31.10.5 Frequency of Stones, Strictures and Carcinoma Head of Pancreas in Patients with Obstructive Jaundice

Original Article

 

Obstructive Jaundice

Frequency of Stones, Strictures and Carcinoma Head of Pancreas in Patients with Obstructive Jaundice

Shahbaz Ahmed Qureshi1, Sana Altaf1, Shahnaz Noor2, Sadia Bashir2, Javeria Shahbaz3 and Anas Ahmed Qureshi4

ABSTRACT

Objective: The objective of this study is to know the frequency of choledocholithiasis, biliary stricture and carcinoma head of pancreas among patients having obstructive jaundice.

Study Design: Cross-sectional, descriptive study

Place and Duration of Study: This study was conducted at the Department of Gastroenterology, four Medical units and four Surgical units at Bahawal Victoria Hospital Bahawalpur from January 2019 to June 2019.

Materials and Methods: A total of 201 patients diagnosed as obstructive jaundice with serum bilirubin level of greater than 3 mg/dl were included. The Intra and Extra hepatic biliary channels, presence of gall stones, common bile duct and any abdominal mass were seen by ultrasonography abdomen. Endoscopic retrograde cholangiopancreatography also done in patients with obstructive jaundice. Data regarding choledocholithiasis, carcinoma head of pancreas and biliary stricture was collected.

Results: This study included age range from 40 to 70 years with mean age of 52.24 ± 5.34 years. Majority of the patients were between 51 to 60 years age groups i.e. 57.8%. Majority of patients were females (62.7%). Mean weight was 78.78 ± 12.52 Kg and mean BMI was 26.293±2.87 kg/m2. The frequency of choledocholithiasis was 33.3%, carcinoma of head of pancreas 30.8% and biliary stricture was 7%.

Conclusion: The results concluded that Choledocholithiasis is the commonest benign etiology among patients with obstructive jaundice. It is more prevalent in females. This study shows that early diagnosis and intervention has significant role for the prognosis of patients with obstructive jaundice.

Key Words: Obstructive Jaundice, Choledocholithiasis, Carcinoma head of pancreas, Biliary stricture

Citation of article: Qureshi SA, Altaf S, Noor S, Bashir S, Shahbaz J, Qureshi AA. Frequency of Stones, Strictures and Carcinoma Head of Pancreas in Patients with Obstructive Jaundice. Med Forum 2020;31(10):16-19.

 

 

INTRODUCTION

The deposition of bilirubin pigment in sclera, mucous membranes and skin causes yellowish discoloration known as jaundice .1 The biliary obstruction at any level from liver up to gall bladder and small intestine results in obstructive jaudince.2 Obstructive jaundice could be intra-hepatic or extra hepatic. The most common intrahepatic causes are cirrhosis, hepatitis and hepato-cellular carcinoma.3

 

 

1. Department of Gastroenterology & Hepatology / Pathology2 / Biochemistry3, Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur.

4. Department of Medicine, Shahida Islam Teaching Hospital, Lodhran.

 

 

Correspondence: Prof. Dr. Shahbaz Ahmed Qureshi, Professor, Gastroenterology & Hepatology, Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur.

Contact No: 0321-6818394

Email: Shahbazq08@hotmail.com

 

 

Received:    March, 2020

Accepted:    August, 2020

Printed:        October, 2020

 

 

 

The intra-ductal and extraductal obstruction are further subdivision of the extra hepatic causes. Choledocholithiasis, biliary strictures, neoplasm, primary sclerosing cholangitis and worm infestation (parasites) can leads to intraductal obstruction. The biliary channels compression externally by pancreatitis, neoplasm and cystic duct stones with gall bladder distension consequently can cause extra ductal obstruction.4-6

Treatment of symptomatic gallstone disease by laparoscopic cholecystectomy (LC) in late 1980’s is associated with high incidence of BDIs than open cholecystectomy (OC). The incidence of BDIs shows a rise from 0.1-0.2% to as high as 0.8-1.4% in different studies.7 Although learning curve effect decreases the incidence of complications but it is still at least twofold compared to OC.8 Obstructive jaundice is concerning usually with the conditions like: Tumors (Carcinoma head pancreas, cholangiocarcinoma), Parasitic Infections (Hepato-biliary complicated hydatid disease, Ascariasis), Benign Stricture, Acute inflammation (cholangitis, Mirizzi syndrome). Congenital disease (Choledochal cyst).9

