| What happens once bilirubin starts reducing in a patient? | taken up for surgery or chemo/radiotherapy or refer back to regional cancer centre | Imaging – MRCP to confirm diagnosis & look for level of obstruction, CECT abdomen to decide for definitive vs palliative care • Suspected cholangitis – Fluid resuscitation & I/V antibiotics • Biliary drainage (PTBD/ERCP) to make patient fit for surgery/palliative care (chemotherapy/radiotherapy) • PTBD preferred for high CBD/hilar obstruction, ERCP preferred in low CBD obstruction Once the bilirubin starts reducing, the patient can be: taken up for surgery or chemo/radiotherapy or refer back to regional cancer centre | 440 | summary | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | Imaging – MRCP to confirm diagnosis & look for level of obstruction, CECT abdomen to decide for definitive vs palliative care • Suspected cholangitis – Fluid resuscitation & I/V antibiotics • Biliary drainage (PTBD/ERCP) to make patient fit for surgery/palliative care (chemotherapy/radiotherapy) • PTBD preferred for high CBD/hilar obstruction, ERCP preferred in low CBD obstruction Once the bilirubin starts reducing, the patient can be: taken up for surgery or chemo/radiotherapy or refer back to regional cancer centre | 1 | page=1,block=31 | 0.700 | valid |
| What is the palliative treatment approach for bile drainage when ERCP is not possible? | PTBD# followed by Biliary stenting | If signs of cholangitis: Jaundice with fever, rigor, pain Urgent referral to higher centre Choledocholithiasis/other benign cause needing bile drainage • ERCP • PTBD# (If ERCP not possible) DEFINITIVE TREATMENT • PTBD followed by surgery PALLIATIVE TREATMENT • PTBD# followed by Biliary stenting • Chemotherapy/Radiotherapy | 261 | summary | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | If signs of cholangitis: Jaundice with fever, rigor, pain Urgent referral to higher centre Choledocholithiasis/other benign cause needing bile drainage • ERCP • PTBD# (If ERCP not possible) DEFINITIVE TREATMENT • PTBD followed by surgery PALLIATIVE TREATMENT • PTBD# followed by Biliary stenting • Chemotherapy/Radiotherapy | 1 | page=1,block=8 | 0.700 | valid |
| What does elevated SAP and GGT with relatively normal AST/ALT indicate in the presence of jaundice? | obstructive etiology | KEY TO DIAGNOSIS • In presence of jaundice • High AST/ALT + relatively normal SAP/GGT suggests hepatitis • Elevated SAP & GGT + relatively normal AST/ALT suggests obstructive etiology • USG* abdomen would mostly differentiate between obstructive and non-obstructive causes COMMON ETIOLOGIES • Non obstructive: Hepatitis related- viral hepatitis (A,B,C,E,NASH, alcohol, auto-immune cirrhosis) • Obstructive: Mechanical obstruction • Benign: stone, sludge, stricture, worm, primary sclerosing cholangitis, bilio-enteric anastomotic stricture (HJ stricture) • Malignant: Carcinoma GB, hepatocellular carcinoma cholangiocarcinoma, hepatic metastasis, pancreatic head carcinoma, extrinsic compression by lymph node/mass, pseudotumor PHC Patient with clinical features and/or red flag signs CHC/DISTRICT HOSPITAL • Clinical examination; hematological investigations – LFT, CBC, PT/INR and Imaging – USG abdomen • If cholangitis is suspected – Fluid resuscitation and IV antibiotics and refer to tertiary level care for further management TERTIARY CARE • Clinical examination, repeat hematological investigations if > 2 weeks. | 163 | relationship | 0.890 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf |
