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Obstructive jaundice

Obstructive jaundice. I C Cameron. Acute on call. Deranged LFTs, esp Alk Ph and GGT Conjugated Bilirubin high Take a good history Onset, drugs, pain, previous attacks, alcohol, gallstones, pale stools, dark urine, wt loss Look for signs of liver failure USS - gallstones?

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Obstructive jaundice

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  1. Obstructive jaundice I C Cameron

  2. Acute on call • Deranged LFTs, esp Alk Ph and GGT • Conjugated Bilirubin high • Take a good history • Onset, drugs, pain, previous attacks, alcohol, gallstones, pale stools, dark urine, wt loss • Look for signs of liver failure • USS - gallstones? - dilated CBD +/- dilated IH ducts

  3. Common causes • Gallstones and carcinoma of pancreas • Rare cholangiocarcinoma, pancreatitis • USS > 90% gallstones • No gallstones or significant pain – CT • Avoid knee-jerk ERCP • Serial LFTs vital – fluctuant or progressive • GS in GB but history equivocal - MRCP

  4. Case Presentation • 52 year old man, previously fit and well • 2 week Hx progressive J, dark urine • Vague abdo discomfort • Uss – gallstones in thin walled GB - dilated CBD 14mm, poor views • Next move?

  5. ERCP • 1st attempt failed, oedematous papilla • Bilirubin continues to rise • Next move?

  6. 2nd ERCP • No deep cannulation, cholangiogram • Short stricture distal CBD stricture • PD normal • What next?

  7. Patient becomes very unwell • Pain, pyrexia, amylase 1370 • IVI, catherterised, inotropes, HDU • 3 days: bilirubin increased, much better • Priority?

  8. Drain biliary system • PTC and external drain • CT scan + Transfer

  9. RHH management • Repeat PTC and internalise stent • Bilirubin falling • CT review – inflammatory mass centred around HOP, stranding in soft tissue • Conservative treatment • Next step?

  10. Repeat CT • 8 weeks later repeat CT – infl change better • 2 weeks later – exploratory laparotomy • Inflammatory mass involving HOP, stomach, duodenum , TC • No procedure

  11. Clinic follow up • Probable distal CBD cholangiocarcinoma • Never well enough for chemotherapy • Deceased 7 months later

  12. Lessons to learn • What Ix after USS? • Avoid ERCP if at all possible • Preop biliary drainage 20% complication rate (less with PTC and stent) • Obst jaundice with GS odd history

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