Ultrasound in obstructive jaundice

One hundred and twenty-five consecutive patients with obstructive jaundice were prospectively studied by ultrasonography to determine the level and cause of obstruction. These were diagnosed precisely in 80 (72%) and 52 patients (41.6%) respectively. The results were compared with cholangiography. The final diagnosis was established at surgery (97 cases) and fine needle aspiration cytology (28 cases). While US is an excellent screening modality in distinguishing obstructive and non-obstructive jaundice, cholangiography is still the gold standard for determining the precise anatomic level and cause of obstruction.     

Pancreatic enlargement in obstructive jaundice

To verify the influence of obstructive jaundice on pancreatic growth, the anteroposterior width of the pancreas was measured by computed tomography in 30 cholangiocarcinoma patients excluded patients with distal bile duct tumor (jaundice group) and 74 control subjects. Follow-up examinations were performed on 12 patients with and without internal biliary drainage to elucidate the temporal relationship between pancreatic enlargement and the diversion of the obstructed biliary stream. Histologic analysis on autopsy samples from 13 control and 10 jaundice cases also was performed. Mean pancreatic head and body widths in the jaundice group were 2.93±0.3 cm and 2.01±0.3 cm, respectively. These values were significantly greater than those of the controls (2.13±0.3 cm and 1.49±0.3 cm,P<0.01). The glandular widths returned to their normal sizes following internal biliary drainage. No changes were seen in patients who underwent external drainage alone. Histologic examination revealed that enlargement of the acinar cells or of the islet of Langerhans was often seen in the jaundiced patients. Therefore obstructive jaundice is thought to cause pancreatic growth through a trophic effect by interrupting biliary circulation.     

Renal failure in obstructive jaundice

BACKGROUND/AIMS: The optimal preoperative management of patients with acute obstructive jaundice is still a matter of debate. Reduction in effective plasma volume and systemic endotoxemia are major consequences both in experimental acute bile duct ligation and in patients with acute obstructive jaundice (AOJ). The objective of this study is to show the necessity for adequate preoperative hydration and lactulose administration for the prevention of postoperative renal dysfunction in patients with AOJ. METHODOLOGY: Fifty-five patients (35 male, 20 female) with a mean age of 62 years were entered into the study. There were 23 benign and 32 malignant strictures in this group. All patients received oral lactulose (30-45mL per day) and IV cefazoline (3-4g/day) before surgery. Fluid and electrolyte balance was precisely maintained throughout the hospitalization via daily body weight calculations. High-risk elderly patients with left ventricular systolic dysfunction were assessed by echocardiography and therapeutic measures were undertaken. Renal function was assessed by creatinine clearance (ClCr) measurements and impairment of renal function was defined as a >20% fall in ClCr value post-surgery. RESULTS: Mean preoperative bilirubin level was 11.05mg/dL (range: 3.45-27.0mg/dL). None of the patients developed postoperative renal failure. The difference between pre- and postoperative ClCr value (104.02mL/min vs. 101.0mL/min respectively) was not significant (t=0.698, P=0.489). One patient with mild renal function impairment before surgery (ClCr=45.4mL/min) successfully recovered with 60% rise in creatinine clearance (ClCr=78.1mL/min) after the operation. Three patients with normal functioning kidneys died within 30 days of operation. The principle cause of death was carcinomatosis and pulmonary embolus in two and intraoperative hemorrhagic shock in one patient. CONCLUSIONS: These results further substantiated the importance of adequate preoperative hydration and endotoxin inactivation in terms of acute renal failure prophylaxis in patients with AOJ. This regimen obviates the afferent events in obstructive jaundice and provides prevention of acute renal failure even in high-risk elderly patients.     

Aminoglycoside nephrotoxicity in obstructive jaundice

PURPOSE: Although it is known that liver disease predisposes to aminoglycoside nephrotoxicity, specific features of such disease that may predispose to aminoglycoside-induced renal injury have not been identified. We sought to identify such features. PATIENTS AND METHODS: We undertook a retrospective review of the charts of 42 consecutive patients with biliary obstruction and/or cholangitis who had received more than three doses of an aminoglycoside. RESULTS: Comparison of patients in whom aminoglycoside nephrotoxicity did and did not develop revealed no differences in age, race, sex, dose, and duration of aminoglycoside therapy; mean peak and trough aminoglycoside levels; initial pre-treatment levels of serum creatinine, aspartate transaminase, alkaline phosphatase, or albumin; or prothrombin time. The initial pre-treatment serum bilirubin level was higher in the patients in whom aminoglycoside nephrotoxicity developed (12.2 +/- 8.8 mg/dl versus 3.4 +/- 3.2 mg/dl, p less than 0.01). Aminoglycoside nephrotoxicity occurred in eight patients (19 percent): in seven of 15 patients (47 percent) with an initial bilirubin value greater than 5.0 mg/dl, but in only one of 27 patients (4 percent) with an initial bilirubin value below 5.0 mg/dl (p less than 0.01). The pre-treatment bilirubin level correlated with the change in creatinine during aminoglycoside therapy (n = 42, r = 0.66, p less than 0.01). CONCLUSION: Aminoglycosides should probably be avoided in patients with biliary obstruction and a high serum bilirubin level.     