Pancreatic tumors that cause biliary obstruction usually arise from the head and periampullary pancreatic region due to the fact that the bile duct courses through the pancreatic head. The jaundice may show more advanced-stage disease due to malignancies in ampullary region which leads to biliary obstruction in 64-77% of cases.10, 11 The narrowed common bile duct leads to bile duct stricture which may prevent the bile flow into the intestine. Chalya PL and his associates have found the frequency of Choledocholithiasis by 62.5%, Biliary stricture by 25% and Carcinoma head of pancreas by 64.7% in patients with obstructive jaundice.12 Another study reported by Siddique K and his associates in patients with obstructive jaundice showed that frequency of Choledocholithiasis 35%, Carcinoma head of pancreas 30% and Biliary stricture 5%.13

The data regarding the frequency of Choledocholithiasis, Biliary stricture and Carcinoma head of pancreas in Pakistani cohort studies is limited. The different causes at various centers shows a big discrepancy and it is very important to know the nature of obstruction and its existence because a bad-chosen treatment can lead to high morbidity and mortality in local population.

MATERIALS AND METHODS

The study was Cross-sectional and carried out in the Department of Gastroenterology, four Medical units and four Surgical units at Bahawal Victoria Hospital Bahawalpur from January 2019 to June 2019 after taking ethical approval. The calculated sample size for the study at 95% level of confidence, 5% margin of error and 5% anticipated population proportion (biliary stricture)13 was 201. Male and female patients between 25-75 years of age with clinical diagnosis of obstructive jaundice and serum bilirubin level > 3mg/dl through non-probability consecutive sampling method were included in our study. Patients with liver cirrhosis and pregnant females were excluded from the study. Data was collected by using preformed, pretested questionnaire. Demographic information of patients (name, age, gender, weight, BMI) were noted. Trans-abdominal ultrasonography carried out for all patients to look for biliary channels, common bile duct, gall stones or abdominal mass. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in patients of obstructive jaundice where it was indicated. Patients with mass on ultrasound in conjunction with dilated bile ducts and serum bilirubin level >3 mg/dl were taken as cases of obstructive jaundice. The presence of echogenic rounded focus with size ranges between 2 to > 20mm in bile duct on ultrasound was taken as choledocholithiasis. The short segment Bile duct with irregular and shouldered margins along with >1.5mm thickness and on arterial and or portal venous phase enhancement of duct walls on ERCP (Endoscopic retrograde cholangiopancreatography) was taken as biliary stricture. Presence of cancerous cells in histopathology report of the pancreatic cells taken by ERCP was taken as carcinoma head of pancreas. The final diagnosis was concluded after the results of these investigations and histopathology. All procedures performed by a consultant gastroenterologist having post fellowship experience of at least 5 years. The analysis of data was done by statistical analysis program (SPSS version 22). The frequency and percentage were computed for qualitative variables like gender, different age groups, choledocholithiasis, biliary stricture and carcinoma head of pancreas. Mean ±SD was presented for quantitative variables like age, weight and BMI. Effect modifiers like age, gender and BMI were controlled by stratification. Post stratification chi square test was applied p <0.05 was considered statistically significant.

RESULTS

The study showed the age ranges from 40 to 70 years with mean age of 52.2±5.3 years. Most patients were between 41 to 60 years age groups i.e. 84.6%. About two third patients were females i.e. 126 (62.7%). Mean weight of the patients was 78.9±12.5 Kg and mean BMI of the respondents was 26.293±2.87 kg/m2. Choledocholithiasis was diagnosed in 67(33.3%) patients, biliary stricture in (7%) and carcinoma head of pancreas in 62(30.8%) patients with obstructive jaundice. Stratification of choledocholithiasis, biliary stricture and carcinoma head of pancreas in respect of age groups, gender and BMI are shown in Table 2.

Table- I: Age & Gender distribution of patients (n=201)

Variable

Frequency

Percentage

Age (years)

25-40

12

5.9%

          41-60

170

84.6%

          61-75

19

9.5%

Gender

         Male

75

37.3%

         Female

126

62.7%

Table No.2: Percentage of choledocholithiasis, biliary stricture and carcinoma head of pancreas among patients (n=201)

Variable

Frequency

Percentage

Choledocholithiasis

Yes

67

33.3%

No

134

66.7%

Biliary Stricture

Yes

14

7.0%

No

187

93.0%

Carcinoma Head of Pancreas

Yes

62

30.8%

No

139

69.2%

 

BMI of patients showed a significant association with choledocholithiasis (p=0.001) and carcinoma head of pancreas (p=<0.001).

