obstructive jaundice 19_9_2014
TRANSCRIPT
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OBSTRUCTIVE JAUNDICEPresented by: Dr. Anum ArifResident 1 (Surgical Unit 2)
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OBJECTIVES
1. DEFINITION
2. TYPES
3. OBSTRUCTIVE
JAUNDICE
4. CAUSES
5. SIGN/SYMPTOMS
6. DIAGNOSIS
7. TREATMENT
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1. DEFINITION
Jaundice is the yellow discoloration of the sclera and skin, as a result of raised serum bilirubin and is usually detectable clinically when the bilirubin is greater than 3 .g/dl.
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2. TYPES
1. PREHEPTIC
2. HEPATIC
3. POST HEPATIC
JAUNDICE TYPES
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2. TYPES
1. PREHEPTIC
2. HEPATIC
3. POST HEPATIC
JAUNDICE TYPES
1. HEMOLYTIC DISEASES
• Intravascular and extravascular
hemolytic disease.
• Autoimmune hemolytic disease.
• Paroxymal nocturnal
hemoglobinuria
2. INEFFECTIVE ERYTHROPESIS
1. IMPAIRED OR ABSENT
CONJUGATION OF
BILIRUBIN.
2. HEREDITIARY DISORDERS.
3. ACQUIRED DISORDERS
1. INTRAHEPATIC-LIVER CELL
DAMAGE/BLOCAKGE OF
BILE CANALICULI
2. EXTRAHEPATIC-
OBSTRUCTION OF BILE
DUCTS
Features Prehepatic (hemolytic)
Intrahepatic Heptocellular
Post-hepatic (Obstructive)
UCB ↑ ↑ Normal
CB Normal ↑ ↑
AST or ALT Normal ↑↑ Normal
ALPO Normal Normal ↑↑
Urine Bilirubin
Absent Present Increased
Urobilinogen Increased Present Absent
Features Prehepatic (hemolytic)
Intrahepatic Heptocellular
Post-hepatic (Obstructive)
Plasma Albumin
Normal Decreased Normal or decreased
PT Normal Increased Increased but correctted by Vitamin K
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OBSTRUCTIVE JAUNDICE
• Also called as surgical jaundice.
• Most important in surgical setting.
• Obstruction may be
intrahepepatic or extrahepatic.
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CAUSES
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CLASSIFICATION OF OBSTRUCTIVE JAUNDICE
# CLASSIFICATION DESCRIPTION
1. CONGENITAL Biliary atresiacholedochal cyst
2. INFLAMMATORY Ascending cholangitisSclerosing cholangitis
3. OBSTRUCTIVECBD stonebiliary stricture,parasitic infestation
4. NEOPLASTIC
Carcinoma head of pancreasPeriampullary carcinomacholangiocarcinomaKlatskin tumor
5. EXTRINSIC COMPRESSION OF CBD Lymph node or tumor(Mirzzi’s syndrome)
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CHOLEDOCHOLETHIASIS
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CA PANCREAS
DILATED CBD DUE TO CA PANCREAS
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CA PANCREAS
CA HEAD OF PANCREAS
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PRIMRY SCLEROSING CHOLANGITIS
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HEPATOCELLULAR CARCINOMA
HEPATOCELLULAR CARCINOMA
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CHOLANGIOCARCINOMA
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CHOLANGIOCARCINOMA
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MIRZZI’S SYNDROME
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CHOLEDOCHAL CYST
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PARASITIC INFESTATION
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BENJAMIN CLASSIFICATION
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TYPE 1: COMPLETE OBSTRUCTION
Classical symptoms with biochemical changes:
• Ca. head of Pancreas
• Cholangiocarcinoma
• Parenchymal Liver diseases
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TYPE II : INTERMITTENT OBSRUCTION• Symptoms and typical biochemical changes • But jaundice may or may not be present
o Choledocholithiasis
o Periampullary tumor
o Duodenal diverticula
o Choledochal Cyst
o Papillomas of the bile duct
o Parasitic infestation
o Hemobilia
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TYPE III : CHRONIC INCOMPLETE OBSTRUCTIONWith or without classical symptoms but pathological changes are present in bile duct and liver
o Strictures of the CBD
• Congenital
• Traumatic
• Sclerosing cholangitis
• Post radiotherapy
o Stenosed biliary enteric anastamosis
o Cystic fibrosis
o Chronic pancreatitis
o Stenosis of the Sphincter of Oddi
ERCP showing distal common bile duct stricture
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TYPE IV : SEGMENTAL OBSTRUCTION
One or more segment of intrahepatic biliary tract is obstructed
o Traumatic
o Sclerosing cholangitis
o Intra hepatic stones
o Cholangio carcinoma
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SYMPTOMS• Yellowish discoloration of sclera• Epigastric pain• Fever • Pruritis• Loss of weight• Loss of appetite• Increased bleeding tendency• Steatorrhoea or Dark stool• Dark orange urine
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SYMPTOMS
SIGNS• Charcot’s triad• Reynold’s pentad• palpable and / or tender
gallbladder (Courvioser’s law)• Hepatomegaly• Spleenomegaly• xanthomas• xanthelasma • scratch marks: excoriation • finger clubbing • loose, pale, bulky, offensive
stools • dark orange urine
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INVESTIGATIONS
• Serum Direct Bilirubin
• Feceal urobilinogen (incomplete
obstruction)
• Feceal urobilinogen absence
(complete obstruction)
• urobilinogenuria is absent in
complete obstructive jaundice
• bilirubinuria
• ALP
• cholesterol
• (GGT) is a sensitive marker of biliary
tract disease and its raised
• 5’nucleotidase is raised and its more
specific
• ALT AST may rise
• Albumin decreased
• PT prolonged
• clotting factor decreased
• Tumor markers Ca19-9 and CEA raised
according to underlying cause.
