Cause Of Obstructive Jaundice Research Articles

Endoscopic retrograde cholangiopancreatographic evaluation of patients with obstructive jaundice.

To evaluate the role of endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive jaundice. A retrospective, observational study. The study was carried out at Valley Clinic, Rawalpindi, from January 1999 to January 2002. Two-hundred and twenty-six patients, who underwent ERCP for evaluation of obstructive jaundice were included. ERCP in each case was performed with standard technique and the findings were recorded. Therapeutic procedures like sphincterotomy, Dormia extraction for stone, and stent placements were performed whenever indicated. Of the 226 patients, 117 (51.8%) were males, and 109 (48.2%) females, their mean age being 51.8+/-16.6 years. Common bile and pancreatic ducts were visualized in 81.8% and 68.1% patients respectively. Growth/masses and stones were commonest causes of obstructive jaundice. Choledocholithias was common in males, while biliary channel related growth/masses were common in females (p-value=0.03). Common bile duct stone clearance rate was 88%, stenting was highly successful in patients with growth and strictures. ERCP related complications were noted in 11 (4.8%) patients. ERCP is an important diagnostic and therapeutic modality for evaluation of patients with obstructive jaundice. Growth/masses and stones are common causes of obstructive jaundice which can be diagnosed and treated with ERCP.

Obstructive jaundice secondary to lymphoma in childhood

In children, biliary obstruction secondary to lymphoma is rare. Previous reports in adults and children suggest that these lymphomas are associated with a poor prognosis. The authors reviewed the medical records and imaging studies of 4 children treated for pancreaticobiliary lymphoma at our children's hospital over the past 10 years. All 4 presented with jaundice. Abdominal ultrasound scan and computed tomography (CT) scans were helpful in defining the anatomy of the obstruction. In the cases of involvement of the porta hepatis, the diagnosis was made by biopsy. In one child a mass was in the head of the pancreas, and evaluation of frozen section biopsy results were not diagnostic for lymphoma, and a major resection was performed. All the lymphomas were of nonHodgkin's B-cell type and one was a Burkitt's lymphoma. All responded promptly to chemotherapy. One child had a testicular relapse and currently is receiving additional therapy. Pancreaticobiliary lymphomas are an unusual cause of obstructive jaundice in children. Biopsy alone without resection or biliary drainage is recommended surgical therapy. Long-term survival rate in children with this disorder appears to be more promising than previously reported. J Pediatr Surg 36:1792-1795. Copyright © 2001 by W.B. Saunders Company.

E-cadherin, alpha-catenin and beta-catenin in biliary atresia: correlation with apoptosis and cell cycle.

Biliary atresia (BA) is the most common cause of obstructive jaundice in infancy. Although the etiology of BA remains unknown, the ductal plate malformation has been considered to play an important role in the development of BA. Cell-cell adhesion has long been recognized as one of the most important processes in organogenesis. E-cadherin is involved in cell-cell adhesion, together with the catenins. Abnormalities of E-cadherin and associated catenins have not been examined in detail in the liver with BA. We therefore examined immunolocalization of E-cadherin and alpha- and beta-catenins in the BA liver (n = 45) and compared the findings with those in non-BA (n = 11) and fetal liver (n = 21). We semiquantitatively evaluated the findings using H score, which were generated according to the percentage of immunopositive cells and their immunointensity. We also examined mRNA localization of E-cadherin using mRNA in situ hybridization. We then studied the correlation of E-cadherin immunoreactivity with apoptotic cells, and cyclin-dependent kinase inhibitor p27Kip1 immunolocalization of bile duct cells in BA liver (n = 10) and fetal liver (n = 10). In fetal liver, H score of E-cadherin, but not of alpha- and beta-catenins, was significantly lower in the remodeling stage than in the ductal plate (P = 0.0034) and remodeled stages (P = 0.0024). In addition, the H score of E-cadherin, but not alpha- and beta-catenin, in bile duct cells was significantly lower in BA liver than in non-BA liver (P = 0.0132). E-cadherin mRNA hybridization signals were relatively conserved in bile duct cells of BA liver, but decreased in remodeling ductal plate cells of fetal liver. An inverse correlation was detected between the H score of E-cadherin and the TUNEL labeling index (LI) in both fetal and BA liver. In contrast, a positive correlation was detected between the H score of E-cadherin and p27 LI in both fetal and BA liver. These findings suggest that impaired expression of E-cadherin in bile ducts may play an important role in the biological features of BA, possibly associated with cell cycle and apoptosis.