Intestinal failure in obstructive jaundice

TO THE EDITOR We read with great interest the article by Ding LA and LiJS, which aimed to review the current knowledge on the physiology of normal intestinal barrier function and highlight the role of intestinal failure after various injurious insults in the development of septic complications or multiple organ failure with subsequent rapid clinical deterioration or even death.     

Human neutrophil functions in obstructive jaundice

BACKGROUND/AIMS: The effect of obstructive jaundice on neutrophil function has not been extensively studied. Therefore, the present study aimed at evaluating the effect of obstructive jaundice on human neutrophils. METHODOLOGY: Twelve patients with obstructive jaundice due to common bile duct obstruction underwent endoscopic biliary drainage. Neutrophil functions (chemotaxis and superoxide anion generation) were evaluated before and 7 days after drainage. RESULTS: Neutrophil chemotaxis in response to FMLP (formyl-methionyl-leucyl-phenylalanine) or interleukin-8 was abnormally increased before drainage, and was normalized after drainage. Similarly, enhanced superoxide anion generation in response to FMLP or phorbol myristate acetate before drainage was alleviated after drainage. CONCLUSIONS: The results suggest neutrophil overactivity in patients with obstructive jaundice. The ameliorating effect of biliary drainage on neutrophil overactivity might play a role in the prevention of postoperative complications.     

Magnetic resonance cholangiopancreatography in obstructive jaundice

GOALS: To determine the ability of magnetic resonance cholangiopancreatography (MRCP) to diagnose the level and cause of obstruction in patients with obstructive jaundice. BACKGROUND: The limitations of available imaging modalities have led to the increasing use of MRCP, which is a noninvasive and highly accurate technique in evaluating patients with biliary obstruction. STUDY: Thirty patients were included in this study. MRCP was done using a fat suppressed, heavily T2 weighted fast spin echo sequence. The MRCP findings were confirmed on surgical exploration or clinical follow-up. RESULTS: MRCP could correctly identify ductal dilatation and the level of obstruction in all cases, except one. All causes of obstruction, except three, were detected. It failed to detect a common bile duct calculus in a minimally dilated ductal system and misdiagnosed a case of focal chronic pancreatitis as carcinoma head pancreas and a small pancreatic head mass as cholangiocarcinoma. It had a sensitivity of 94.44%, specificity of 81.81%, positive predictive value of 89.47%, and negative predictive value of 90% for the detection of malignant causes. The overall diagnostic accuracy for detection of level and cause of obstruction was 96.3% and 89.65%, respectively. CONCLUSION: The high diagnostic accuracy of MRCP in evaluating patients with obstructive jaundice indicates that it has the potential to become the diagnostic modality of choice in such patients.     

Palliation of malignant obstructive jaundice

Palliation of obstructive jaundice can be achieved in most patients using various approaches. The method chosen should be individualized to the patient and based upon performance status, patient preferences, and available expertise.The best approach ideally should be determined by a multi-discipline approach with endoscopists, interventional radiologists, oncologists, and surgeons.     

Parasitic causes of obstructive jaundice

Short case reports are presented of two patients seen in the U.K. with 'parasitic' obstructive jaundice. In one case the parasite involved was Clonorchis, and in the other it was Echinococcus. Both these parasites are uncommon in this country.     

Imaging diagnosis of obstructive jaundice

In the past, before the development of biochemical tests for serum enzymes, differentiation between obstructive (surgical) and parenchymal (medical) jaundice was difficult. It was based mainly on patient history, physical examination and the experience of the physician, and the definitive diagnosis depended on surgical exploration. Even with known serum aminotransferase and alkaline phosphatase levels, a distinction between the two types of jaundice was not always certain. Then came the era of new imaging techniques. With the development of direct cholangiography followed by x-ray CT and real-time ultrasonography (US), differential diagnosis of surgical and medical jaundice is no longer a problem. In the clinical setting, the current issue is how quickly and how less invasively the diagnosis could be made. In this chapter, current imaging diagnosis in patients with obstructive jaundice will be discussed, along with its differentiation from medical jaundice.     

Ultrasonography in the diagnosis of obstructive jaundice

Forty-seven patients with cholestatic jaundice were evaluated for extrahepatic biliary obstruction by ultrasonic cholangiography and the results verified by contrast cholangiography, celiotomy, or autopsy. Sonograms were evaluated both with ("official" reading) and without ("blind" reading) clinical information. By showing dilated bile ducts, sonography correctly diagnosed extrahepatic obstruction in 26 of 30 patients on "official" reading and 23 of 30 on "blind" reading. In all 17 patients without extrahepatic obstruction, sonography revealed the absence of dilated bile ducts. Among patients with extrahepatic obstruction, those with larger bile ducts had higher bilirubin concentrations, longer duration of jaundice, and were more reliably detected by sonography. In these patients, 94% with total bilirubin concentration greater than 10 mg/dl were detected by sonography, while 47% with total bilirubin concentration less than 10 mg/dl were detected. Although we recognize the limited sensitivity of sonography in early extrahepatic obstruction, we find it to be a valuable screening test in cholestatic jaundice.