When jaundice is due to an obstruction in the flow of bile: (1) The patient's stools are pale. (2) His urine is dark, and contains little or no urobilinogen. (3) His skin itches. These features are most marked in complete obstruction, as when carcinoma blocks the common duct. Stones typically cause an intermittent obstruction, and a less characteristic picture.
If a stone impacts in Hartmann's pouch or in the cystic duct, it causes pain but does not impede the flow of bile down the common duct, so jaundice is absent or is mild (due to associated cholangitis).
If a an older patient has a steadily deepening and usually painless obstructive jaundice, and his gall-bladder is palpably enlarged, some tumour is probably obstructing his common duct. He is probably incurable, but a cholecystojejunostomy to decompress his gall-bladder, by diverting his bile into his jejunum, may make his last days more bearable. So make the best of such means of diagnosing him as you may have, and don't necessarily give him up as hopeless. In East and Central Africa, for example, obstructive jaundice is most commonly caused by: (1) Secondary carcinoma of the liver. (2) A secondary tumour in the porta hepatis, usually from a primary in the stomach. (3) Carcinoma of the head of the pancreas. (4) Gall-stones. (5) Hepatoma; although this is a common disease, presentation as obstructive jaundice is unusual. (6) Carcinoma of the extrahepatic bile-ducts. (7) Carcinoma of the gall-bladder. This is rare in Africa, but is the most common cause of malignant obstructive jaundice in India.
With the exception of gallstones, in which the jaundice may be intermittent, all these diseases present with progressively deepening jaundice over weeks or months, usually without the fever and rigors of cholangitis that so often complicate the jaundice of gallstones. The patient may have no pain, but if he has, it is usually not severe; it is deep, penetrating, and present most of the time[md]quite unlike the agonizing episodic biliary colic that gallstones cause. He is anorexic, and nauseated, and may lose so much weight that he becomes severely emaciated, with no other symptoms than jaundice.
First exclude hepatocellular jaundice, which has ''obstructive' features at first, although these diminish later. Then, if you decide that his jaundice is obstructive, weigh the evidence for malignancy or stones. If his jaundice continues to deepen, he needs surgery, if he is fit enough.
Fig. 13-5 CHOLECYSTOJEJUNOSTOMY. A, the incision. B, the first layer of the anastomosis.
OBSTRUCTIVE JAUNDICE DIFFERENTIAL DIAGNOSIS. First try to decide what kind of jaundice the patient has.
Haemolytic jaundice. His stools are dark. There is no bilirubin in his urine, but his urinary urobilinogen is increased. His blood shows increased levels of unconjugated prehepatic bilirubin (leading to high readings on the indirect van den Bergh test). His transaminases (GPT and GOT) are normal, and so is his alkaline phosphatase.
Obstructive jaundice. His stools are pale (clay-coloured if obstruction is complete), and show no improvement in colour in 10 days. There is bilirubin in his urine, but little or no urobilinogen. He has high blood levels of conjugated (posthepatic) bilirubin (giving high readings on the direct van den Bergh test). His alkaline phosphatase is very high. His transaminases are normal.
Hepatocellular jaundice This is commonly viral hepatitis with an obstructive phase lasting 7[nd]10 days, but sometimes much longer. At this stage his stools are pale. His urine contains bilirubin but little urobilinogen. His serum bilirubin is moderately increased (mostly conjugated). His alkaline phosphatase is usually only moderately increased, but if cholestasis is a prominent feature it can rise to levels seen in obstructive jaundice. His transaminases are increased.
As the oedema of his cells settles, his stools become normal or even dark, his serum bilirubin falls, his urinary urobilinogen rises or reappears, and his transaminases fall gradually. The return of stool colour is the most important sign. This form of jaundice is not common in most developing countries after the age of 35.
CAUTION ! You may have difficulty distinguishing the obstructive phase of hepatocellular jaundice from surgical obstructive jaundice. Do try to make the distinction. A laparotomy for stone may be life saving, but anaesthesia and the trauma of surgery may cause hepatocellular jaundice to deteriorate, perhaps fatally.
Ultrasound is very useful. An intravenous cholangiogram is not helpful in the presence of jaundice. The ducts will not be outlined.
Suggesting malignancy[md](1) Relentlessly progressive steadily deepening obstructive jaundice, weight loss. (2) A palpable gall-bladder which you can feel as an elongated, smooth, non-tender mass, normal in contour, and slightly mobile, which may extend to the patient's umbilicus or even below it. If you can feel his distended gall-bladder, it strongly suggests a malignant obstruction at the lower end of his common bile-duct, but its absence does not exclude this.
Suggesting secondary deposits in his liver[md]a large, knobbly liver.
Suggesting a carcinoma of his stomach with secondaries in his porta hepatis[md]pain, anorexia, vomiting, an upper abdominal mass, and the visible peristalsis of pyloric stenosis. Anaemia is common.
Suggesting carcinoma of the head of his pancreas[md]vague epigastric pain, and weight loss.
Suggesting gallstones [md]a long history of intermittent varying jaundice, severe intermittent colicky pain, a non-palpable gall-bladder, fever, chills, and rigors (suggesting cholangitis), little or no weight loss, flatulent dyspepsia. A raised white count suggests cholecystitis.
Suggesting hepatoma[md]a large, hard, irregular liver. A bruit is often present, ascites is common, and is often bloodstained.
