be removed and release
stagnated bile into the duodenum

48. This image
demonstrates the
completion of the
ERCP. A stent has
been placed in the
common bile duct
(white arrow).
After a stone was
removed

49. T-tube cholangiogram. The tube inserted into the common bile duct. As you
can see the tube is long extending to the outside of the body.

50. 22--PANCREATIC DISEASEPANCREATIC DISEASE
Periampullary cancers are usually resectable and
are treated by pancreatoduodenectomy if the
patient is fit for major surgery
By contrast most proximal pancreatic
adenocarcimomas are not resectable and are
managed palliatively (biliary bypass) with
stenting (by interventional endoscopy or
interventional radiology)

51.  In patients with jaundice thought to be due to chronic
pancreatitis the options are between a formal
pancreatoduodenectomy or subtotal resection of the head
leaving a rim of pancreas in the duodenal curve and
releasing the transpancreatic duct (Beger’s procedure)
 Amodification of Beger’s procedure involves transection
of the bile duct just above the pancreas with reimplantation
into the duodenum , Both operations preserve the duodenum
 If there is doubt concerning the diagnosis the appropriate
procedure is a formal pancreatoduodenectomy

52. 3-BILIARY TRACT MALIGNANCIES
A-CARCINOMA OF THE GALLBLADDER
 is the most common malignancy of the
biliary tract and accounts for 3-4 % of all
gastrointestinal malignancies
 It is a disease of old age and carries a poor
prognosis
 Gall stones are present in 75-90% of cases

53. B-BILE DUCT CANCERS (cholangiocarcinomas)
1-intrahepatic:from major hepatic ducts
2-proximal:from right and left hepatic ducts ,hilar
confluence and proximal CHD
3-middle :from distal CHD ,cystic duct and its
confluence with the CHD
4-distal: included with periampullary tumours
Radiologically they give rise to a stricture with
proximal dilatation

55. TREATMENT OF BILIARY MALIGNANCY
cacinoma of the gall bladder is a miserable
disease that is always incurable when
diagnosed clinically
Palliation of the jaundice and itching due to
involvement of the C.H.D. is achieved by
endoscopic or radiological stenting
In the rare instance when the disease is
resectable and the patient is fit resection is
indicated

56. If the tumour invades the hepatic parenchyma
a right hepatectomy with resection of the
C.B.D.and nodal clearance is performed
In selected cases if the lesion is confined to the
G.B. the liver resection is limited to the gall
bladder bed

57. Middle and distal bile duct tumours are
resected with removal of the pancreas and
duodenum
Proximal tumours (hilar) may be resected if the
patient’s condition is good . The resection
extendes beyond the bifurcation and must
always include the caudate lobe
Non-resectable or inoperable bile duct tumours
can be either stented or bypassed surgically

58. Expandable metalic wall stents give better
palliation than plastic stents
There is some debate as to whether surgical
palliation should include a gastroenterostomy
in addition to biliary bypass

59. 4-HEPATIC
MALIGNANCY
 hepatic malignancy can be primary (H.C.C.)
or secondary from a primary in another site
 The presence of jaundice in association
with liver tumours indicate extensive
involvement of the liver parenchyma with the
patient being incurable and unlikely to
benefit from any form of treatment

60. HEPATOCELLULAR CARCINOMA
 may arise on a morphologically normal liver or
complicate established cirrhosis
The aetiology is varied but the vast majority is the
result of HBV or HCV
 Some cases are associated with oral
cotraceptives and androgenic steroids
 Ingestion of food contaminated with aflatoxins
produced by fungus Aspergillus flavus has been
incriminated in some cases

61. Symptoms include pain in the right
hypochondrium ,hepatic enlargement and
ascites
In some cases the tumour gives rise to
systemic manifestations including
polycythemia, carcinoid syndrome
,hypoglycaemia and hypercalcaemia
Raised alpha-fetoprotein is present in 60-70%
of cases

62. HEPATIC METASTASIS
 90% of hepatic tumours are metaststic from
primary in the gastrointestinal tract
,pancreas,lungs and breast
 The most common are secondary hepatic
deposits from colorectal cancer
 Morphologically on laparoscopic inspection
secomdary hepatic tumours may be
1- discretely nodular : (single or muliple)
2-miliary: widespread small seedling deposits

