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    This document summarizes a study on the presentation, clinical features, and treatment of 24 cases of obstructive jaundice seen at a tertiary care surgical unit from 2003-2004. Key findings include: 1) The most common causes of obstructive jaundice were malignancy (54.17% of cases), stones in the common bile duct (37.5% of cases), and amoebic liver abscesses (8.33% of cases). 2) Early diagnosis of the obstruction's cause is important, especially for malignant cases, as resection may only be possible at an early stage. 3) Surgery was the treatment for all patients with stones in the common bile duct and liver abs

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    Management of Obstructive Jaundice Exper PDF

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    This document summarizes a study on the presentation, clinical features, and treatment of 24 cases of obstructive jaundice seen at a tertiary care surgical unit from 2003-2004. Key findings include: 1) The most common causes of obstructive jaundice were malignancy (54.17% of cases), stones in the common bile duct (37.5% of cases), and amoebic liver abscesses (8.33% of cases). 2) Early diagnosis of the obstruction's cause is important, especially for malignant cases, as resection may only be possible at an early stage. 3) Surgery was the treatment for all patients with stones in the common bile duct and liver abs

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    This document summarizes a study on the presentation, clinical features, and treatment of 24 cases of obstructive jaundice seen at a tertiary care surgical unit from 2003-2004. Key findings include: 1) The most common causes of obstructive jaundice were malignancy (54.17% of cases), stones in the common bile duct (37.5% of cases), and amoebic liver abscesses (8.33% of cases). 2) Early diagnosis of the obstruction's cause is important, especially for malignant cases, as resection may only be possible at an early stage. 3) Surgery was the treatment for all patients with stones in the common bile duct and liver abs

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    Management of Obstructive Jaundice Exper PDF

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    This document summarizes a study on the presentation, clinical features, and treatment of 24 cases of obstructive jaundice seen at a tertiary care surgical unit from 2003-2004. Key findings include: 1) The most common causes of obstructive jaundice were malignancy (54.17% of cases), stones in the common bile duct (37.5% of cases), and amoebic liver abscesses (8.33% of cases). 2) Early diagnosis of the obstruction's cause is important, especially for malignant cases, as resection may only be possible at an early stage. 3) Surgery was the treatment for all patients with stones in the common bile duct and liver abs

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    Original Article

    MANAGEMENT OF OBSTRUCTIVE JAUNDICE:


    EXPERIENCE IN A TERTIARY CARE SURGICAL UNIT

    MUHAMMAD SADDIQUE, SYED ABDULLAH IQBAL


    Department of Surgery (Unit IV), Dow Medical College & Civil Hospital, Karachi

    ABSTRACT
    Objective: To evaluate the presentation, clinical features and treatment of Obstructive Jaundice cases.
    Design & Duration: Prospective observational study from Jan. 2003 to Dec. 2004.
    Setting: Surgical Unit IV, Civil Hospital, Karachi.
    Patients: All patients who were admitted and treated for Obstructive Jaundice.
    Methodology: The patients were evaluated clinically and by investigations. After appropriate preparations surgery
    was carried out; the procedure depending upon the nature of the lesion. Intra and post-operative complications, and
    the outcome of the patient was noted and the whole data analyzed.
    Results: This study comprises of 24 cases of Obstructive Jaundice. Their ages varied from 25-65 years (mean age
    being 41.12 years); 10 were males and 12 females. Amongst these 13 (54.17%) patients had jaundice due to malig-
    nancy, 9 (37.5%) had stones in the common bile duct (CBD) and the remaining 2 (8.33%) patients had amoebic liver
    abscesses. In the malignant group five patients had Carcinoma Head of the Pancreas (two treated by pancreato-
    duodenectomy and three by cholecystojejunostomy), three had Cholangiocarcinoma (treated by hepatojejunostomy),
    three had Carcinoma Gall bladder (one treated by hepatojejunostomy, two inoperable) and two patients with malignant
    nodes at the porta hepatis who refused surgery and were referred for endoprostheses. All patients with stones in the
    CBD were treated by cholecystectomy and choledocholithotomy, whereas those with amoebic liver abscess underwent
    drainage/aspiration.
    Conclusion: Early diagnosis of the cause of obstruction is very important especially in malignant cases, as resection
    is only possible at that stage.

