Title: Approaching the jaundiced patient Session No.: 1. Name: Maximilian Schöniger-Hekele Institution: Medical University of Vienna Country: Austria

Transcription

1 Title: Approaching the jaundiced patient Session No.: 1 Name: Maximilian Schöniger-Hekele Institution: Medical University of Vienna Country: Austria

2 Initial evaluation - Initial laboratory test Serum liver biochemical tests total bilirubin, direct and indirect bilirubin, alanine aminotransferase aspartate aminotransferase alkaline phosphatase gamma-glutamyltransferase prothrombin time/international normalized ratio (INR) albumin

3 Jaundice Determination of direct and indirect bilirubin and other liver function parameters Careful clinical examination cannot detect jaundice until the serum bilirubin is greater than 2 mg/dl elevation of predominantly unconjugated bilirubin due to: overproduction reduced bilirubin uptake conjugation defect elevation of both unconjugated and conjugated bilirubin due to: hepatocellular disease biliary obstruction impaired canalicular excretion

4 Diagnostic approach to the jaundiced patient Mediacal history: alcohol consumption, risk for viral hepatitis, exposure to toxic substances (eg, mushroom picking), HIV status. Drugs: prescription medications, over-the-counter medications, herbal and dietary supplements Other diseases/conditions: right-sided heart failure, diabetes mellitus and obesity (nonalcoholic fatty liver disease), pregnancy (gallstones), IBD, Physical examination: Clues to the etiology, Stigmata of (chronic) liver disease, right upper quadrant pain, history of fever, acholic stool. Initial laboratory tests - patterns of LFP abnormalities cholestatic hepatocellular isolated hyperbilirubinemia alkaline phosphatase and aminotransferases are normal: hemolysis or inherited disorders of bilirubin metabolism Predominant alkaline phosphatase elevation ( ) and serum aminotransferases ( ): biliary obstruction or intrahepatic cholestasis Predominant serum aminotransferase elevation: intrinsic hepatocellular disease

5 Imaging tests used in the evaluation of biliary obstruction Ultrasound usually first hepatic imaging Low probability of obstruction: abdominal CT Dilated biliary ducts are visualized in ultrasound, direct imaging of the biliary tree should be performed: MRPC, EUS, ERCP

6 Ultrasound Extrahepatic biliary obstruction Choledocholithiasis Malignant obstruction Pancreas Gallbladder Bile duct Biliary strictures Primary sclerosing cholangitis with extrahepatic bile duct stricture Complications after invasive procedures Chronic pancreatitis with stricturing of distal bile duct Biliary anastomotic stricture following liver transplantation Infections AIDS cholangiopathy Ascaris lumbricoides Intrahepatic cholestasis Drug and toxins associated with cholestasis Primary biliary cholangitis Primary sclerosing cholangitis Intrahepatic cholestasis of pregnancy Benign postoperative cholestasis Total parenteral nutrition Infiltrative diseases Amyloidosis Lymphoma Sarcoidosis Tuberculosis Hepatic abscess Metastatic carcinoma to the liver Liver allograft rejection Ischemic cholangiopathy

7 Extrahepatic biliary obstruction Choledocholithiasis is the most common cause of biliary obstruction Approximately 5% to 22% of the Western population has gallstones Patients suspected of having CBD stones are diagnosed with a combination of laboratory tests and imaging studies

8 Can we rely on biochemical test results? negative predictive value of completely normal liver biochemical test results in a series of more than 1000 patients undergoing laparoscopic cholecystectomy was more than 97% the positive predictive value of any abnormal liver biochemical test result was only 15% Surg Endosc, 22 (2008), pp BUT: more abnormally elevated values will result in an increased likelihood of CBD stones (specificity ~75% at a cutoff of 4 mg/dl) Ann Surg, 220 (1994), pp

9 Transabdominal US The first imaging study obtained is typically a transabdominal ultrasonography (US). Poor sensitivity for direct visualization of CBD stones Dilation of the CBD is associated with choledocholithiasis normal bile duct diameter is 3 to 6 mm Biliary dilation greater than 8 mm in a patient with an intact gallbladder is usually indicative of biliary obstruction Radiology, 145 (1982), pp a normal bile duct US has a 95% to 96% negative predictive value Surg Endosc, 22 (2008), pp