Hepatic artery aneurysm: a rare cause of obstructive jaundice diagnosed by endoscopic ultrasound

Hepatic artery aneurysm: a rare cause of obstructive jaundice diagnosed by endoscopic ultrasound

Primary pancreatic lymphoma—a diagnosis to remember

Primary lymphoma of the pancreas is a rare cause of obstructive jaundice. Unlike most pancreatic malignancies, survival is much better with aggressively treated lymphoma. To highlight the importance of aggressive surgical management and prompt oncologic therapy in this rare disease, we report a case of primary pancreatic lymphoma with painless obstructive jaundice. When confronted with an apparent aggressive pancreatic mass on imaging studies, surgeons must remember this diagnosis, as it carries real hope for the patient.

Biliary varices on endoscopic ultrasonography: clinical presentation and outcome.

Bile duct varices are not a well-recognized feature of portal venous obstruction. The aim of the present study was to describe the clinical and endosonographic features of biliary involvement in patients with extrahepatic portal venous obstruction (EPVO). A retrospective study was conducted of the clinical features, outcome, and endosonographic findings (using Olympus EUM-3 or EUM-20 probes) in 21 patients with EPVO and endosonographic features of biliary varices. Biliary varices were defined as multiple, large, serpiginous, anechoic vascular channels in and/or surrounding the extrahepatic biliary tracts. Biliary varices have not previously been visible using conventional imaging methods (computed tomography and ultrasonography). They were identified using EUS in the wall of the common bile duct in 16 patients (76%), surrounding the common bile duct (CBD) in 11 patients (52%), and in the gallbladder in nine (43%). The varices were the cause of obstructive jaundice in three of the 21 patients (14%), but only when they were in the wall of the CBD. Two of these patients were treated using portosystemic shunting, and the other received a biliary endoprosthesis. The EUS examination also provided evidence of unrecognized pancreatic or biliary tumors in three other patients with EPVO of undetermined origin. EUS can serve to diagnose biliary varices in patients with EPVO and jaundice. Although biliary varices are mainly asymptomatic, they may cause obstructive jaundice when they are located in the wall of the CBD. EUS can also detect unrecognized malignant tumors in patients with EPVO of undetermined origin.

Gallbladder carcinoma with a tumor thrombus in the common bile duct: An unusual cause of obstructive jaundice

A 47-year-old man was admitted to our hospital complaining of epigastralgia and jaundice that had been present for 7 days. Laboratory tests revealed elevated levels of serum total bilirubin (13.5 mg/dL; normal, 0.3-1.3), alkaline phosphatase (871 U/L; normal, 60-201), and carbohydrate antigen 19-9 (CA19-9) (460 U/mL; normal, 0-37). Imaging modalities showed a tumor of the gallbladder with intrahepatic bile duct dilatation. Subsequently, percutaneous transhepatic biliary drainage was carried out: Cholangiography showed a filling defect in the common bile duct with no irregularity of the wall (Figure).

7010 Evaluation of obstructive jaundice using endoscopic ultrasound in a three year old.

INTRODUCTION: Obstructive jaundice is uncommon during childhood. Among the most common causes are congenital malformations of the pancreatobiliary tree. Transabdominal Ultrasound (TUS) and CT are of limited value in these disorders. ERCP has been the preoperative method of choice but is usually limited to major referral centers and has a relatively high morbidity. In adults, Endoscopic Ultrasound (EUS) has been used to evaluate obstructive jaundice. However, because of the size of echoendoscopes, the use of EUS in pediatrics has been limited to larger children. Alternatively, ultrasonic miniprobes can be passed through the 2.8 mm biopsy channel of a thin videoendoscope for use in smaller children. We describe the use of an ultrasonic miniprobe to help define the cause of obstructive jaundice in a three year old. CASE SUMMARY: A 35 month, 12 kg girl presented with jaundice (total bilirubin 6.6 mg/dl, alkaline phosphatase 471 IU/L) and pancreatitis (amylase 569 IU/L). TUS showed a markedly dilated 10 mm common bile duct (CBD). CT revealed CBD and intrahepatic duct dilation but no masses. To preoperatively define the patient's pancreatobiliary anatomy, we performed EUS using a Pentax EG- 2930 videoendoscope (outer diameter 9.8 mm) with a 12 MHz Olympus UM-2R ultrasonic miniprobe placed through the 2.8 mm biopsy channel into a water-filled duodenum. She was intubated for the procedure and was sedated with propofol. Because of the patient's small size, the miniprobe was able to visualize all the porta hepatis and pancreatic head. Miniprobe EUS showed a thick-walled 7 mm CBD which tapered down to a short narrowed segment about 2 cm proximal to the ampulla. No masses, stones or cysts were seen. EUS did demonstrate an anomalous junction of the pancreatic duct with the intrapancreatic portion of the CBD. The gallbladder had no stones and was thick-walled. Based on this information, the patient was explored. Intraoperative cholangiogram (IOC) confirmed the EUS findings. In addition, the IOC demonstrated an anomalous connection of the cystic duct into the right hepatic duct, a finding that was out of the range of view on EUS. A Roux-en-Y choledochojejunostomy with cholecystectomy was performed and the patient made an uneventful recovery. CONCLUSION: EUS can be successfully performed using an ultrasonic miniprobe passed through the 2.8 mm channel of a thin endoscope in relatively small children. As seen in adults, the high quality endosonographic images can be valuable in the evaluation of the pediatric patient with obstructive jaundice.

