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

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