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PubMed1992

Endoscopic approaches in the diagnosis of obstructive jaundice--with special reference to endoscopic retrograde cholangiopancreatography.

Duodenofiberscopy with endoscopic retrograde cholangiopancreatography (ERCP) was performed in 102 patients with obstructive jaundice. Peritoneoscopy and peritoneoscopic cholecystocholangiography were done in patients whose ERCP was inconclusive. The causes of obstructive jaundice were carcinoma of the pancreas in 14 cases, carcinoma of the papilla of Vater in 12 cases, choledocholithiasis in 37 cases, carcinoma of the common bile duct in seven cases, hepatocellular carcinoma (HCC) in seven cases, intrahepatic cholestasis in three cases and miscellaneous causes in eight cases. No final diagnosis was made in 14 patients. The duodenofiberscopic examination with biopsy revealed the cause of obstructive jaundice directly in eight cases, when carcinoma of the pancreas or papilla of Vater extended to the duodenal mucosal surface. In 34 of the 37 patients with choledocholithiasis, ERCP alone was successful in making the diagnosis. Percutaneous transhepatic cholangiography and ERCP were used together to reach a diagnosis in the remaining three patients. We propose a classification for HCC on ERCP which may be useful for the study of icteric type HCC.

Ampulla of Vater↗
PubMed2001

EUS with EUS-guided fine-needle aspiration as the first endoscopic test for the evaluation of obstructive jaundice.

BACKGROUND: This study assesses the cost savings associated with using endoscopic ultrasound (EUS) before endoscopic retrograde cholangiopancreatography (ERCP) for evaluating patients with suspected obstructive jaundice. METHODS: One hundred forty-seven patients with obstructive jaundice of unknown or possibly neoplastic origin had EUS as their first endoscopic procedure. With knowledge of the final diagnosis and actual management for each patient, their probable evaluation and outcomes and their additional costs were reassessed assuming that ERCP would have been performed as the first endoscopic procedure. Also calculated were the additional costs incurred if EUS were unavailable for use after ERCP and had to be replaced by computed tomography or other procedures. RESULTS: The final diagnoses in these patients included malignancies (65%), choledocholithiasis or cholecystitis (18%), "medical jaundice" (11%), and miscellaneous benign conditions (6%). Fifty-four percent had EUS-guided fine-needle aspiration but only 53% required ERCP after EUS. An EUS-first approach saved an estimated $1007 to $1313/patient, but the cost was $2200 more if EUS was unavailable for use after ERCP. Significant savings persisted through sensitivity analysis. CONCLUSIONS: Performing EUS with EUS-guided fine-needle aspiration as the first endoscopic procedure in patients suspected to have obstructive jaundice can obviate the need for about 50% of ERCPs, helps direct subsequent therapeutic ERCP, and can substantially reduce costs in these patients.

Adult↗
PubMed1998

[Changes in serum and bile tumor necrosis factor alpha before and after percutaneous transhepatic cholangio-drainage for obstructive jaundice].

The aim of this study was to evaluate the correlation between tumor necrosis factor alpha (TNF alpha) and jaundice reduction by percutaneous transhepatic cholangio-drainage (PTCD) in patients with obstructive jaundice. Thirty patients who had undergone PTCD were divided into two groups: those with rapidly decreasing bilirubin (the fast group; n = 21) and those with slowly decreasing bilirubin (the slow group; n = 9). We compared clinical features before PTCD between groups. We also compared serum and bile TNF alpha before and after PTCD in the fast group with those in the slow group. The rate of patients with recurrence of malignancy in other organs involved in the etiology of obstructive jaundice was significantly higher in the slow group than in the fast group. Before and after PTCD, serum and bile TNF alpha were significantly higher in the slow group than in the fast group. These results suggest that TNF alpha may play an important role in the protracted recovery from obstructive jaundice after PTCD.

Aged↗
PubMed1976

Endotoxin, bile salts and renal function in obstructive jaundice.