63. TREATMENT OF HEPATIC
TUMOURS
Hepatocellular carcinoma
Only patients who are not jaundiced ,have no
evidence of disease elsewhere (including
hepatic nodes) and are fit with good liver
functions are suitable for hepatic resection
Hepatectomy is not usually possible in
patients who develop the disease on a
backgroud of cirrhosis ,treatment is by in situ
ablation or embolization

64. Secondary tumours
 usually from colorectal cancer are a much
more common problem
 There is a definite place for surgical resection
if the disease is confined to one side and there
are no more than 3 deposits
 The most imortant factor infuencing outcome
after surgical resection is a tumour free margin
of at least 1.5 cm

65.  Systemic chemotherapy with high dose 5FU
with folinic acid induces disease regression in
30% of cases
 There is no evidence that regional hepatic
intra-arterial chemotherapy is any more
effective than systenic chemotherapy

66.  Only discretely nodular disease is potentially
curable by surgical resection
 Only 5% of patients with hepatic metastasis
are suitable for this treatment
 Palliation can be obtained by systemic
chemotherapy and by insitu ablation
techniques provided that the extent of hepatic
involvement is <25%

67. IN SITU ABLATION
In situ ablation either laparoscopic or image –
guided can be achieved by:
1-alcoholinization (small lesions <2 cm)
2-cryosurgery with high eficiency liquid
nitrogen
3-radiofrequency thermal ablation
4-interstitial laser hyperthermia

68. The advantage of in situ ablation is that it can
be repeated if new lesions or recurrence at
the treated sites detected on follow up
The early results of a combination of in situ
ablation with systemic chemotherapy look
very promising

69. 5-BENIGN BILE DUCT STRICTURES
1-Iatrogenic bile duct injury during
cholecystectomy
2-the constriction and compression of the
intrapancreatic segment of the CBD by the
pseudotumour of chronic pancreatitis
3-parasitic infestation of the biliary tract
4-multiple strictures of sclerosing cholangitis

70. ERCP
Radiograph
shows a
stricture of
the
common
bile duct.

71. SCLEROSING CHOLANGITIS
Is arare chronic disease characterized by fibrous
thickening of the intrahepatic or extrahepatic bile
ducts often associated with multiple strictures
CAUSES
PRIMARY SCLEROSING CHOLANGITIS: the
exact cause of which remains unknown ,probably
an autoimmune disease
SECONDARY TO :ductal stones,congenital lesions
or operative trauma

72. PRESENTATION
 the disease is 2-3 times more common in men
than in women
 Symptoms include malaise ,jaundice,abdominal
pain ,anorexia,weight loss ,fever,pruritis
About one third of cases are associated with
chronic inflammatory bowel disease (U.C. or
C.D.)
 Hepatitis virus does not cause primary
sclerosing cholangitis

73. DIAGNOSIS
 The diagnosis of primary sclerosing cholangitis is based on
clinical suspicion confirmed by cholangiographic demonstration of
multiple strictures separated by segments of ducts of normal or
increased diameter (beaded apperance)
 Liver biopsy confirm the diagnosis
DIFFRENTIAL DIAGNOSIS.
 The clinical and histologic patterns of S.C. overlap those of
primary biliary cirrhosis ,however the latter disease typically affects
middle aged women with keratoconjunctivitis
sicca,hyperpigmentation and high titres of A.M.A.
 Cholangiography allows diffrentiation as primary biliary cirrhosis
never involves extrahepatic ducts

74. TREATMENT(controversial)
 If a major stricture involves extrahepatic duct (bypass
procedure)
 Other cases have been treated successfully by T.tube
drainage of the C.B.D. and by stenting of strictures
 High dose steroids can be effective in relieving the fibrous
strictures
 The oral adminstration of ursodiol shows promise ,it
reduces serum bilirubin , decreases clinical jaundice
,decreases serum transaminase levels and improve
symptoms
 Liver transplantation is the only effective treatment of end
stage liver disease

75. PROGNOSIS
 Some patients die from liver failure within
months of diagnosis
 Others may live relatively symptom free for
many years
 10% of patients with sclerosing cholangitis
will develop bile duct carcinoma

76. THANK
YOU