Table No.3: Stratification of choledocholithiasis, biliary stricture and carcinoma head of pancreas with respect to age, gender and BMI of patients (n=201)

Variables

Choledocholithiasis

P value

Yes

No

Age

25-40

06 (50%)

06 (50%)

0.499

41-60

55(32.4%)

115(67.6%)

61-75

6 (33.3%)

13 (68.4%)

Gender

    Male

19(25.3%)

56 (74.7%)

0.063

Female

48(38.1%)

78 (61.9%)

BMI

     <20

02 (20%)

08 (80%)

0.001

     20-30

65(38.7%)

103(61.3%)

>30

00 (0%)

23 (100%)

Age

    Biliary Stricture

 

Yes

No

 

   25-40

01 (8.3%)

11 (91.7%)

 

   41-60

12 (7.1%)

158(92.9%)

0.941

   61-75

01 (5.3%)

18 (94.7%)

 

Gender

    Male

02 (2.7%)

73 (97.3%)

0.065

    Female

12 (9.5%)

114(90.5%)

 

BMI

     <20

01 (10%)

09 (90%)

 

     20-30

13 (7.7%)

155(92.3%)

0.364

     >30

00 (0%)

23 (100%)

 

Carcinoma Head of Pancreas

Age

Yes

No

 

   25-40

04(33.3%)

08 (66.7%)

 

   41-60

52(30.6%)

118(69.4%)

0.978

   61-75

06(31.6%)

13 (68.4%)

 

Gender

    Male

26(34.7%)

49 (65.3%)

0.366

    Female

36(28.6%)

90 (71.4%)

 

BMI

     <20

01 (10%)

09 (90%)

 

     20-30

38(22.6%)

130(77.4%)

<0.001

     >30

23 (100%)

00  (0.0%)

 

DISCUSSION

The obstructive jaundice may lead to increase morbidity and mortality leading to a diagnostic and therapeutic challenge for gastroenterologists.14 In countries like Pakistan, due to limited health facilities and illiteracy patients presents very late when they develop advanced disease. Moreover, in different cities, the non-availability of advanced diagnostic modalities like ERCP, CT scan, MRCP, PTC and therapeutic facility like T-tubes is a big challenge.15

The results of our study showed that the incidence in middle aged patients of obstructive jaundice was seen more commonly. The most common cause was Choledocholithiasis in 33.3% while carcinoma head of pancreas in 30.8%. Khurram et al in his study showed choledocholithiasis as most common cause of biliary obstruction.16

The female gender in the study were amongst more common having stone disease; a finding similar to that of other workers.17 The females showed increased incidence of Obstructive jaundice because the gall stones are more commonly present among them.18-20 The study done by Vargus and Astete amongst male patients undergoing ERCP showed that choledocholithiasis as first and carcinoma of common bile duct as third common diagnosis.21

Malignancies leading to obstruction of biliary channels are ampullary carcinomas, tumors of gall bladder extending into CBD, tumors leading metastasis (most common from gastrointestinal tract), cholangiocarcinoma and secondary lymphadenopathy at the level of porta hepatis.21 Both genders are equally affected by malignancies of Biliary channels.22 Choledochal cyst is the congenital cystic dilatations of either or both intra and extra-hepatic biliary channels. The high prevalent areas are in Asia, like Japan, and are more common 3 to 4 times in females.15, 23 Our study showed that biliary strictures were present in 7% of cases. After cholecystectomy few other studies showed traumatic strictures and ligation of CBD as one of the commonest causes.24,26

In developing countries like Pakistan, due to non-availability of advanced diagnostic and therapeutic modalities in every city, trans-abdominal ultrasonography is one of the non-invasive, easily available and best baseline imaging modalities in patients with obstructive jaundice because the results showed high sensitivity and specificity to find the cause.

CONCLUSION

It is concluded that obstructive jaundice more common in females. Choledocholithiasis was the most common cause in these patients. The results of our study suggest that early diagnosis and intervention had a significant role to reduce the morbidity and mortality along with improving the prognosis of patients with obstructive jaundice.

Author’s Contribution:

Concept & Design of Study:

Shahbaz Ahmed Qureshi, Sana Altaf

Drafting:

Anas Ahmed Qureshi

Data Analysis:

Shahnaz Noor, Javeria Shahbaz

Revisiting Critically:

Sadia Bashir, Javeria Shahbaz

Final Approval of version:

Shahbaz Ahmed Qureshi

Conflict of Interest: The study has no conflict of interest to declare by any author.

REFERENCES

1.      Tummala P, Munigala S, Eloubeidi MA, Agarwal B. Patients with obstructive jaundice and biliary stricture±mass lesion on imaging: prevalence of malignancy and potential role of EUS-FNA. J Clin Gastroenterol 2013;47(6):532-7.

2.      Fang Y, Gurusamy KS, Wang Q, Davidson BR, Lin H, Xie X, et al. Meta‐analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice. Bri J Surg 2013;100(12):1589-96.

3.      Decker C, Christein JD, Phadnis MA, Wilcox CM, Varadarajulu S. Biliary metal stents are superior to plastic stents for preoperative biliary decompression in pancreatic cancer. Surg Endoscop 2011;25(7):2364-7.