It is generally agreed that there is an increased incidence of postoperative renal failure in patients with obstructive jaundice. The proposition that this may be due to endotoxin, and that the endotoxin may be absorbed from the patient's own bowel flora, has been investigated. The study was conducted in patients and in animals. Twenty-four patients with obstructive jaundice were studied. Sixteen had endotoxin in the portal blood at operation and 13 of these had peripheral endotoxaemia at the time of operation or developed it during the 72 hours following operation. Only 3 of the patients had a proved possible site of infective origin for the endotoxaemia, the remainder absorbing the endotoxin from their own gastro-intestinal organisms. Portal endotoxaemia occurred when the serum bilirubin was 8-5 mg/100 ml or greater. There was a highly significant decrease in mean endogenous creatinine clearance postoperatively in patients with endotoxaemia, and expression of this as a percentage postoperative fall compared with preoperative levels enhanced the significance. Jaundiced patients without endotoxaemia had no significant fall in endogenous creatinine clearance. Matched non-jaundiced control patients did not develop portal or peripheral endotoxaemia, and there was no significant fall in postoperative creatinine clearance. Experiments using animals showed that the absence of bile salts in the intestinal tract in obstructive jaundice allows endotoxin to be absorbed, and that this absorption can be prevented by the oral administration of bile salts. The therapeutic implications in patients are discussed.

Acute Kidney Injury↗
PubMed2001

Experimental study on lipid and bilirubin metabolism after biliary drainage for obstructive jaundice.

BACKGROUND: The present experimental study was carried out to determine variations in bilirubin and lipid metabolism in obstructive jaundice after external biliary drainage alone and in combination with intraintestinal administration of the drained bile. MATERIALS AND METHODS: Variations in lipid and bilirubin metabolism were studied in adult mongrel dogs with obstructive jaundice treated by external biliary drainage (EBD) and EBD plus intraintestinal administration of autologous bile (IBD). RESULTS: There was no difference between these two groups in regard to the volume of excreted bile after drainage. The biliary concentration and total daily excretion of bilirubin were higher in the IBD group (P < 0.0001), but there was no intergroup difference in the rate of decrease of serum bilirubin. In regard to lipid metabolism, the levels of total cholesterol, triglyceride, and low-density lipoprotein were decreased after biliary drainage; improvement in lipid metabolism was more rapid in the EBD group. Although the triglyceride level was lower after drainage, the activity of HMG-CoA reductase, the level of high-density lipoprotein 3-C, and the carrier protein apolipoprotein A-I were increased after drainage, with more rapid improvement in the EBD group. CONCLUSIONS: To improve lipid metabolism in obstructive jaundice, external biliary drainage is superior in the early stages of treatment, while replacement by EBD plus intraintestinal administration of autologous bile may be advantageous in cases of prolonged use.

Animals↗
PubMed1992

Early recurrence of obstructive jaundice after placement of a self-expanding metal endoprosthesis.

Self-expanding metal endoprostheses have ben used in the treatment of malignant obstructive jaundice for a few years. We report on a patient with obstructive jaundice due to a metastasis of a squamous cell lung cancer into the pancreatic head who received an expandable metal endoprosthesis and suffered recurrent jaundice and cholangitis after 38 days. On repeat ERCP, a very narrow stenosis was seen in the stent lumen caused by tumor ingrowth through the mesh. Intraluminal biopsies showed squamous cell carcinoma. A 10 Fr plastic endoprosthesis was inserted through the self-expanding stent with good drainage. On the basis of this experience, we feel that when faced with a patient with obstructive jaundice due to metastatic disease from a rapidly progressive carcinoma, the use of the currently available self-expanding metal endoprosthesis should be discouraged until the results of prospective studies with large numbers of patients have proven its superiority over the plastic endoprostheses. Meanwhile, modifications to prevent tumor ingrowth through the mesh of the stent are under investigation.

Carcinoma, Squamous Cell↗
PubMed2003

Serous cystadenoma of the pancreas associated with obstructive jaundice.