Apoptosis and cell proliferation in biliary atresia.

Biliary atresia (BA), which is thought to result from progressive destruction of the bile ducts by a necroinflammatory process, is the most common cause of obstructive jaundice in infancy. Abnormalities in the cell turnover of remodelling ductal plates are considered one of the important aetiological factors in this disorder, but little work has been done on this topic. Programmed cell death or apoptosis was therefore examined by TdT-mediated dUTP biotin nick end labelling (TUNEL) and cell proliferation by Ki67 immunostaining in 34 cases of BA. The results were compared with normal control liver (five cases) and congenital dilatation of the bile ducts (CDB, five cases) in order to study the cell turnover or tissue dynamics of BA. The TUNEL labelling index (LI) in bile ducts (48.9 +/- 13.2 per cent) was significantly higher than that of the control normal liver (3.6 +/- 2.8 per cent) and of CDB (2.5 +/- 5.1 per cent). The Ki67 LI in the bile ducts of BA (15.0 +/- 5.57 per cent) was also significantly higher than that of CDB (8.6 +/- 5.4 per cent). No significant differences of the TUNEL and Ki67 LIs in hepatocytes were, however, observed between BA, CDB, and normal liver. The TUNEL LI was significantly higher than the Ki67 LI in the bile ducts of BA. BA is therefore associated with increased and disorganized cell turnover of the bile ducts, which is related to malformation of the ductal plate or abnormal bile duct development.

Pseudo-Mirizzi syndrome in acute cholecystitis

Common hepatic duct obstruction secondary to an impacted cystic duct stone is commonly referred to as the Mirizzi syndrome. Mirizzi syndrome is an uncommon cause of obstructive jaundice and can be mimicked by several other rare conditions. We describe a patient with a massively distended gallbladder due to acute cholecystitis who presented with clinical and cholangiographic findings simulating the Mirizzi syndrome. Endoscopists should be aware of acute cholecystitis as a possible etiology of common hepatic duct obstruction.

Percutaneous Transhepatic Duodenal Drainage as an Alternative Approach in Afferent Loop Obstruction with Secondary Obstructive Jaundice in Recurrent Gastric Cancer

Two cases are reported of chronic, partial afferent loop obstruction with resultant obstructive jaundice in recurrent gastric cancer. The diagnosis was made by characteristic clinical presentations, abdominal computed tomography, and cholescintigraphy. Percutaneous transhepatic duodenal drainage (PTDD) provided effective palliation for both afferent loop obstruction and biliary stasis. We conclude that cholescintigraphy is of value in making the diagnosis of partial afferent loop obstruction and in differentiating the cause of obstructive jaundice in such patients, and PTDD provides palliation for those patients in whom surgical intervention is not feasible.

THERAPEUTIC BILIARY ENDOSCOPY: EXPERIENCE AT A SERVICE HOSPITAL

Therapeutic Biliary Endoscopy (TBE) is becoming a popular mode of treatment for patients with obstructive jaundice. This paper highlights our early experience of TBE at Armed Forces Medical College and Command Hospital (SC), Pune with this mode of treatment. TBE was used as a primary therapeutic option in 46 patients with obstructive jaundice. The age of the patients ranged from 11 to 80 (mean and SD:45.5 ± 16) years and majority 29 (63%) were males. The cause of obstructive jaundice in these patients was choledocholithiasis (n=31), benign biliary stricture (n=8), post cholecystectomy recurrent stones (n=3), carcinoma of pancreas (n=3) and papillary stenosis (n-1). Endoscopic Sphincterotomy (ES) was technically successful in all the 46 patients and brought prompt symptomatic relief in 43 patients. Sixteen patients (34.8%) required additional drainage such as stenting or nasobiliary drain. In patients with choledocholithiasis, bile duct could be cleared of stones in 29 (93.5%) patients and in two surgical removal was required. Of the remaining patients, surgery was required in 4 (50%) patients with benign biliary structure, in 1 (33.3%) of those with malignant stricture and none of the patients presenting with papillary stenosis or recurrent bile duct stones after cholecystectomy. Complications were seen in only two patients (4.4%): one had mild acute pancreatitis and another had GI bleed, which did not require blood transfusion. Both the complications were self-limiting. No procedure related deaths were noted. Endoscopic therapy, thus, a simple, effective and safe method of treatment in patients with choledocholithiasis and selected patients with malignant biliary obstruction.

