Algorithm for an aggressive diagnostic approach to obstructive jaundice

If intrahepatic cholestasis exists, watchful waiting may delay appropriate medical therapy and worsen the prognosis. In extrahepatic cholestasis, hepatocellular damage, secondary biliary cirrhosis, gallstone fistula, deterioration of coagulation and nutrition or ascending cholangitis may ensue while the clinician charts the course of the bilirubin and enzymes. If malignant obstruction exists, the chances for resection or cure may be missed. Although a diagnostic laparotomy can disclose whether or not an extrahepatic block exists, there are pitfalls to this approach. Patients with primarily hepatocellular disease present a formidable operative risk and generally tolerate a surgical procedure and its attendant anesthesia poorly. Over the past few yr, several authors have accepted the premise that the optimal diagnostic workup should establish or exclude extrahepatic cholestasis, and if extrahepatic cholestasis exists, the nature and extent of the process should be made known to the surgeon before laparotomy, so that he can plan the most effective operative approach. Physicians are now faced with a staggering list of diagnostic studies. Some are simple with little or no morbidity but offer low accuracy; other methods are complicated and expensive and present varying degrees of morbidity and even mortality. The question is which procedure or procedures should be employed and in what sequence. A summary of these techniques is presented with emphasis on endoscopic retrograde pancreato cholangiography and arteriography.