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What Is Jaundice?

Jaundice is a condition in which an excess amount of bilirubin—a yellow-orange substance that circulates in the bloodstream—accumulates and dissolves in the fatty layer just beneath the skin, causing a yellowish discoloration of the skin, mucous membranes, and the whites of the eyes.

What Are the Types of Jaundice?

  1. Prehepatic (Hemolytic Jaundice): Caused by the rapid breakdown of a large number of red blood cells, leading to an excess of bilirubin in the blood.

  2. Hepatic (Liver-Related Jaundice): Occurs when the liver is unable to convert indirect bilirubin into direct bilirubin, resulting in hepatocellular jaundice.

  3. Posthepatic (Obstructive Jaundice): Caused by a blockage in the bile ducts at any level, preventing bile flow. This condition is referred to as obstructive jaundice.

In Which Type of Jaundice Is Interventional Radiology Applied?

In cases of obstructive jaundice, interventional radiology techniques can be used to lower the bilirubin levels in the bloodstream, providing significant benefit to the patient.

What Are the Causes of Obstructive Jaundice?

  • Gallstones: The most common cause of bile duct obstruction.

  • Post-Surgical Strictures: Narrowing of the bile ducts may occur after gallbladder surgery, liver transplantation, or treatments for liver cysts and ablation procedures. These strictures can be treated with balloon dilatation or stent placement.

  • Primary or Secondary Sclerosing Cholangitis:

  • Primary Sclerosing Cholangitis (PSC): Characterized by inflammation of the major bile ducts, leading to alternating areas of narrowing and dilation that appear like a “string of beads.” It is often associated with inflammatory bowel diseases, especially ulcerative colitis (in 60–80% of cases). Patients with PSC have an increased risk of developing bile duct cancer (cholangiocarcinoma).

  • Secondary Sclerosing Cholangitis: Similar in appearance to PSC but occurs due to an underlying cause.

  • Cancer: Tumors originating from the bile ducts (cholangiocarcinoma), or cancers compressing the bile ducts such as gallbladder cancer, liver cancer, pancreatic head cancer, metastases from other organs to the liver, or enlarged lymph nodes, can lead to bile duct obstruction.

  • Chronic Pancreatitis: Recurrent inflammation can cause strictures in the common bile duct (choledochus). Decreased pancreatic size, calcifications within the pancreas, and irregular dilation of the pancreatic duct are typical findings suggesting chronic pancreatitis.

  • Autoimmune Diseases:

  • IgG4-Related Systemic Disease: Similar to primary sclerosing cholangitis, this condition causes thickening and narrowing of the bile ducts.

  • Ischemic Cholangiopathy: May develop as a result of previous chemotherapy treatments.

What Are the Symptoms of Obstructive Jaundice?

  1. Yellowing of the skin and the whites of the eyes.
    Darkening of the urine.
    Pale or clay-colored stools.
    Itching of the skin.
    If bile duct inflammation occurs: fever, chills, and abdominal pain may develop.

How Is Obstructive Jaundice Diagnosed?

  1. Blood Test:
    Elevated bilirubin levels and liver enzymes.

  2. Imaging Studies for the Liver and Biliary System:

  3. Ultrasonography (US): The primary and first-choice imaging method.

  4. Computed Tomography (CT): Used when ultrasonography is insufficient and for lesion characterization.

  5. Magnetic Resonance (MR): Helps determine the cause of obstruction.

  6. MRCP (Magnetic Resonance Cholangiopancreatography): Used for imaging the bile ducts, typically without contrast, using special MR sequences; contrast use can provide additional information.

  7. ERCP (Endoscopic Retrograde Cholangiopancreatography): The bile ducts are accessed endoscopically through the mouth, filled with contrast dye, and imaged.

  8. PTC (Percutaneous Transhepatic Cholangiography): A contrast agent is injected into the bile ducts via a fine needle through the skin to visualize the bile ducts.

What is the Treatment for Obstructive Jaundice?

Treatment varies depending on the cause of the obstruction.

  • If the obstruction is caused by a stone:
    When a gallstone falls into the bile duct, it can be removed or pushed into the duodenum either endoscopically (via ERCP) or percutaneously (via PTC).
    If the stone is located in the gallbladder, the gallbladder is surgically removed.

  • If the obstruction is caused by a tumor (cancer):
    The definitive treatment is surgical removal. However, in most patients (about 90–95%) who are not suitable for surgery, the goal is to restore bile flow into the intestines by bypassing the obstruction.
    For this purpose, a catheter (a thin tube with small openings) or a stent is used.

    • Stents: These can be metal or plastic.

      • Metal stents expand to about 1 cm in diameter once placed but are inserted in a collapsed form (2.7 mm wide) into the bile duct. They are typically placed percutaneously (through the skin).

      • Plastic stents are generally placed endoscopically (via ERCP) and have a smaller inner diameter—3–4 times narrower than metal stents—making them more prone to blockage. They can also migrate into the intestine or liver.

    Due to these issues, metal stents are preferred in developed countries, although they are 10–20 times more expensive than plastic stents.

Percutaneous Treatment of Bile Duct Disease

The procedure is performed by an Interventional Radiology Specialist in a fluoroscopy or angiography unit, under ultrasound or fluoroscopic guidance. After administering sedative and pain-relieving medication intravenously, the procedure is carried out.

What are the Percutaneous Treatment Procedures Used in Bile Ducts?

  • Percutaneous Transhepatic Cholangiography (PTC):
    This is a procedure used to visualize the bile ducts. A fine needle is inserted through the patient’s right upper abdomen, between the ribs, into a dilated bile duct within the liver. A contrast dye is then injected to obtain images of the bile ducts. The purpose is to determine the level and extent of any obstruction.

  • Percutaneous Biliary Drainage:
    After passing a guidewire through the narrowed area, a catheter (thin tube) with multiple holes at its tip and sides is placed into the intestine. Through this catheter, saline is periodically injected to flush the bile ducts, preventing blockage.

  • Percutaneous Biliary (Bile Duct) Stent Placement:
    A guidewire is advanced beyond the narrowed or obstructed area of the bile duct into the intestine. Over this wire, a metallic or plastic stent is deployed to cover the site of narrowing. To prevent the stent from clogging, a drainage catheter extending into the duodenum is also inserted.

  • Percutaneous Balloon Dilatation:
    This is performed to widen the bile duct or ensure full expansion of a previously placed stent. If a metallic stent does not fully open due to tumor-related narrowing, a balloon is inflated inside the stent to achieve complete expansion — often resulting in 100% opening. Balloon dilatation may also be used to widen the duct to allow a stone to pass into the duodenum.

  • Percutaneous Stone Extraction:
    After the bile duct is widened, a Fogarty catheter or balloon is advanced over a guidewire to push the stone into the duodenum. If the stone cannot be pushed, it is fragmented using various techniques and then moved into the duodenum.
    After the procedure, the patient is observed for 2–4 hours and discharged home once fully awake.

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