MANAGEMENT OF OBSTRUCTIVE JAUNDICE

Dr. Ajith Nair, Dr. Benoy Sebastian, Dr. Sunil K. Mathai

Dept. of Gastroenterology, Medical Trust Hospital

 

Interpretation of LFT and causes in obstructive jaundice

 

The single most parameter denoting obstruction of the biliary tract is Alkaline phosphatase. This is synthesized by the biliary epithelial cells in response to increased pressure in the tract. Various manifestation of obstruction include, progressive jaundice, intense pruritus, acholic stools, and in long standing cases Xanthelasma and Fat soluble vitamin deficiencies. The causes of obstruction occurring at various levels are :

1. Intrahepatic - like metastatic deposits, HCC, Granulomatous liver disease

2. Extrahepatic  - hilar level lesions like cholangiocarcinoma, perihilar lymph nodes

3. Extrahepatic - bile duct lesions like stones, strictures neoplastic and inflammatory.

4. Periampullary and head of pancreas lesions

 

Imaging in obstructive jaundice

The simplest and basic imaging modality is USG abdomen. It confirms the presence of obstruction and level of obstruction with an insight into the etiology. Further workup is done depending on the cause. Further imaging done to analyse the biliary tract include CT scan, MRCP (magnetic resonance cholangiopancreatography) endosonography and nuclear scintigraphy. ERCP provides diagnosis and access to the biliary tract for therapeutic purposes.

 

Endoscopic management

Stones are removed after cutting the sphincter and basketing. This requires accessories and fluoroscopic imaging. Lithotripsy is offered for difficult stones. The stone is broken down with mechanical, electrohydaulic and laser lithotriptors. ESWL may be useful in some cases. Strictures are considered malignant unless otherwise proved. Cytological brushes are used for analysis. Drainage procedures adopted include plastic and metallic stenting.

Balloon dilatation of strictures may be adopted for benign structures. Percutaneous drainage is done for proximal hilar lesions. Surgical indications are operable malignancies, difficult stones and benign strictures.