What is the treatment for obstructive jaundice?

Treatment of Obstructive Jaundice

Endoscopic biliary drainage with stent placement via ERCP is the first-line treatment for most patients with obstructive jaundice, offering lower morbidity and mortality compared to surgical or percutaneous approaches. 1

Initial Management Approach

Medical Stabilization

• Begin with hemodynamic stabilization and treatment of infection (cholangitis) before definitive biliary decompression 1
• Correct coagulopathy when possible, as vitamin K deficiency is common in obstructive jaundice 1

Treatment Selection Based on Etiology

Choledocholithiasis (Gallstone Obstruction)

• Endoscopic sphincterotomy with stone extraction during ERCP is the definitive treatment, with 90% success rate 1
• For large stones (>10-15 mm) or impacted stones, add lithotripsy or stone fragmentation (79% success rate, though 30% require multiple sessions) 1
• If complete stone extraction fails or severe cholangitis is present, place an internal plastic stent to ensure adequate drainage 1
• Important caveat: Endoscopic sphincterotomy carries 6-10% major complication rate, increasing to 19% in elderly patients with 7.9% mortality 1

Malignant Obstruction (Pancreatic Cancer, Cholangiocarcinoma)

For distal common bile duct obstruction:

• Endoscopic internal biliary stent placement is first-line, successful in >90% of cases 1
• Plastic stents are appropriate for most patients; metal stents should be used for patients expected to survive >3-6 months 1
• Metal stents have longer median patency (3.6 months vs 1.8 months for plastic stents, P=0.002) 1
• Surgical bypass is reserved for patients with good performance status and expected survival >6 months, as it provides better long-term patency but higher early complication rates 1

For hilar obstruction (Klatskin tumors):

• Percutaneous transhepatic biliary drainage (PTBD) is first-line treatment, demonstrating superior outcomes compared to endoscopic drainage 1
• PTBD achieves longer median survival (8.7 months vs 1.8 months, P<0.001) and shorter time to adequate drainage (11 weeks vs 15 weeks, P=0.033) for hilar tumors 1
• High conversion rates from endoscopic to percutaneous drainage occur with Klatskin tumors 1

Sclerosing Cholangitis

• Endoscopic internal biliary catheter with removable plastic stent is the appropriate initial therapeutic procedure 1
• Perform ERCP with caution, as suppurative cholangitis may be induced by catheter manipulation of obstructed biliary systems 1

Post-Surgical Complications (Bile Leak, Anastomotic Stricture)

• Either endoscopic or percutaneous internal/external biliary catheter is appropriate 1
• Choice depends on patient anatomy, available resources, and institutional expertise 1

Special Clinical Scenarios

Acute Cholangitis/Biliary Sepsis

• Urgent biliary decompression is lifesaving 1
• Either endoscopic or percutaneous drainage is appropriate; choose based on anatomy and availability 1

Coagulopathy (Uncorrected)

• Endoscopic drainage is strongly preferred over percutaneous approach 1
• ERCP-associated bleeding risk is only 1-2%, primarily from sphincterotomy 1
• Balloon sphincteroplasty can substitute for sphincterotomy when coagulopathy cannot be corrected 1
• PTBD is contraindicated with uncorrected coagulopathy due to 2.5% bleeding risk, higher with coagulopathy 1
• Transjugular bare metal stent insertion is an alternative when endoscopic placement fails, avoiding liver capsule violation 1

Altered Anatomy (Prior Gastric Surgery)

• ERCP is technically difficult with gastroenteric anastomoses 1
• Consider percutaneous approach or EUS-guided biliary drainage (requires high technical expertise) 1

Massive Ascites

• Relative contraindication for PTBD 1
• Medical management to reduce ascites before drainage, or choose endoscopic approach 1

Key Procedural Considerations

ERCP Risks and Benefits

• Overall major complication rate: 4-5.2% (pancreatitis, cholangitis, hemorrhage, perforation) 1
• Mortality risk: 0.4% 1
• Allows tissue diagnosis via brushing or FNA (sensitivity 46% for pancreatic malignancies, 68% for biliary malignancies) 1

When Endoscopic Approach Fails

• Standard ERCP succeeds in 90-95% of patients requiring biliary decompression 1
• Failure factors include gastric outlet obstruction from tumor or altered anatomy 1
• Switch to percutaneous transhepatic cholangiography or EUS-guided biliary drainage 1

Surgical Bypass Indications

• Reserved for fit patients with good performance status and expected survival >6 months 1
• Provides more durable palliation than stents but higher early complication risk 1
• Choledochojejunostomy or hepaticojejunostomy preferred over cholecystojejunostomy for durability 1