We herein report a case of pancreatic serous cystadenoma in a patient who presented with jaundice, and we provide a review of the literature. A 53-year-old man was admitted with complaints of jaundice and weight loss. With a preoperative diagnosis of pancreatic serous cystadenoma with obstructive jaundice, he underwent pylorus-preserving pancreatoduodenectomy. A cystic tumor partially protruding into the bile duct was observed in the pancreatic head. Histology verified serous cystadenoma of the pancreas. Histologically, no atypia was proven in the epithelium. There have been only eight case reports dealing with serous cystadenoma of the pancreas with obstructive jaundice. Although serous cystadenoma of the pancreas has essentially a benign nature, pylorus-preserving pancreatoduodenectomy is the treatment of choice when available to avoid the recurrence of obstructive jaundice.

Cholangiopancreatography, Endoscopic Retrograde↗
PubMedDate not supplied

Serum endothelin-1 and hepatocyte growth factor levels in patients with obstructive jaundice.

BACKGROUND/AIMS: Endothelin-1, a potent vasoconstrictive peptide, is known to modulate changes in local circulation. Additionally, hepatocyte growth factor, a potent mitogen for hepatocytes, is increased in various liver diseases. The present study examined changes in serum endothelin-1 and hepatocyte growth factor levels in patients with obstructive jaundice before and after percutaneous transhepatic cholangio drainage. METHODOLOGY: Endothelin-1 and hepatocyte growth factor levels were measured by enzyme-linked immunosorbent assay using sera from 16 patients with obstructive jaundice before and after percutaneous transhepatic cholangio drainage. RESULTS: Serum endothelin-1 levels decreased rapidly in the good bilirubin decrease group after biliary drainage. Endothelin-1 levels decreased 1 week after drainage but then increased gradually in the worse bilirubin decrease group. Serum hepatocyte growth factor levels decreased gradually after biliary drainage, and were higher in the worse bilirubin decrease group than in the good bilirubin decrease group throughout the study. CONCLUSIONS: These results suggest that endothelin-1 may be associated with the microcirculatory disturbance in obstructive jaundice and prolonged cholestasis. Measurement of hepatocyte growth factor levels in patients with obstructive jaundice before percutaneous transhepatic cholangio drainage may be an early clinical predictor of the subsequent rate of decrease of the serum bilirubin concentration.

Adult↗
PubMed2000

Bacterial translocation in obstructive jaundice in rats: role of mucosal lacteals.

OBJECTIVE: To study the ultrastructure of the ileal wall in rats with obstructive jaundice alone and after passive external biliary drainage to see if we could discover the reason for the increased risk of infective complications and multisystem failure in the presence of obstructive jaundice and after external biliary drainage. DESIGN: Histological examination of the wall of the terminal ileum using light microscopy, as well as scanning and transmission electron microscopy (EM). SETTING: Experimental laboratory, Republic of Georgia. ANIMALS: 56 adult male Wistar rats. INTERVENTIONS: Rats were divided into 7 groups: controls (not operated on, n = 6); sham-operated and studied after 6 and 12 days (n = 6 in each); bile duct ligation alone studied after 6 and 12 days (n = 10 in each); and bile duct ligation followed 6 and 12 days later by one-day of external biliary drainage (n = 9 in each). MAIN OUTCOME MEASURES: Percentage of destroyed villi. RESULTS: The extent of oedema of villi, necrosis of neurons, and disturbances in the secretory capacity of enterocytes correlated well with the duration of cholestasis. After 6 and 12 days ligation alone 7.2% and 17.3%, respectively, of villi were found to be destroyed; their connective tissue framework including lymphatics was in direct contact with the intestinal contents. The changes were not reversed by one day of external biliary drainage. CONCLUSION: The gaps in the ileal mucosa caused by obstructive jaundice (and not relieved by one day of external biliary drainage) may enable gut bacteria and their endotoxin to reach the systemic circulation through the lymphatic-system. This could increase the risk of infective complications.