10 Predictors of choledocholithiasis Moderate Strong Very Strong <10% probability of choledocholithiasis (Clinical gallstone) pancreatitis Abnormal liver biochemical test other than bilirubin Age older than 55 y 10-50% probability of choledocholithiasis Dilated CBD on US (>6 mm with gallbladder in situ) Bilirubin level mg/dl * most reliable predictor of choledocholithiasis >50% probability of choledocholithiasis CBD stone on transabdominal US* Clinical ascending cholangitis Bilirubin >4 mg/dl ASGE Standards of Practice Committee, Gastrointest Endosc Jan; 71(1):1-9

11 Model for estimating probability of CBD stones Barkun AN et al., Ann Surg, 220 (1994), pp Karakan T et al., Gastrointest Endosc Feb;69(2):244-52

12 Transabdominal US Laboratory Tests CBD stones ERCP EUS MRCP

13 ERCP high sensitivity (90%) and specificity (98%) in detecting CBD stones or strictures. allows obtaining cytology, stenting, stone extraction at the same time. Frey CF et al., Am J Surg, 144 (1982), pp associated with a 5% to 10% complication rate. mortality rates of 0.02% to 0.5% after diagnostic and therapeutic ERCP. Freeman ML et al., N Engl J Med, 335 (1996), pp Cotton PB et al., Gastrointest Endosc, 37 (1991), pp % to 67% of ERCPs done for suspected CBD stones ultimately have negative results. Barkun JS et al., Ann Surg, 218 (1993), pp Hauer-Jensen M et al., Surgery, 113 (1993), pp

14 Suspected Bile Stones Indication for ERCP? Stones No Stones High Risk No benefit ERCP Benefit Stones

15 Risk factors for CBD stones EUS or MRCP? Frossard JL et al, Gastrointest Endosc. 2010;72(4):808-16

16 EUS OR MRCP EUS MRCP Sensitivity 93-97% 85-92% Specificity 94-95% 93-97% Zidi et al., Gut, 44 (1999), pp Sugiyama, Am J Gastroenterol, 93 (1998), pp

17 EUS OR MRCP EUS MRCP Sensitivity 93-97% 85-92% Sensitivity Stone <6mm 33-71% Specificity 94-95% 93-97% Zidi et al., Gut, 44 (1999), pp Sugiyama, Am J Gastroenterol, 93 (1998), pp

18 EUS OR MRCP EUS MRCP Sensitivity 93-97% 85-92% Sensitivity Stone <6mm 33-71% Specificity 94-95% 93-97% Pro High sensitivity and specificity No sedation Nonivasive Con Invasive Implants (Pacemaker,..) Sedation incomplete visualization of the biliary system Sludge Zidi et al., Gut, 44 (1999), pp Sugiyama, Am J Gastroenterol, 93 (1998), pp

19 Effect of size of CBD stones and CBD diameter on diagnostic performance of EUS Karakan T et al., Gastrointest Endosc Feb;69(2):244-52

20 EUS: a meta-analysis of test performance in suspected choledocholithiasis 2673 patients with suspected choledocholithiasis reported in 27 studies EUS had a high overall pooled sensitivity of 0.94 (95% CI, ), a specificity of 0.95 (95% CI, ) for diagnosing choledocholithiasis Tse F. et al., Gastrointest Endosc. 2008;67(2):235-44

21 EUS-directed ERC 4 trials randomized patients at intermediate to high risk for choledocholithiasis to an EUS-first strategy versus an ERC-first strategy 27% to 40% of patients randomized to EUS were found to have CBD stones ERC and concomitant complications were avoided in 60% to 73% strategy seems to be cost-effective Lee YT et al., Gastrointest Endosc, 67 (2008), pp Polkowski M et al., Endoscopy, 39 (2007), pp Liu CL et al., Clin Gastroenterol Hepatol, 3 (2005), pp Karakan T et al., Gastrointest Endosc, 69 (2009), pp

22 Approaching the jaundiced patient Conclusions Determination of liver function parameters, conjugated and unconjugated bilirubin, Medical history Transabdominal ultrasound (US) EUS has an excellent overall sensitivity and specificity. MRC is an alternative. EUS-directed ERC strategy: EUS selects patients for a therapeutic ERCP to minimize the risk of complications associated with unnecessary diagnostic ERCP