    KEY WORDS: Obstructive Jaundice, Choledocholithiasis, Carcinoma Pancreas, Cholangiocarcinoma, Liver Abscess

    INTRODUCTION tic or endoscopic removal may be tried. In the cases of


    malignant obstruction, if an early diagnosis is made
    Obstructive jaundice occurs when there is an obstruction then curative resection may be possible, otherwise only
    to the passage of conjugated bilirubin from liver cells palliative procedures are performed4,5; in inoperable
    to intestine. As the patient with obstructive jaundice malignant cases endoprosthesis may be used to relieve
    has a high morbidity and mortality, the early diagnosis the obstruction.
    is of great importance1-3. Malignancy and stones in the
    CBD are common causes of obstruction. Stone disease PATIENTS & METHODS
    in fit patients is treated by surgical intervention but in
    the elderly and unfit cases, other options like transhepa- Twenty four patients of Obstructive Jaundice were ad-
    mitted in Surgical IV at Civil Hospital Karachi, between
    January 2003 to December 2004. There were 10 male
    and 14 female cases with ages varying from 25 to 65
    years, mean age being 41.12 years. Their diagnosis
    (Table I) was based on history, clinical examination and
    Correspondence: investigations which included LFTs, Urea Creatinine
    Dr. Muhammad Saddique, Department of Surgery, and Electrolytes, Prothrombin time, Ultrasonography,
    Surgical Unit IV, Dow Medical College & PTC and MRCP.
    Civil Hospital, Karachi.
    Phones: 0300-9209027. Pre-operative preparations included maintaining good

    23 Volume 23, Issue 1, 2007


    Management of Obstructive Jaundice Muhammad Saddique, Syed

    while two were found inoperable at laparotomy; both


    Cause Male Female Total the later cases died in the immediate post-operative
    period. Two patients had suspected malignant nodes at
    Malignancy 7 6 13 the porta hepatis; they refused surgery and were advised
    Stone in CBD 2 7 9 endoprosthesis.
    Liver Abscess 1 1 2 Nine cases of Obstructive Jaundice were due to stones
    Total 10 14 24 in the common bile duct. They all underwent cholecys-
    tectomy and choledocholithotomy. No complications
    Table I. Aetiology of Obstructive Jaundice were noticed in them except bile leakage from around
    the T-tube in one patient, which was treated conserva-
    hydration and administration of antibiotics, intravenous tively. Two patients had amoebic liver abscesses; one
    dextrose (10%) solution and Vit. K injections6. In anae- underwent open drainage and the other ultrasonogra-
    mic patients blood transfusion was also carried out. Du- phic guided aspiration. Both made uneventful recovery.
    ring surgery intravenous Mannitol was used in all the
    patients. The nature of surgical procedure carried out DISCUSSION
    depended upon the cause and the findings at the time
    of surgery. Obstructive Jaundice is a common surgical problem.
    Its commonest cause was malignancy (54.17%) in our
    RESULTS study followed by choledocholithiasis (37.5%) and am-
    oebic liver abscess (8.33%). Sharma et al reported a
    All the 24 cases with Obstructive Jaundice presented higher incidence (75.3%) of malignant cases in a series
    with pain, while weight loss and pruritis was seen in of 429 patients3.
    14 (58.33%) patients. Ultrasound abdomen, performed
    in all the patients, revealed extrahepatic biliary obs- Tompkins et al, and other authors described pain as a
    truction amongst 17 patients (70.83%), though the cause symptom in less than one third of their patients1,7; but
    was correctly diagnosed in 12 (50%) cases only. pain in the right hypochondrium was present in all of
    our cases. Weight loss and pruritis was seen in 50% of
    Out of the 13 patients of Obstructive Jaundice due to the patients elsewhere7; in our series the incidence of
    malignancy, five had Carcinoma Head of the Pancreas; these symptoms was 58.33%.
    two were treated by pancreatoduodenectomy and three
    by cholecystojejunostomy (Table II). All the three cases Ultrasonography detected extrahepatic biliary obstruc-
    of cholangiocarcinoma were treated by hepatojejunos- tion reliably in 70.83% of our cases, but the cause was
    tomy; one deteriorated postoperatively and died in the correctly reported only in 50% of the cases. Other stu-
    ward after 10 days. Three patients had Carcinoma of dies established the site of obstruction in 94% cases
    the Gall bladder, one was treated by hepatojejunostomy with a specificity of 96%3,8.
    Table II. Surgery and Outcome in cases of Obstructive Jaundice