Detection of reovirus RNA in hepatobiliary tissues from patients with extrahepatic biliary atresia and choledochal cysts.

Extrahepatic biliary atresia (EHBA) and choledochal cysts (CDC) are important causes of obstructive jaundice in pediatric patients. Viruses in general, and reoviruses in particular, have long been considered as possible etiologic agents responsible for inciting the inflammatory process that leads to these infantile obstructive cholangiopathies. In an effort to determine whether reovirus infection is associated with these disorders, we used a sensitive and specific reverse-transcriptase polymerase chain reaction (RT-PCR) technique designed to amplify a portion of the reovirus L1 gene segment from extracts of liver and/or biliary tissues. These tissues were obtained at the time of liver biopsy or surgical procedures from 23 patients with EHBA, 9 patients with CDC, and 33 patients with other hepatobiliary diseases. Hepatic and biliary tissues obtained at autopsy from 17 patients who died without known liver or biliary disease were also analyzed. Reovirus RNA was detected in hepatic and/or biliary tissues from 55% of patients with EHBA and 78% of patients with CDC. Reovirus RNA was found also in extracts of hepatic and/or biliary tissue from 21% of patients with other hepatobiliary diseases and in 12% of autopsy cases. The prevalence of reovirus RNA in tissues from patients with EHBA and CDC was significantly greater than that in patients with other hepatobiliary diseases (chi2 P = .012 EHBA vs. OTHER, P = .001 CDC vs. OTHER), or AUTOPSY cases (chi2 P = .006 EHBA vs. AUTOPSY, P < .001 CDC vs. AUTOPSY).

A Case of Postbulbar Duodenal Ulcer with Jaundice

Abstract: A 63‐year‐old man was hospitalized because of jaundice and anorexia. An upper gastrointestinal series and hypotonic duodenography revealed circumferential sclerosis and stenosis of the duodenal wall. Endoscopic examination disclosed an ulcer, the upper margin of which was located at the papilla of Vater. The papilla was situated in the base of the ulcer. Endoscopic retrograde cholangiopancreatography disclosed mild dilatation of the common bile, intrahepatic bile and pancreatic ducts, but with neither severe stenosis nor occlusion. Nevertheless, there was some degree of circumferential compression and mild stenosis of the terminal portions of the bile and pancreatic ducts, as potential causes of obstructive jaundice in this patient. Computed tomographic examination of the abdomen revealed a tumorous lesion at the duodenal bulb. Because malignancy in the duodenum could not be ruled out, a pancreatoduodenectomy was performed. Histopathological examination showed a postbulbar duodenal ulcer, associated with inflammation of the papillary orifice and fibrosis of the region near the papilla. There was no evidence of a tumorous lesion. In this case, a postbulbar duodenal ulcer may have caused obstructive jaundice.

Mirizzi's syndrome. Diagnostic and therapeutic controversies in the laparoscopic era.

Mirizzi's syndrome (MS) is an unusual cause of obstructive jaundice. It can mimic bile duct cancer, and the role of laparoscopic surgery is not well defined. The aim of this paper is to report five cases and describe the pitfalls encountered in its diagnosis and treatment with a laparoscopic approach. From January 1992 to January 1996, five cases of MS out of 560 patients with gallstones prospectively treated and recorded were found (0.9%). There were two men and three women, (mean age: 54 years [30-93]). In one case diagnosis of bile duct carcinoma was established but surgery revealed MS. Four cases were approached by laparoscopy, but all of them were converted: in two, due to a distorted anatomy, in a third due in the difficulty of visualizing the distal end of the bile duct, and in the last case due to the impossibility of retrieving the stones. All were treated with a cholecochorrhaphy over a T tube, except one, in which a hepaticojejunostomy was performed. Morbidity and mortality were nil, and they remain asymptomatic after a mean follow-up of 19 months (3-36). MS constitutes an important laparoscopic challenge, both to clearance of duct stones and to the proper reconstruction of the biliary duct. A prudent policy is to perform a dissection trial and convert if local conditions are not clear for an experienced laparoscopic surgeon.

