extrahepatic cholestasis
TRANSCRIPT
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Extrahepatic Cholestasis
Prof. Dr. Salih PekmezciIU Cerrahpaşa Medical Faculty
Department of General Surgery
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Definition
Cholestasis is any condition in which the flow of bile from the liver is blocked.
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Extrahepatic cholestasis
= obstructive jaundice= mechanical extrahepatic bile duct obstruction= posthepatic jaundice
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Etiology• Bile duct tumors • Cysts • Narrowing of the bile duct (strictures) • Stones in the common bile duct • Pancreatitis• Pancreatic cancer or pseudocyst • Periampullary tumor• Pressure on an organ due to a nearby mass or
tumor • Primary sclerosing cholangitis• Parasites: ascariasis
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Diagnosis
• Symptoms & Signs• Physical examination• Laboratory• Imaging
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Symptoms & Signs
• History: duration and onset, progression• Jaundice (skin, sclera)• Dark urine• Pale stool• Pruritus• Weight loss• Abdominal pain
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Physical examination
• Jaundice • Scratch Marks• Masses – Liver/Spleen• Gall Bladder
– Murphy’s Sign– Courvoisier’s Law
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Physical examination
• Jaundice • Scratch Marks• Masses – Liver/Spleen• Gall Bladder
– Murphy’s Sign– Courvoisier’s Law
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Laboratory tests
• Conjugated bilirubin• Alkaline phosphatase
Bilirubin: normal range 0.3-1.2 mg/dLClinically obvious hyperbilirubinemia: >2.5 mg/dL
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Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic
Jaundice
Total bilirubin Normal / Increased Increased Increased
Conjugated bilirubin Normal /decreased Normal /increased Increased
Unconjugated bilirubin Increased Normal / Increased Normal
Urobilinogen Increased Normal / Increased Decreased / Negative
Urine Color Normal Dark Dark
Stool Color Normal Normal/pale Pale
Alkaline phosphatase levels Normal Increased Increased
Alanine transferase and Aspartate transferase levels Normal Increased Increased
Conjugated Bilirubin in Urine Not Present Present Present
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Imaging• Ultrasound:
– More sensitive than CT for gallbladder stones– Portable, cheap, no radiation, no IV contrast
• CT:– Better imaging of the pancreas and abdomen
• MRCP:– Imaging of biliary tree comparable to ERCP
• ERCP– Therapeutic intervention– Brushing and biopsy for malignancy
• Endoscopic US• Laparoscopic US
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PeriampullaryTumor
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CBD stones vs. Tumor Differential Diagnosis• Clinical features favoring CBD stones:
– Age < 45– Biliary colic– Fever– Intermittent jaundice
• Clinical features favoring cancer:– Painless and progressive jaundice– Weight loss – Palpable gallbladder – Bilirubin > 10
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Choledocholithiasis
• Gallstones within common bile duct (or common hepatic duct
• DD: cholelithiasis, hepatitis, sclerosing cholangitis, cholangiocarcinoma
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CholedocholithiasisManagement
• ERCP• Laparoscopic procedures
– Trancystic exploration– Laparoscopic choledochotomy
• Open procedures
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Cholangiocellular Carcinoma
• Originates from epithelium of extrahepatic or intrahepatic large or medium sized bile ducts
• 5-10% of malignant liver tumors, occurs in noncirrhotic livers
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Clinical Presentation
• Jaundice• Pain• Weight loss• High CA 19.9
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Surgical therapy
• In tumors located at distal 1/3 of bile ducts Whipple operation
• In tumors of middle and upper 1/3 combined liver (right hepatect, left hepatect, trisectionectomy, central resection) and extrahepatic bile duct resection +/- vascular resection
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Primary Sclerosing Cholangitis
• Cholestatic liver disease (ALP)• Inflammation of large bile ducts• 90% associated with IBD
– but only 5% of IBD patients get PSC
• Diagnosis: ERCP (now MRCP)– Biopsy: concentric fibrosis around bile ducts
• Cholangiocarcinoma: 10-15% lifetime risk• Definitive Treatment: Liver Tx
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Whipple procedure n:1000Mean age: 63.4 (15-103) Malignant periampullary tm:
652
Cameron JL, Ann Surg 2006
n 5 year survivalPancreatic head tm 405
(62.1%)18%
Ampulla Vateri tm 113(17.3%)
39%
Distal CBD tm 95(14.5%)
22%
Duodenum tm 39(5.98%)
52%
Total 652
Periampullary Tm
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Pancreatic head Ca• 1,3 and 5 year survival %64, %27 ve %18
Lymph node (-) and surgical margin (-)• 1,3 and 5 year survival %80, %49 ve %41
5 year survivalLymph node (-): %23 Lymph node (+): %14
Cameron JL, Ann Surg 2006
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Pancreatic head carcinoma
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S. Pekmezci
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S. Pekmezci
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Ampulla Vateri Tumor
• May be originated from bile duct, duodenum or Wirsung duct epithelium
• Prognosis is related to the epithelial origin s başı kanserine göre daha iyidir (%35-67’ye karşın %20)
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Ampulla Vateri Tumor
• Local resection• Radical surgery (treatment of
choice)
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S. Pekmezci
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Distal CBD Tm
• Resectability is high • PD is the standard treatment
Bahra et al, Chirurg, 2006
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