Obstructive jaundice

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Obstructive jaundice

• I C Cameron

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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

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Common causes

• Gallstones and carcinoma of pancreas
• Rare cholangiocarcinoma, pancreatitis
• USS gt 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

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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?

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ERCP

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

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2nd ERCP

• No deep cannulation, cholangiogram
• Short stricture distal CBD stricture
• PD normal
• What next?

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Patient becomes very unwell

• Pain, pyrexia, amylase 1370
• IVI, catherterised, inotropes, HDU
• 3 days bilirubin increased, much better
• Priority?

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Drain biliary system

• PTC and external drain
• CT scan Transfer

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RHH management

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

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Repeat CT

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

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Clinic follow up

• Probable distal CBD cholangiocarcinoma
• Never well enough for chemotherapy
• Deceased 7 months later

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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