| What does high AST/ALT with relatively normal SAP/GGT suggest in the presence of jaundice? | hepatitis | KEY TO DIAGNOSIS • In presence of jaundice • High AST/ALT + relatively normal SAP/GGT suggests hepatitis • Elevated SAP & GGT + relatively normal AST/ALT suggests obstructive etiology • USG* abdomen would mostly differentiate between obstructive and non-obstructive causes COMMON ETIOLOGIES • Non obstructive: Hepatitis related- viral hepatitis (A,B,C,E,NASH, alcohol, auto-immune cirrhosis) • Obstructive: Mechanical obstruction • Benign: stone, sludge, stricture, worm, primary sclerosing cholangitis, bilio-enteric anastomotic stricture (HJ stricture) • Malignant: Carcinoma GB, hepatocellular carcinoma cholangiocarcinoma, hepatic metastasis, pancreatic head carcinoma, extrinsic compression by lymph node/mass, pseudotumor PHC Patient with clinical features and/or red flag signs CHC/DISTRICT HOSPITAL • Clinical examination; hematological investigations – LFT, CBC, PT/INR and Imaging – USG abdomen • If cholangitis is suspected – Fluid resuscitation and IV antibiotics and refer to tertiary level care for further management TERTIARY CARE • Clinical examination, repeat hematological investigations if > 2 weeks. | 95 | relationship | 0.890 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf |
| What are some benign causes of mechanical obstruction in obstructive etiologies? | stone, sludge, stricture, worm, primary sclerosing cholangitis, bilio-enteric anastomotic stricture (HJ stricture) | KEY TO DIAGNOSIS • In presence of jaundice • High AST/ALT + relatively normal SAP/GGT suggests hepatitis • Elevated SAP & GGT + relatively normal AST/ALT suggests obstructive etiology • USG* abdomen would mostly differentiate between obstructive and non-obstructive causes COMMON ETIOLOGIES • Non obstructive: Hepatitis related- viral hepatitis (A,B,C,E,NASH, alcohol, auto-immune cirrhosis) • Obstructive: Mechanical obstruction • Benign: stone, sludge, stricture, worm, primary sclerosing cholangitis, bilio-enteric anastomotic stricture (HJ stricture) • Malignant: Carcinoma GB, hepatocellular carcinoma cholangiocarcinoma, hepatic metastasis, pancreatic head carcinoma, extrinsic compression by lymph node/mass, pseudotumor PHC Patient with clinical features and/or red flag signs CHC/DISTRICT HOSPITAL • Clinical examination; hematological investigations – LFT, CBC, PT/INR and Imaging – USG abdomen • If cholangitis is suspected – Fluid resuscitation and IV antibiotics and refer to tertiary level care for further management TERTIARY CARE • Clinical examination, repeat hematological investigations if > 2 weeks. | 440 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf |
| What are some clinical presentations mentioned in the document? | Jaundice • Pruritus • Dark coloured urine & Pale stool | This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit the website of ICMR for more information: (icmr.gov.in) for more information. ©Indian Council of Medical Research, Ministry of Health & Family Welfare, Government of India. CLINICAL PRESENTATION • Jaundice • Pruritus • Dark coloured urine & Pale stool | 665 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | CLINICAL PRESENTATION • Jaundice • Pruritus • Dark coloured urine & Pale stool | 1 | page=1,block=64 | 0.700 | valid |
| What are some non-obstructive causes of jaundice related to hepatitis? | viral hepatitis (A,B,C,E,NASH, alcohol, auto-immune cirrhosis) | KEY TO DIAGNOSIS • In presence of jaundice • High AST/ALT + relatively normal SAP/GGT suggests hepatitis • Elevated SAP & GGT + relatively normal AST/ALT suggests obstructive etiology • USG* abdomen would mostly differentiate between obstructive and non-obstructive causes COMMON ETIOLOGIES • Non obstructive: Hepatitis related- viral hepatitis (A,B,C,E,NASH, alcohol, auto-immune cirrhosis) • Obstructive: Mechanical obstruction • Benign: stone, sludge, stricture, worm, primary sclerosing cholangitis, bilio-enteric anastomotic stricture (HJ stricture) • Malignant: Carcinoma GB, hepatocellular carcinoma cholangiocarcinoma, hepatic metastasis, pancreatic head carcinoma, extrinsic compression by lymph node/mass, pseudotumor PHC Patient with clinical features and/or red flag signs CHC/DISTRICT HOSPITAL • Clinical examination; hematological investigations – LFT, CBC, PT/INR and Imaging – USG abdomen • If cholangitis is suspected – Fluid resuscitation and IV antibiotics and refer to tertiary level care for further management TERTIARY CARE • Clinical examination, repeat hematological investigations if > 2 weeks. | 329 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf |