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RADIOLOGY
• IMAGING GOALS• To confirm the presence of obstruction
• To determine the level of the obstruction
• cause of the obstruction
• To provide complementary information relating to the underlying
diagnosis (eg., Staging information in cases of malignancy).
• What is the best therapeutic approach?
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• IMMAGING MODALITIES are:• Ultrasound • ERCP• MRCP• PTC
Ultrasound abdomen• More sensitive than CT for gallbladder stones and other pathology of gall
bladder
• Sensitive for dilated ducts (Dilation of the extrahepatic (>10 mm) or intrahepatic (>4 mm) bile ducts suggests biliary obstruction.)
• Liver parenchymal mass and mets
PortableThe sensitivity of EUS for the identification of focal mass lesions in pancreas is superior to that of CT scanning
Cheap
no radiation,
• Operator dependant
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Ultrasound showing gallbladder stonesEndoscopic ultrasound showing CBD stone
Endoscopic retrograde cholangiogram (ERCP)
• invasive procedure • Diagnostic and therapeutic
potential. • biopsy • brush cytology • Stone extraction • stenting.
COMPLICATIONS Pancreatitis Cholangitis Hemorrhage SepsiS
CT SCAN ABDOMEN
• Main role in malignant conditions mainly for localization of primary tumors and mets.
• Best for Pancreatic Carcinoma(Highly sensitive for lesion >1mm.)
•Mainly done when ultrasound fail or when there is ductal dilation on ultrasound. •level and cause of obstruction.
Carcinoma head of pancreas
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)• Noninvasive test to visualize the hepato biliary
tree
• Entire biliary tree and pancreatic duct can be seen
• Best for Intra Hepatic stones and CHOLEDOCHAL CYST
• SINGLE BEST FOR CHOLANGIOCARCINOMA
• MRCP is better to determine the extent and type of tumor as compared to ERCP
Percutaneous Transhepatic Cholangiogram (PTC)
• PTC is indicated when percutaneous intervention is needed and ERCP either is inappropriate or has failed.
• Can be used to drain biliary obstructions.
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SUPPORTIVE MANAGEMENT
• Preoperative biliary decompression (ERCP or PTC)
• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop
diuretics to prevent hepatorenal syndrome/ renal failure(12 to 24 hours prior to
surgery)
• catheterization to monitor output
• Broad spectrum antibiotic prophylaxis with 3rd generation cephalosporins
• Parenteral vitamin K +/- fresh frozen plasma
• Need careful fluid balance to correct dehydration
• Correction of hypokalemia and other electrolyte imbalance.
• Cholestyramine and antihistamine for symptomatic relief of pruritis
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DEFINITVE MANAGEMENT DEPENDS ON THE CAUSE
CHOLOEDOCHOLITHISIS
• Ideally ERCP follwed by laproscopic Cholecystectomy.
• Open exploration of common bile duct is indicated in: Presence of multiple stones (more than 5) and Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones
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2. Ca HEAD OF PANCREAS
• Whipple resection:
• Removal of head & neck of pancreas,
duodenum, distal 40% of stomach, lower
CBD, GB, upper 10 cm of jejunum, regional
L.Ns and reconstruction through
gastrojejunostomy,choledochojejunostmy
and pancreaticojejunostomy
• If not operable then we go for ?????biliary
drainage
CARCINOMA GALLBLADDER
• if involving cbd then whipple resection is done
• And in case of inoperable cases Endoscopic / Radiological stenting is done
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4)CHOLEDOCHAL CYST
Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree Biliary drainage is accomplished by Choledocho–jejunostomy with a Roux – en – Y anastamosis
5) Cholanchiocarcinoma
Surgery depends on the stage of tumor and may involve • Removal of the bile ducts
In Stage 1 tumor ,just the bile ducts containing the cancer are removed.
• Partial liver resectionIf the tumor has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts.
• Whipple procedureIf the tumor is larger and has spread into nearby structures, whipples proceedure is done.
• Inoperable cases it may be possible to relieve the blockage through stents via ERCP or PTC.
CHOLEDOCHOLITHISIS
Treatment of choice is stone extraction through ERCP
Open exploration of common bile duct is indicated in Presence of multiple stones (more than 5) and Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones
7)STRICTURE
• Treated by endoscopic stenting.• Therefore, surgery should probably be reserved for those patients
with complete ductal obstruction or for those in whom endoscopic therapy has failed.
• Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care.
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8)STRICTURE OF SPINCHTER OF ODDI
• Endoscopic or operative sphincterotomy
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SUMMARY
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