75 year old female with abdominal pain..
1.ALP and GGT elevated > ALT, elevated bilirubin suggesting obstructive liver enzyme picture with mild biochemical jaundice and transaminitis
Normal inflammatory markers – no obvious cholangitis
Normal UEC and no obvious acid base disorder
2. Obstructive jaundice
Causes of biliary obstruction can be separated into intrahepatic and extrahepatic.
Mechanical or intrahepatic causes are most commonly hepatitis and cirrhosis. Drugs such as anabolic steroids and chlorpromazine may also cause direct damage to hepatocytes and metabolic obstruction.
Extrahepatic causes may be further subdivided into those that are intraductal and those that are extraductal.
- Intraductal causes include neoplasms, stone disease, biliary stricture, parasites, primary sclerosing cholangitis (PSC), AIDS-related cholangiopathy, and biliary tuberculosis.
- Extraductal obstruction caused by external compression of the biliary ducts may be secondary to neoplasms, pancreatitis, or cystic duct stones with subsequent gallbladder distension.
- Neoplasms are various tumors that may lead to biliary obstruction.
- Cholangiocarcinomas (rare tumors arising from the biliary epithelium), ampullary carcinomas (neoplasms of the ampulla of Vater), and gallbladder carcinomas (tumors with extension into the CBD) cause obstruction within the ducts.
- Metastatic tumors (usually from the gastrointestinal tract or the breast) and the secondary adenopathies in the porta hepatis that may be associated with these tumors can cause external bile duct compression.
- Of pancreatic tumors, 60% occur in the head of the pancreas and manifest early with obstructive jaundice.
- Stone disease is the most common cause of obstructive jaundice. Gallstones may pass through the CBD and cause obstruction and symptoms of biliary colic and cholecystitis. Larger stones can become lodged in the CBD and cause complete obstruction, with increased intraductal pressure throughout the biliary tree. Mirizzi syndrome is the presence of a stone impacted in the cystic duct or the gallbladder neck, causing inflammation and external compression of the common hepatic duct and thus biliary obstruction.
- Of biliary strictures, 95% are due to surgical trauma and 5% are due to external injury to the abdomen or pancreatitis or erosion of the duct by a gallstone. Stone disease is the most common cause of biliary strictures in patients who have not undergone an operation. A tear in the duct causes bile leakage and predisposes the patient to a localized infection. In turn, this accentuates scar formation and the ultimate development of a fibrous stricture.
- Of parasitic causes, adult Ascaris lumbricoides can migrate from the intestine into the bile ducts, thereby obstructing the extrahepatic ducts. Eggs of certain liver flukes (eg, Clonorchis sinensis, Fasciola hepatica) can obstruct the smaller bile ducts within the liver, resulting in intraductal cholestasis. This is more common in Asian countries.
- PSC is most common in men aged 20-40 years, and the cause is unknown. However, PSC is commonly associated with inflammatory bowel disease (IBD), most commonly in patients with pancolitis. IBD (the vast majority being ulcerative colitis) is present in 60-80% of patients with PSC, and PSC is found in approximately 3% of patients with ulcerative colitis. PSC is characterized by diffuse inflammation of the biliary tract, causing fibrosis and stricture of the biliary system. It generally manifests as a progressive obstructive jaundice and is most readily diagnosed based on findings from endoscopic retrograde cholangiopancreatography (ERCP).
- AIDS-related cholangiopathy manifests as abdominal pain and elevated liver function test results, suggesting obstruction. The etiology of this disorder in patients who are HIV-positive is thought to be infectious (cytomegalovirus, Cryptosporidium species, and microsporidia have been implicated). Direct cholangiography often reveals abnormal findings in the intrahepatic and extrahepatic ducts that may closely resemble PSC.
- Biliary tuberculosis is extremely rare. However, with the resurgence of tuberculosis and the emergence of Mycobacterium tuberculosis strains that are resistant to many drugs, biliary tuberculosis may be encountered more frequently in the future. Histopathologic evidence of caseating granulomatous inflammation with bile cytology revealing M tuberculosis is confirmatory. Polymerase chain reaction is useful to expedite the diagnosis if biliary tuberculosis is being considered.
- Biliary obstruction associated with pancreatitis is observed most commonly in patients with dilated pancreatic ducts due to either inflammation with fibrosis of the pancreas or a pseudocyst.
- Notably, intravenous feedings predispose patients to bile stasis and a clinical picture of obstructive jaundice. Consider this in the evaluation of biliary obstruction.
- Sump syndrome is an uncommon complication of a side-to-side choledochoduodenostomy in which food, stones, or other debris accumulate in the CBD and thereby obstruct normal biliary drainage
3. Patients commonly complain of pale stools, dark urine, jaundice, and pruritus.
The following considerations are important:
- Patients’ ages and associated conditions
- The presence or absence of pain
- The location and characteristics of the pain
- The acuteness of the symptoms
- The presence of systemic symptoms (eg, fever, weight loss)
- Symptoms of gastric stasis (eg, early satiety, vomiting, belching)
- History of anemia
- Previous malignancy
- Known gallstone disease
- Gastrointestinal bleeding
- Previous biliary surgery
- Diabetes or diarrhea of recent onset
Also, explore the use of alcohol, drugs, and medications.
4. Exclude life threats, consider resuscitation, antibiotics as indicated
General surgical admission – these patients should not be sent home irrespective of how well they feel until they have been thoroughly investigated.
Older pateints are likely to have cancer as the cause.
In all likelihood will require ERCP with/ without stent procedure
This patient had a 12mm lesion in her distal CBD near the head of the pancreas on CT. She was sent home the day before because of how well she looked and the fact that she had IBD with abdominal pain that was ongoing and settled with simple analgesia