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Obstructive jaundice algorithm – An interdisciplinary approach for the management of bile duct obstruction

      Surgical resection is the only curative therapy for perihilar cholangiocarcinoma. However, a majority of patients present with an unresectable disease and are treated with palliative chemotherapy or chemoradiation. Almost all patients present with obstructive jaundice symptoms such as cholangitis, pruritus, and pain. Biliary decompression is mandatory for symptomatic relief, mitigation of sepsis, and enabling further treatment such as surgery, chemotherapy, or chemoradiation.
      The ideal biliary drainage remains controversially discussed. Endoscopic biliary drainage (EDB) has the advantage of internal instrumentation of the biliary tract. Percutaneous transhepatic biliary drainage (PTCD) is recommended if EBD expertise is not available, failed, or in the presence of multiple isolated segments with cholangitis.
      The figure illustrates the obstructive jaundice algorithm for patients with new onset or previously drained obstructive jaundice. Early computed tomography defines separation of neoplasm versus inflammatory origin by points of stricture such that a neoplastic process is presumed in the case of an isolated stricture. Proximal neoplasm undergo unilateral PTCD of the liver remant whereas mid duct and distal tumors are triaged to one attempt of EDB. A bilateral PTCD is anticipated if unilateral drainage fails. In the case of successful drainage of biliary tract per the suggested algorithm, subsequent management, including antibiotic therapy and drain internalization is predefined.