Suggesting stenosis of his bile-ducts, either malignant or benign[md]a tender, enlarged liver. His gall-bladder may or may not be palpable.
Suggesting carcinoma of the gall-bladder[md]the patient is a woman with an enlarged liver and a hard, irregular mass in her right hypochondrium.
MANAGEMENT. If the patient has gall-stones, try to refer him to an expert. If he has malignant disease with obstruction at the lower end of his common bile-duct, a cholecystojejunostomy may help.
CHOLECYSTOJEJUNOSTOMY [s7]FOR OBSTRUCTIVE JAUNDICE INDICATIONS. In practice the presence of a smooth enlarged gall-bladder is the only clear indication to operate. Its absence does not exclude the possibility of doing the operation.
CONTRAINDICATIONS. Cachexia, debility, a hard irregular gall-bladder mass, a hard, craggy liver due to secondary deposits, hepatoma, a large gastric tumour, ascites,,, etc.
PREPARATION. Give him vitamin K[,1] (water-soluble) 10 mg intramuscularly daily for 3 days preoperatively. This will reduce his tendency to bleed.
HYDRATION. Patients with jaundice are prone to acute renal failure if their glomerular filtration rate falls. So make sure he is well-hydrated preoperatively. Give him plenty of saline during the operation, catheterize his bladder, and leave the catheter in. Also give him frusemide.
INCISION. Open his abdomen through an upper midline or an upper right paramedian incision. Expose his liver and subhepatic area as in Section 13.7. Good exposure is essential.
Inspect and feel his upper abdominal viscera carefully. Is his gall-bladder normal in size and appearance? If it is a hard, irregular mass which is fixed to the surounding organs, it is probably malignant.
Feel his pancreas, especially its head. (1) Lift his transverse colon upwards and forwards out of the wound with your left hand, while you feel his pancreas at the base of his transverse mesocolon. Its head lies to the right of his vertebral column at this level. A hard, knobbly, craggy mass suggests a tumour. (2) You can also feel the head of his pancreas from above. Stand on the left side of the table and feel with your right hand while you pull the hepatic flexure of his colon medially. Place your thumb anteriorly and your fingers posteriorly. Feel the head of his pancreas lying in the concavity of his duodenum. If necessary, Kocherize it (66.16), so that you can feel it properly.
CAUTION ! Don't biopsy his pancreas. Unless you use special methods you will cause pancreatitis and a fistula.
Feel his porta hepatis and the structures lying in the free edge of his lesser omentum. Can you feel any craggy, fixed, indurated masses, suggesting primary carcinomas of his bile-ducts or secondary deposits? Feel his stomach.
THE INDICATIONS FOR PROCEEDING FURTHER can only be decided at this stage.
A bypass is indicated if he has an enlarged and distended but otherwise normal gall-bladder, showing that he has an obstruction in his common bile-duct, proximal to or within the head of his pancreas, with no obstruction to his cystic duct. If you find any gallstones, remove them. Then make sure that his jaundice is not caused by stones. If it is, do a choledochostomy as in Fig. 13-2.
A bypass is contraindicated if: (1) He has multiple liver secondaries, a hepatoma, or a carcinoma of his gall- bladder. (2) The tumour involves his gall-bladder or porta hepatis. (3) He has an advanced tumour of his stomach, or colon, etc. Most of these conditions make the operation impossible.
CAUTION ! (2) If his gall-bladder is diseased, or contains many stones, abandon the operation. Don't try to anastomose a thick walled, inflamed, oedematous gall-bladder.
METHOD. Decompress his distended gall-bladder as for a cholecystostomy in Figure 13-1. Remove the purse string suture, and extend the opening with scissors to a length of 1.5 cm. Apply Babcock clamps to the fundus of his gall-bladder about 1 cm from each end of the incision. Lift his transverse colon upwards and look for the ligament of Treitz. This is the point where the retroperitoneal 4th part of his duodenum emerges to become his jejunum,,, slightly to the left of his vertebral column, and distal to the attachment of the mesentery of his transverse colon. Choose a loop of jejunum 30 cm distal to the ligament of Treitz, and draw it up towards his open gall-bladder.
Apply two Babcock clamps 3 cm apart on the antimesenteric border of his jejunum, to match those on the fundus of his gall- bladder. Bring these clamps alongside one another, making sure that there is no tension on the jejunal loop. Aim to make a 1.5 cm stoma.
CAUTION ! Make the anastomosis neatly and carefully: it must not leak, because bile easily escapes, and a pool of bile is a serious complication.
The anastomosis is similar to that for a gastroenterostomy (11.6) or ileotransversostomy. Make the seromuscular first layer of interrupted sutures of 3/0 silk on an atraumatic needle. Insert five sutures, which should ideally pick up only the seromuscular layer of his jejunum, but which will probably be of full thickness, in the wall of his gall-bladder. Place them about 2 mm away from the cut edge of the incision, and on the gut side about 2 cm back from the antemesenteric border of his jejunum.
Incise his jejunum 3 mm back from the suture line. Trim away redundant mucosa with fine scissors. Apply Babcock's forceps temporarily over any bleeding points.
Insert a continuous ''all coats' posterior layer of 3/0 atraumatic chromic catgut sutures, starting at one end; then continue to close the anterior layer with the same sutures. Finally, use 3/0 silk to insert an anterior layer of seromuscular interrupted Lembert sutures.
Close his abdominal wall as soundly as you can, as in Section 9.8.