4.      Siddiqui AA, Mehendiratta V, Loren D, Kowalski T, Fang J, Hilden K, et al. Self-expanding metal stents (SEMS) for preoperative biliary decompression in patients with resectable and borderline-resectable pancreatic cancer: outcomes in 241 patients. Digestive Dis Sci 2013;58(6):
1744-50.

5.      Shukla S, Kharat PR, Kumar K. Clinicopathological study on patients presenting with obstructive jaundice. Int Surg J 2018; 5(2):705-10.

6.      Scheufele F, Aichinger L, Jäger C, Demir IE, Schorn S, Sargut M, et al. Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer. Br J Surg 2017; 104(2):e182-8.

7.      Kim JJ, Walia S, Lee SH, Patel B, Vetsa M, Zhao Y, et al. Lower yield of endoscopic ultrasound-guided fine-needle aspiration in patients with pancreatic head mass with a biliary stent. Digestive Dis Sci 2015;60(2):543-9.

8.      Spanheimer PM, Cyr AR, Liao J, Johlin FC, Hoshi H, Howe JR, et al. Complications and survival associated with operative procedures in patients with unresectable pancreatic head adenocarcinoma. J Surg Oncol 2014;109(7):697-701.

9.      Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P. Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 1997;184:571-8.

10.  Nuzzo G, Giuliante F, Giovannini I, Ardito F, D'Acapito F, Vellone M, et al. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56591 cholecy-stectomies. Arch Surg 2005;140:986-92.

11.  Clarke JS, Barrett P, Fonkalsrud EW, Johnson JN, Longmire WP, Pops MA, et al. Pathogenesis and Diagnosis of obstructive jaundice. Western J Med 2006;112:44-58.

12.  Chalya PL, Kanumba ES, Mchembe M. Etiological spectrum and treatment outcome of Obstructive jaundice at a University teaching Hospital in northwestern Tanzania: a diagnostic and therapeutic challenges. BMC Res Notes 2011; 4:147.

13.  Siddique K, Ali Q, Mirza S, Jamil A, Ehsan A, Latif S, et al. Evaluation of the aetiological spectrum of obstructive jaundice. J Ayub Med Coll Abbottabad 2008;20(4):62-6.

14.  Ahmad I, Jan AU, Ahmad R. Obstructive Jaundice. J Postgrad Med Inst 2001;15:194-8.

15.  Bekele Z, Yifru A. Obstructive jaundice in adult Ethiopians in a referral hospital. Ethiop Med J 2000;38:267-75.

16.  Khurram M, Durrani AA, Hasan Z. Endoscopic retrograde cholangiopancreatographic evaluation of patients with obstructive jaundice. J Coll Physicians Surg Pak 2003;13:325-28.

17.  Zhi ZNZ. The common causes and differential diagnosis of malignant jaundice. Pubmed 1993; 329:400-4.

18.  Channa NA, Khand FD, Bhanger MI, Leghari MH. Surgical incidence of Cholelithiasis in Hyderabad and adjoining areas (Pakistan). Pak J Med Sci 2004;20:13–7.

19.  Zarin M, Ahmed M, Gohar A, Waheed D, Khurram S. Incidence of gall stones in ca rcinoma Gall Bladder patients. Pak J Surg 2005;21:19–22.

20.  Ullah N, Gondal SK, Shahbaz RA. Carcinoma Gall Bladder; an incidence study at Services Hospital Lahore. Pak Postgrad Med J 2000;11:156–7.

21.  Vargus CG, Astete BM. Endoscopic retrograde cholangiopancreatography (ERCP): Experience in 902 procedures at the Endoscopic Digestive Center of Arzobipolayza Hospital. Rev Gastroenterol Peru 1997;17:222-30.

22.  Bonheur JL, Ellis P. Biliary Obstruction[Internet]. Emedicine 2001;[cited 2015 Sep 22]. Available from URL: http://www.emedicine.com/med/ topic3426.htm.

23.  Kiran RP, Pokola N. Bile duct tumors[Internet]. Emedicine 2001;[cited 2015 Sep 22]. Available from: URL: http://www.emedicine.com/med/ topic2705.htm.

24.  Sawyer MAJ, Sawyer EM, Patal TH, Varma M, Allen A, Murphy T. Choledochal cysts[Internet]. Emedicine 2002 ;[cited 2015 Sep 22]. Available from: URL:http://www.emedicine.com/med/topic 349.htm.

25.  Shennak MM. Endoscopic retrograde cholangio-pancreatography (ERCP) in the diagnosis of biliary and pancreatic duct disease: a prospective study on 668 Jordanian patients. Ann Saudi Med 1994;14:409-14.

26.  Kumar R, Nguyen K, Shun A. Gallstones and common bile duct calculi in infancy and childhood. Aust NZ J Surg 2000;70:188-91.