    Cause Surgical Procedure Cured Palliation Not improved Mortality

    Ca. Head Pancreas Pancreatodudenectomy (2) 2 - - -


    Cholecystojejunostomy (3) - 3 - -
    Cholangiocarcinoma Hepatojejunostomy (3) - 3 1 1
    Ca. Gall Bladder Hepatojejunostomy (1) - 1 - -
    Laparotomy/inoperable (2) - - 2 2
    Malignant nodes at porta Refused surgery (2) - - - -
    Choledocholithiasis Choledocholithotomy+ (9) 9 - - -
    Cholecystectomy
    Amoebic LiverAbscess Drainage of abscess (2) 2 - - -

    24 Volume 23, Issue 1, 2007


    Management of Obstructive Jaundice Muhammad Saddique, Syed

    In our study 13 (54.17%) patients had jaundice due to 1999 Oct-Dec; 20(4): 167-9.
    malignancy; out of these in nine (37.5%) patients curative
    surgery was not possible. Seven (29.17%) patients, how 4. Gores GJ. Early detection and treatment of Cholan-
    ever, underwent palliative bypass surgery; three with giocarcinoma. Liver Transpl 2000; 6-S: 30-34.
    Ca. Head of Pancreas had cholecystojejunostomy, while
    three with cholangiocarcinoma and one with Ca. Gall 5. Khan SA, Davidson BR, Goldin R, et al. Guidelines
    bladder had hepaticojejunostomy. Two with nodes in for the diagnosis and treatment of Cholangiocarci-
    the porta hepatis refused surgery and were advise endo- noma: Consensus document. Gut 2002; 51: 1-9.
    prosthesis. Fortner9 in his study on 52 patients with
    obstructive jaundice reported palliative procedures in 6. Provoski SP, Karpeh M Jr, Conlon KC, et al. Pre-
    38 (73.1%) cases including endoprosthesis placement operative biliary drainage: Impact on intra-opera
    in 22 (42.31%) and bypass surgery in 16 (30.8%) cases. tive bile cultures and infectious morbidity and mor-
    Other authors have also quoted similar figures10-14. tality. J Gastrointest Surg 1999; 3: 496-505.

    In the study nine patients had jaundice due to stones in 7. Tompkins RK, et al. Changing pattern in the diag-
    the common bile duct; they underwent choledocholitho- nosis and management of Bile duct Cancer. Ann
    tomy and T-tube insertion. No complication was noted Surg 1990; 211: 614-621.
    except bile leakage from around the T-tube in one case.
    Pappas et al15 reported choledocholithotomy and T-tube 8. De Groen PC, Gores GJ, La Russo NF, et al. Biliary
    insertion in 93 out of 95 patients; five (5.26%) cases tract Cancers. N Engl J Med 1999; 341: 1368-79.
    had retained stones.
    9. Fortner JG. Proximal extrahepatic bile duct tumors.
    CONCLUSION Arch Surg 1989; 143: 1275-1279.

    Early diagnosis of the cause of obstruction is very im- 10. Hadjis NS, Collier NA, Blumgart LH, Malignant
    portant especially in malignant cases. For this there masquerade at the hilum of liver. Br J Surg 1985;
    should be trained staff at primary care health centers 72: 659-661.
    all over the country. Cholecystectomy & exploration
    of CBD remains the first line of therapy for stone disease 11. Blumgart LH, Hadjis NS, Benjamin IS, Beazley R.
    of gall bladder and bile ducts. In malignant jaundice, Surgical approaches to Cholangiocarcinoma at the
    resection is only possible when the diagnosis is made confluence of hepatic ducts. Lancet 1984; 1: 66.
    early, otherwise palliation is only alternative.
    12. Stain SC, Baer HU, Dennison AR, et al. Current
    REFERENCES management of hilar Cholagiocarcinoma. Surg Gy-
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    1. Kelson DP, Portenoy R, Thalor H, et al. Pain as a
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    J Hepatobiliary Pancreat Surg 1998; 5: 52-61.
    2. Magnuson TH, Bender JS, Duncan MD, et al. Uti-
    lity of Magnetic Resonance Cholangio-Pancreato- 14. Wagner M, et al. Stent or Surgical bypass as pallia-
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    3. Sharma MP, et al. Aetiological spectrum of Obstruc- 15. Pappas TN, Slimane TB, Brooks DC. 100 conse-
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    graphy: A clinician’s perspective. Trop Gastroenterol tality. Ann Surg 1990; 211: 260-262.

    25 Volume 23, Issue 1, 2007

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