| What are the indications for the procedure described? | Decrease bilirubin to commence appropriate therapy (surgical/palliative) • Cholangitis (draining infected bile) • Intense pruritus | INDICATIONS • Decrease bilirubin to commence appropriate therapy (surgical/palliative) • Cholangitis (draining infected bile) • Intense pruritus CONTRAINDICATIONS • Deranged coagulation (correct before procedure) • Emergent cases: infuse fresh frozen plasma (FFP) - 10ml/kg body weight prior to the procedure • Elective cases: I/V vitamin K injection (5-10 mg) - 3 to 5 days • Ascites (to be dried before therapy) OUTCOME MEASURES Normal bile drainage through the catheter PROCEDURAL DETAILS • External drainage for infected cases (aim to establish internal drainage with or without biliary stenting, once the infection is treated. | 14 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | INDICATIONS • Decrease bilirubin to commence appropriate therapy (surgical/palliative) • Cholangitis (draining infected bile) • Intense pruritus CONTRAINDICATIONS • Deranged coagulation (correct before procedure) • Emergent cases: infuse fresh frozen plasma (FFP) - 10ml/kg body weight prior to the procedure • Elective cases: I/V vitamin K injection (5-10 mg) - 3 to 5 days • Ascites (to be dried before therapy) OUTCOME MEASURES Normal bile drainage through the catheter PROCEDURAL DETAILS • External drainage for infected cases (aim to establish internal drainage with or without biliary |
| What are the key biochemical findings in patients with raised serum bilirubin? | Markedly raised ALP and/ or GGT • Normal/ mildly raised AST/ALT | • Raised serum bilirubin with • Markedly raised ALP and/ or GGT • Normal/ mildly raised AST/ALT GB/CBD stone causing biliary dilatation Periampullary mass causing biliary dilatation(obstruction) GB mass/cholangiocarcinoma causing biliary radicle dilatation (obstruction) Percutane- ously dilated bile duct is accessed with needle Obstruction After needle placement wire is used to cross stricture and place catheter/ stent percutaneously Patients with obstructive jaundice having no/ minimal IHBRD with distended GB may be considered for percutaneous cholecystostomy in emergent situations. | 32 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | • Raised serum bilirubin with • Markedly raised ALP and/ or GGT • Normal/ mildly raised AST/ALT GB/CBD stone causing biliary dilatation Periampullary mass causing biliary dilatation(obstruction) GB mass/cholangiocarcinoma causing biliary radicle dilatation (obstruction) Percutane- ously dilated bile duct is accessed with needle Obstruction After needle placement wire is used to cross stricture and place catheter/ stent percutaneously Patients with obstructive jaundice having no/ minimal IHBRD with distended GB may be considered for percutaneous cholecystostomy in emergent situations. |
| What findings can ultrasonography reveal in cases of obstructive jaundice? | CBD/IHBR dilatation • GB stone/Mass | Ultrasound image showing causes and findings in of obstructive jaundice MEDICAL MANAGEMENT FOLLOWED BY • USG/MRCP • Lower CBD obstruction: ERCP • Higher common bile duct/Hilar Obstruction PTBD# MRCP • Ascertain level and cause of obstruction in the biliary tree • Lower CBD obstruction: ERCP preferred • High CBD obstruction: PTBD# preferred USG • CBD/IHBR dilatation • GB stone/Mass | 348 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1726644019_4_image_guided_management_of_obstructive_jaundice.pdf | Ultrasound image showing causes and findings in of obstructive jaundice MEDICAL MANAGEMENT FOLLOWED BY • USG/MRCP • Lower CBD obstruction: ERCP • Higher common bile duct/Hilar Obstruction PTBD# MRCP • Ascertain level and cause of obstruction in the biliary tree • Lower CBD obstruction: ERCP preferred • High CBD obstruction: PTBD# preferred USG • CBD/IHBR dilatation • GB stone/Mass | 1 | page=1,block=67 | 0.700 | valid |