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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

Symptoms and Signs

  • • Jaundice

    • Malaise

    • Anorexia

    • Fatigue

    • Pruritus

    • Encephalopathy

    • Kernicterus

Laboratory Findings

  • • Hyperbilirubinemia (conjugated or unconjugated)

    • Associated elevation of liver function tests if hepatocellular dysfunction

    • Anemia if associated sepsis, bleeding, or hemolysis

Imaging Findings

  • 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

  • • Conjugated hyperbilirubinemia in neonate

Rule Out

  • • Anatomical obstruction to bile flow

  • • History and physical exam

    • Bilirubin (conjugated and unconjugated)

    • US

    • CT

    • ERCP, MRCP, or PTC

When to Admit

  • • Cholangitis

    • Obstructive jaundice in neonate

    • Encephalopathy

Surgery

  • • 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

Indications

  • • Biliary obstruction

Contraindications

  • • Medical comorbidity precluding resection or general anesthesia

    • Extrahepatic disease if malignant cause

Medications

  • • Ursodiol

    • Phototherapy (neonate)

    • Exchange transfusion (neonate)

Treatment Monitoring

  • • Serum bilirubin

Complications

  • • Biliary-enteric anastomotic leak or stricture

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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