Animals↗
PubMed1994

Glucagon responses in rabbits with obstructive jaundice and a low energy status in the liver.

Glucagon has a choleretic effect and also stimulates energy-consuming reactions, such as gluconeogenesis and ureogenesis in the liver. The effect of glucagon on energy metabolism in the liver was analyzed in rabbits with obstructive jaundice that had severe liver damage, indicated by significantly lower hepatic energy charge levels. The gluconeogenetic responses to glucagon administration, as shown by increases in the plasma glucose levels, were usually observed in normal rabbits, but these responses were completely depressed after glucagon administration in rabbits with obstructive jaundice. The energy charge levels in the latter animals decreased even further after glucagon administration. Even though the energy consumption for gluconeogenesis after glucagon administration was limited in the jaundiced rabbits, it was sufficient to cause a deterioration in the hepatic energy balance. The above findings show that the administration of glucagon increases the amount of energy expended in the liver following a reduction in the hepatic energy charge in rabbits with obstructive jaundice. Therefore, even though glucagon has a choleretic effect, it should be administered carefully to patients with obstructive jaundice, especially in those with severe liver damage, such as in patients with cholangitis.

Adenine Nucleotides↗
PubMed1994

Prospective study of postoperative renal function in obstructive jaundice and the effect of perioperative dopamine.

A prospective study was undertaken to assess postoperative renal dysfunction in patients with obstructive jaundice and to determine the effectiveness of dopamine in reducing its incidence. A total of 23 patients undergoing surgical relief of obstructive jaundice (serum bilirubin level above 100 mumol l-1) were randomized into two groups. Those in the control group (n = 10) received 3 litres 5 per cent dextrose intravenously during the 24 h before surgery plus a bolus of intravenous frusemide 1 mg kg-1 at induction of anaesthesia. The second group (n = 13) received a similar fluid and frusemide regimen plus an infusion of dopamine 3 micrograms kg-1 min-1 starting at induction of anaesthesia and continuing for 48 h after surgery. Postoperative oliguria occurred in two of the ten patients in the control group and in three of the 13 given dopamine (P = 0.74). No patient developed acute renal failure. There was no significant difference in mean levels of serum bilirubin, urea and creatinine, creatinine clearance and 24-h urinary output, on the day before and on days 1-5 after operation, between the two groups. It is concluded that, with careful preoperative resuscitation and control of fluid and electrolyte balance, the incidence of postoperative renal dysfunction in patients with obstructive jaundice is not as high as in some previous studies and is unaltered by administration of perioperative low-dose dopamine.

Acute Kidney Injury↗
PubMed2005

Obstructive jaundice in a child with pancreatic hemangioma.

We report the case of a 2-year-old boy who presented with obstructive jaundice by pancreatic hemangioma. In this case, a minimal operation for obstructive jaundice without resection of the tumor was performed. Three years after the operation, the pancreatic hemangioma almost disappeared. We discuss treatment of the pancreatic hemangioma in children.

Child, Preschool↗
PubMed1985

Surgical relief of obstructive jaundice in a district general hospital.

Fifty consecutive patients with obstructive jaundice treated by operation in Canterbury & Thanet Health District hospitals under the care of one surgeon (RECC) over a 6-year period have been studied. The pathology was found to be common bile duct (CBD) stone in 22 patients (44%); pancreatic carcinoma in 15 (30%), 3 of whom also had CBD stones; chronic pancreatitis in 4 (8%); extrahepatic CBD carcinoma in 4 (8%); ampulla of Vater carcinoma in 3 (6%); primary duodenal carcinoma in 1 (2%); and portahepatis obstruction in 4 (8%). The 8 postoperative deaths (16%) were found to be associated with high preoperative levels of serum bilirubin, but all occurred in patients with malignant disease. Complications occurred in 20 patients (40%) and bile culture state was found to be intimately related to the morbidity rather than operative mortality. The study represents a careful audit of the pathology distribution and the surgical management of obstructive jaundice as seen in district hospitals.

Adult↗