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Essential Features

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  • • Classified as obstructive (conjugated bilirubinemia) or nonobstructive (unconjugated bilirubinemia)

    • Adult etiologies include:

    • –Obstruction due to benign or malignant causes (stones, tumors, strictures)

      –Sludge or stasis due to infection or total parenteral nutrition (TPN)

      –Hemolysis or hepatocellular dysfunction

    • Neonatal etiologies include:

    • –Physiologic

      –Biliary atresia

      –Choledochal cyst

      –TPN

      –Hemolysis

      –Alagille syndrome

      –Intrahepatic bile duct paucity

      –Byler syndrome

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Clinical Findings

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Symptoms and Signs

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  • • Jaundice

    • Malaise

    • Anorexia

    • Fatigue

    • Pruritus

    • Encephalopathy

    • Kernicterus

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Laboratory Findings

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  • • Hyperbilirubinemia (conjugated or unconjugated)

    • Associated elevation of liver function tests if hepatocellular dysfunction

    • Anemia if associated sepsis, bleeding, or hemolysis

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Imaging Findings

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  • US: Shows biliary dilatation if obstruction present

    CT: Shows biliary obstruction present and accompanying mass

    • ERCP, magnetic resonance cholangiopancreatography (MRCP), or percutaneous transhepatic cholangiogram (PTC): Shows biliary obstruction if mass present and proximal and distal extent

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Diagnostic Considerations

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  • • Conjugated hyperbilirubinemia in neonate

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Rule Out

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  • • Anatomical obstruction to bile flow

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Work-up

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  • • History and physical exam

    • Bilirubin (conjugated and unconjugated)

    • US

    • CT

    • ERCP, MRCP, or PTC

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When to Admit

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  • • Cholangitis

    • Obstructive jaundice in neonate

    • Encephalopathy

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Treatment and Management

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Surgery

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  • • Resolution of bilary tract stone disease by cholecystectomy and decompression of common bile duct by operative, radiologic or endoscopic intervention

    • Resection with biliary reconstruction of mass causing obstruction

    • Biliary-enteric bypass if benign stricture or unresectable malignant disease

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Indications
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  • • Biliary obstruction

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Contraindications
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  • • Medical comorbidity precluding resection or general anesthesia

    • Extrahepatic disease if malignant cause

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Medications

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  • • Ursodiol

    • Phototherapy (neonate)

    • Exchange transfusion (neonate)

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Treatment Monitoring

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  • • Serum bilirubin

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Complications

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  • • Biliary-enteric anastomotic leak or stricture

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Resources

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References

Cipolletta L. et al. Endoscopic palliation of malignant obstructive jaundice: an evidence-based review. Digestive & Liver Disease. 2007, 39(4):375-88.  [PubMed: 17317347]

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