| Background:Disorders of the biliary tract affect a significant portion of the worldwide population, and the overwhelming majority of cases are attributable to cholelithiasis(gallstones). In the United States, 20% of persons older than 65 years have gallstones and 1 million newly diagnosed cases of gallstones are reported each year.To better understand these disorders, a brief discussion of the normal structure and function of the biliary tree is needed. Bile is the exocrine secretion of the liver and is produced continuously by hepatocytes. It contains cholesterol and waste products,such as bilirubin and bile salts, which aid in the digestion of fats. Half the bile produced runs directly from the liver into the duodenum via a system of ducts,ultimately draining into the common bile duct(CBD). The remaining 50% is stored in the gallbladder. In response to a meal, this bile is released from the gallbladder via the cystic duct, which joins the hepatic ducts from the liver to form the CBD. The CBD courses through the head of the pancreas for approximately 2 cm before passing through the ampulla of Vater into the duodenum.Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder or from the gallbladder to the small intestine. This can occur at various levels within the biliary system. The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination.Evaluation of jaundiced patients should include proper history and examination,laboratory investigation and imaging investigations(noninvasive like USG, CT and MRCP or invasive like ERCP and PTC).Objectives:To evaluate patients suspected of obstructive jaundice, by USG, CT, ERCP,MRCP.Methods:72 consecutive patients(41 males and 31 females) were referred to the radiology department of Osmania General Hospital, Hyderabad, India, with a clinical suspicion of obstructive jaundice with raised serum bilirubin and alkaline phosphatase betweenJuly 2014 to June 2015. All the patients underwent sonography and 57 patients underwent ERCP. CT was done in 36 cases and MRCP in 29 cases. Of the 72 patients,67 patients were confirmed to have obstructive jaundice. 5 patients were proved to have hepatocellular jaundice. Of the 67 patients, 36 were males and 31 were females.No. of cases of dilatation of biliary tree for USG are 72, for CT are 34, for MRCP are29 and for ERCP are 57. No. of cases in detecting the level of obstruction for USG are67, for CT are 34, for MRCP are 29 and for ERCP are 52. No. of cases in detecting the cause of obstruction in obstructive jaundice for USG are 67, for CT are 34, for MRCP are 29 and for ERCP are 52. Trans abdominal USG was done using 3.5 Hz Phased array curvilinear probe.(Aloka, Siemens & Hitachi). Most of the cases were done on TOSHIBA ASTEION 3rd generation scanner CT. Axial sections were obtained with patients supine and CT gantry at 0 degree angulation. Magnetic Resonance Chollangio Pancreatography was performed using 2D SSFSE(Single shot fast spin echo) sequence on 1.5T GE Signa MRI using Torso coil. The duodenoscope used for ERCP is similar to the fiber optic endoscope used for EGD with several modifications. The viewing lens and light window at the instrument tip are arranged for side viewing. Within the duodenscope is a channel which can accommodate a polyethylene contrast filled catheter, which can be advanced past the tip of the instrument. This separate catheter is used for cannulating the papilla of Vater.Results:.Reason for referral of patients include obstructive jaundice, pain in abdomen,mass in abdomen, known case of carcinoma on treatment and melena. The most common cause of obstructive jaundice in our study was tumors(41.25%) followed by common bile duct stones(36.25%) then benign strictures(13.75%), hydatid cyst(6.25%) & finally choledochal cyst(2.5%). In this study, MRCP could differentiate surgical from medical jaundice in all cases, while USG could differentiate surgical from medical jaundice in 91.25% of cases. CT and ERCP cannot differentiate surgical from medical jaundice. MRCP correctly suggests the most possible cause of obstruction in 96.25% of cases. While USG correctly suggests the most possible cause in only 36.2 %.. The sensitivity and specificity of USG is 100% and 83%, of CT is100% and 100%, of MRCP is 100% and 100% and of ERCP is 100% and 100% in detecting dilatation of biliary tree, respectively. Incidence of obstruction at variouslevels in the present study shows intrahepatic 1.6%, portal 9.8%, suprapancreatic24.5%, pancreatic 39.3%, ampullary 24.5%. The sensitivity and specificity of USG is60% and 95%, of CT is 77% and 96%, of MRCP is 100% and 95.6% and of ERCP is100% and 100% in detecting choledocholithiasis. Accuracy in detecting benign from malignant causes shows USG can detect 71.6%, CT can detect 94%, MRCP can detect 96.5% and ERCP can detect 98%.The percentage of USG is 77%, of CT is 94%,of MRCP is 96.5% and of ERCP is 100% in detecting the level of obstruction Conclusion:The most common cause of obstructive jaundice in our study is tumors. The incidence of obstruction mostly occur in pancreatic region. The common cause for referral of patients is obstructive jaundice. So that USG, as a screening modality is useful to confirm or exclude biliary dilatation. USG is less sensitive in detection of level and cause of obstruction. CT is an ideal modality to diagnose malignant cause of obstruction. MRCP is a useful non-invasive and essential method in the preoperative evaluation of patients with obstructive jaundice. MRCP is the best modality to differentiate surgical from medical jaundice in all cases. ERCP is the gold standard investigation for evaluating the pancreatic biliary tree and is highly sensitive in differentiating benign from malignant cause of obstructive jaundice. |
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