Extrahepatic Cholestasis Prof. Dr. Salih Pekmezci IU Cerrahpaşa Medical Faculty Department of General Surgery
Extrahepatic Cholestasis
Prof. Dr. Salih PekmezciIU Cerrahpaşa Medical Faculty
Department of General Surgery
Definition
Cholestasis is any condition in which the flow of bile from the liver is blocked.
Extrahepatic cholestasis
= obstructive jaundice= mechanical extrahepatic bile duct obstruction= posthepatic jaundice
Etiology• Bile duct tumors • Cysts • Narrowing of the bile duct (strictures) • Stones in the common bile duct • Pancreatitis• Pancreatic cancer or pseudocyst • Periampullary tumor• Pressure on an organ due to a nearby mass or
tumor • Primary sclerosing cholangitis• Parasites: ascariasis
Diagnosis
• Symptoms & Signs• Physical examination• Laboratory• Imaging
Symptoms & Signs
• History: duration and onset, progression• Jaundice (skin, sclera)• Dark urine• Pale stool• Pruritus• Weight loss• Abdominal pain
Physical examination
• Jaundice • Scratch Marks• Masses – Liver/Spleen• Gall Bladder
– Murphy’s Sign– Courvoisier’s Law
Physical examination
• Jaundice • Scratch Marks• Masses – Liver/Spleen• Gall Bladder
– Murphy’s Sign– Courvoisier’s Law
Laboratory tests
• Conjugated bilirubin• Alkaline phosphatase
Bilirubin: normal range 0.3-1.2 mg/dLClinically obvious hyperbilirubinemia: >2.5 mg/dL
Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic
Jaundice
Total bilirubin Normal / Increased Increased Increased
Conjugated bilirubin Normal /decreased Normal /increased Increased
Unconjugated bilirubin Increased Normal / Increased Normal
Urobilinogen Increased Normal / Increased Decreased / Negative
Urine Color Normal Dark Dark
Stool Color Normal Normal/pale Pale
Alkaline phosphatase levels Normal Increased Increased
Alanine transferase and Aspartate transferase levels Normal Increased Increased
Conjugated Bilirubin in Urine Not Present Present Present
Imaging• Ultrasound:
– More sensitive than CT for gallbladder stones– Portable, cheap, no radiation, no IV contrast
• CT:– Better imaging of the pancreas and abdomen
• MRCP:– Imaging of biliary tree comparable to ERCP
• ERCP– Therapeutic intervention– Brushing and biopsy for malignancy
• Endoscopic US• Laparoscopic US
PeriampullaryTumor
CBD stones vs. Tumor Differential Diagnosis• Clinical features favoring CBD stones:
– Age < 45– Biliary colic– Fever– Intermittent jaundice
• Clinical features favoring cancer:– Painless and progressive jaundice– Weight loss – Palpable gallbladder – Bilirubin > 10
Choledocholithiasis
• Gallstones within common bile duct (or common hepatic duct
• DD: cholelithiasis, hepatitis, sclerosing cholangitis, cholangiocarcinoma
CholedocholithiasisManagement
• ERCP• Laparoscopic procedures
– Trancystic exploration– Laparoscopic choledochotomy
• Open procedures
Cholangiocellular Carcinoma
• Originates from epithelium of extrahepatic or intrahepatic large or medium sized bile ducts
• 5-10% of malignant liver tumors, occurs in noncirrhotic livers
Clinical Presentation
• Jaundice• Pain• Weight loss• High CA 19.9
Surgical therapy
• In tumors located at distal 1/3 of bile ducts Whipple operation
• In tumors of middle and upper 1/3 combined liver (right hepatect, left hepatect, trisectionectomy, central resection) and extrahepatic bile duct resection +/- vascular resection
Primary Sclerosing Cholangitis
• Cholestatic liver disease (ALP)• Inflammation of large bile ducts• 90% associated with IBD
– but only 5% of IBD patients get PSC
• Diagnosis: ERCP (now MRCP)– Biopsy: concentric fibrosis around bile ducts
• Cholangiocarcinoma: 10-15% lifetime risk• Definitive Treatment: Liver Tx
Whipple procedure n:1000Mean age: 63.4 (15-103) Malignant periampullary tm:
652
Cameron JL, Ann Surg 2006
n 5 year survivalPancreatic head tm 405
(62.1%)18%
Ampulla Vateri tm 113(17.3%)
39%
Distal CBD tm 95(14.5%)
22%
Duodenum tm 39(5.98%)
52%
Total 652
Periampullary Tm
Pancreatic head Ca• 1,3 and 5 year survival %64, %27 ve %18
Lymph node (-) and surgical margin (-)• 1,3 and 5 year survival %80, %49 ve %41
5 year survivalLymph node (-): %23 Lymph node (+): %14
Cameron JL, Ann Surg 2006
Pancreatic head carcinoma
S. Pekmezci
S. Pekmezci
Ampulla Vateri Tumor
• May be originated from bile duct, duodenum or Wirsung duct epithelium
• Prognosis is related to the epithelial origin s başı kanserine göre daha iyidir (%35-67’ye karşın %20)
Ampulla Vateri Tumor
• Local resection• Radical surgery (treatment of
choice)
S. Pekmezci
Distal CBD Tm
• Resectability is high • PD is the standard treatment
Bahra et al, Chirurg, 2006
THANK YOU