Malignant biliary tract obstruction (summary)

Changed by Jeremy Jones, 2 Aug 2016

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Malignant biliary tract obstruction (MBTO) is a common cause of jaundice and while most examples are the result of pancreatic head cancers, other malignancies may be causative.

Summary

epidemiology
- reflects the common causes, e.g. head of pancreas cancer
  - predominantly a condition of the elderly
  - 80% over the age of 60
presentation
- jaundice (90%) in the context of weight loss
- may be associated central abdominal pain
- presentation is relatively late
- a palpable mass may be evident on examination
pathology
- obstruction of the biliary tree occurs along the CBD
  - head of pancreas tumours (commonest)
  - cholangiocarcinoma
  - other tumours: gallbladder, duodenal, ampullary cancers
  - metastatic disease
radiology
- US is the primary investigation for jaundice
- CT will identify the cause of obstruction
- MRI may be used to identify the level of obstruction
- radiology may be used to insert a biliary drain
treatment
- despite improvement in treatments prognosis remains dismal
  - 5-year survival of pancreatic cancer is less than 5%

Radiographic features

Ultrasound

Ultrasound is the best first test since it is cheap, easily accessible and quick. It will identify biliary duct dilatation and be able to assess the level of obstruction.

In many cases it will be able to identify the obstructing lesion as a mass rather than a gallstone.

CT

CT with contrast will give more anatomic information than the ultrasound. It will help confirm the location of the mass lesion and identifying where the lesion has arisen. CT is very useful for mapping the vascular supply around tumours which is invaluable when planning surgical options. It may also be useful for local staging and potentially for identifying any metastatic disease.

PTC and drainage

A percutaneous transhepatic cholangiogram allows a radiologist to access the dilated biliary tree from above the level of obstruction and decompress the system. Depending on the cause and completeness of obstruction, this may be considered as a temporising measure while the treatment plan is determined.

~~-<li>epidemiology</li>~~
+<li>
+<strong>epidemiology</strong><ul><li>reflects the common causes, e.g. head of pancreas cancer<ul>
+<li>predominantly a condition of the elderly</li>
+<li>80% over the age of 60</li>
+</ul>
+</li></ul>
+</li>
~~-</ul><h4>Radiographic features</h4><p>Ultrasound</p><p> </p>~~
+</ul><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound is the best first test since it is cheap, easily accessible and quick. It will identify biliary duct dilatation and be able to assess the level of obstruction.</p><p>In many cases it will be able to identify the obstructing lesion as a mass rather than a gallstone. </p><h5>CT</h5><p>CT with contrast will give more anatomic information than the ultrasound. It will help confirm the location of the mass lesion and identifying where the lesion has arisen. CT is very useful for mapping the vascular supply around tumours which is invaluable when planning surgical options. It may also be useful for local staging and potentially for identifying any metastatic disease.</p><h5>PTC and drainage</h5><p>A percutaneous transhepatic cholangiogram allows a radiologist to access the dilated biliary tree from above the level of obstruction and decompress the system. Depending on the cause and completeness of obstruction, this may be considered as a temporising measure while the treatment plan is determined.</p>