Tratamento cirúrgico da icterícia obstrutiva

Os pacientes com icterícia obstrutiva devem ser avaliados e preparados adequadamente, antes da realização de procedimentos invasivos para reduzir as complicações, principalmente as infecciosas, distúrbios de coagulação sanguínea e insuficiência renal. As causas de icterícia obstrutiva são inúmeras, sendo a principal a litíase da via biliar principal. Cerca de 6-10% dos pacientes com litíase da vesícula biliar também apresentam cálculo na via biliar principal. Outras causas comuns de icterícia obstrutiva incluem obstrução maligna e estenoses benignas da via biliar principal. Hemobilia, doença de Caroli, cisto de cóledoco, divertículos duodenais e verminose das vias biliares são causas infreqüentes. O tratamento cirúrgico de todas estas condições é discutido.

Haemophilia A and chronic hepatopathy caused by extrahepatic biliary atresia: two congenital diseases cured by orthotopic liver transplantation.

Since the publication of the first successful liver transplantation in a patient with severe haemophilia A by Lewis et al. in 1985, different authors have reported clinical cure of haemophilia A by orthotopic liver transplantation. In the published cases liver transplantation was performed due to end-stage chronic liver disease secondary to factor replacement therapy for haemophilia A or haemophilia B. Congenital biliary atresia is the most common cause of obstructive jaundice in the neonatal period and the most common indication for liver transplantation in childhood. In this article we report the first successful orthotopic liver transplantation performed in Spain, carried out in the youngest patient thus far described, a 5-year-old boy with haemophilia A and chronic liver disease secondary to congenital biliary atresia.

Obstructive Jaundice in Patients Receiving Hepatic Artery Infusional Chemotherapy: Etiology, Treatment Implications, and Complications after Transhepatic Biliary Drainage

Purpose The authors determined the incidence and cause of obstructive jaundice requiring percutaneous biliary drainage (PBD) occurring in patients treated with hepatic artery infusional (HAI) chemotherapy. The radiographic findings in the different causes of obstruction are characterized, and predictors of outcome are identified. Materials and Methods Charts and radiographs were reviewed for 30 patients who developed obstructive jaundice while receiving HAI chemotherapy and who subsequently required biliary drainage. The cause of obstruction, complications related to PBD, and survival from the time of PBD were recorded for each patient. Results Of 282 patients treated with HAI chemotherapy, 30 (10.6%) developed obstructive jaundice requiring PBD. Obstruction was related to chemotherapy-induced biliary sclerosis in 24 patients (80%). Five patients (17%) had bleeding complications related to PBD. Average survival was 32 weeks after biliary drainage. All four patients who had bilomas at the time of PBD had been treated with high-dose mitomycin, and lived an average of 10 weeks after the procedure. Conclusion Chemotherapy-induced biliary sclerosis is the most common cause of obstructive jaundice in patients receiving HAI chemotherapy. These patients have a higher incidence of bleeding complications and may develop pseudoaneurysms remote from the ductal puncture site. Development of intrahepatic bilomas is associated with high-dose mitomycin-C treatment, and the presence of a biloma at the time of PBD is a poor prognostic indicator.

An unusual cause of obstructive jaundice

An unusual cause of obstructive jaundice

Percutaneous transhepatic biliary drainage for the treatment of obstructive jaundice caused by metastases from nonbiliary and nonpancreatic cancers.

The usefulness of percutaneous transhepatic biliary drainage (PTBD) in the treatment of obstructive jaundice caused by metastases from nonbiliary and nonpancreatic cancers was evaluated. Eighteen patients underwent PTBD during a 3-year period. The primary cancers were located in the stomach (nine cases), colon (four), lung (three), uterus (one), and breast (one). The causes of obstructive jaundice and bile duct strictures were investigated using both abdominal computed tomography and abdominal ultrasonography. The causes of obstructive jaundice, the usefulness of PTBD in terms of the relief of symptoms and laboratory data, survival after PTBD, and the relationship between patient characteristics and survival were evaluated. Obstructive jaundice was most often attributable to metastases to the lymph nodes (17 of 18 cases). One case was attributed to metastasis to the liver. PTBD decreased the jaundice and relieved the symptoms caused by biliary tract obstruction. Median survival after PTBD was 59 days. Patients whose performance status was 2 or less survived longer than those with a performance status of 3 or more (P=0.018). Furthermore, patients aged less than 60 years tended to survive longer than those aged 60 or over (P=0.057). Our results suggest that PTBD is useful for relief of symptoms caused by obstructive jaundice in patients with nonbiliary and nonpancreatic cancers.