treatment of benign conditions causing surgical jaundice
DESCRIPTION
Aetiology and Management of Benign Conditions Causing Surgical Jaundice ; It includes Biliary atresia , Choledochal cyst , Sclerosing Cholangitis , Gall stones , Biliary stricturesTRANSCRIPT
BENIGN CONDITIONSAMARAN.M
FINAL YEAR MBBS , S2PROF.P.RAGUMANI UNIT
JAUNDICE JANEU ( FRENCH ) ; ICTERUS ( LATIN ) DEFINITION “REGAL” DISEASE
BENIGN CONDITIONS
CONGENITAL : BILIARY ATRESIA ; CHOLEDOCHAL CYST.INFLAMMATORY : SCLEROSING CHOLANGITIS.OBSTRUCTIVE : GALLSTONES ; BILIARY STRICTURES.
BILIARY ATRESIA
BILIARY ATRESIA
DEFINITION INCIDENCE 1 :
10,000 ASSOCIATED WITH
CONGENITAL ANAMOLIES
TYPES
TYPES OF BILIARY ATRESIA
PATHOGENESIS
CAUSES INFECTIONS : CMV, HPV,
REOVIRUS,
ROTAVIRUS.
AUTOIMMUNE
ABNORMAL DEVELOPMENT
TOXINS
VASCULAR DEFECTS
TREATMENT
HEPATICO-PORTO-
JEJUNOSTOMY PRESENTLY KASAI
PORTO-ENTEROSTOMY
8 WEEKS OF AGE
CHOLEDOCHAL CYST
CHOLEDOCHAL CYST
CYSTIC DIALTATIONS OF BILE DUCT
MORE COMMON IN ASIA
1 :1000 TYPES CAROLI’S DISEASE
( TYPE 5 ) CAUSE IS EXPLAINED
BY BABBIT THEORY
COMPLICATIONS OF CYSTS
PANCREATITIS MAINLY IN TYPE 3 GALLSTONE AND CBD STONE FORMATION BILIARY CIRRHOSIS MALIGNANCY ( CHOLANGIOCARCINOMA ; COMMON
IN POST.
WALL )
TREATMENT OF CYSTS
TYPE 1 COMPLETE EXCISION
OF CYST RECONSTRUCTION
BY HEAPTICO-JEJUNOSTOMY
TREATMENT OF CYSTS
TYPE 2 EXCISION OF
DIVERTICULUM SUTURING THE CBD
WALL
TREATMENT OF INTRADUODENAL PART
TYPE 3 ENDOSCOPIC
SPHINCTEROTOMY ( FOR
LESIONS < 3cm ) TRANSDUODENAL
APPROACH ( FOR
LESIONS > 3cm )
TREATMENT OF CYSTS
TYPE 4 EXTRAHEAPTIC PART
IS EXCISED AND RECONSTRUCTION PROCEDURE
INTRAHEPATIC PART ARE RESECTED ONLY WHEN THERE IS STRICTURES OR LIVER ABSCESS
LILY’S OPERATION
TREATMENT OF CAROLI’S DISEASE
TYPE 5 LEFT LOBAR DUCTS
ARE USUALLY AFFECTED
LOBAR RESECTION IS DONE.
BILOBAR INVOLVEMENT : TRANSPLANTATION
SCLEROSING CHOLANGITIS
SCLEROSING CHOLANGITIS INFLAMMATION AND SUBSEQUENT OBSTRUCTION OF BILE
DUCTS AT BOTH INTRAHEPATIC & EXTRAHEPATIC LEVELS
+ DILATATION OF PRESERVED SEGMENTS
HIGH RISK FOR CHOLANGIOCARCINOMA TYPES
1. PRIMARY ( NO CAUSE IS FOUND )
2. SECONDARY TO OTHER DISEASES
(CHEMOTHERAPY 5-FU)
PATHOGENESIS OF PSCAUTOIMMUNE ; HLA-B8/DR3
T CELL MEDIATED INFLAMMATION ; FIBROSIS & STRICTURES
PROGRESSIVE DESTRUCTION OF SMALL & MEDIUM SIZED DUCTS WITHIN LIVER & LARGE DUCTS OUTSIDE LIVER
OBSTRUCTION TO BILE FLOW (CHOLESTASIS)
CHRONIC INFLAMMATION
CHRONIC INFLAMMATION MAY PROGRESS TO :
CHOLANGIOCARCINOMA
CIRRHOSIS OF LIVER
MANAGEMENT
IMMUNOSUPPRESSION
•METHOTREXATE•AZATHIOPRINE•CYCLOSPORINE•TACROLIOMUS
GALLSTONE SOLUBILIZER
•URSODIOL ( suppresses hepatic synthesis of cholesterol )
LIPID LOWERING AGENT
•CHOLESTYRAMINE ( forms a non absorbable complex with bile acids and inhibits the reuptake )
STEROIDS IN LARGE DOSES VITAMIN SUPPLEMENTS
STENTING LIVER TRANSPLANTATION is the
only proven long term treatment
GENERAL
GALLSTONE
GALLSTONE CHOLELITHIASIS INVOLVES THE PRESENCE OF GALLSTONES IN
THE GALLBLADDER ;
CHOLEDOCHOLITHIASIS IS THE PRESENCE OD GALLSTONES IN COMMON
BILIARY DUCT
FAT, FERTILE , FORTY, FLATULENT, FEMALE
TYPES CHOLESTEROL STONES
PIGMENT STONES
MIXED ( COMMONEST 90 % )
CHOLESTEROL STONE PATHOGENESIS OBESITY PREGNANCY DRUGS HEREDITARY
PIGMENT STONES
INSOLUBLE Ca SALTS OF UNCONJ. BILIRUBIN
INORGANIC Ca SALTS
PIGMENT STONES
PIGMENT STONES PATHOGENESIS
PREDISPOSING FACTORS
CHRONIC HEMOLYTIC SYNDROMES
BILIARY INFECTION GI DISORDERS
PREDISPOSING FACTORS
ELEVATED LEVELS OF UNCONJUGATED BILIRUBIN
PIGMENT STONES
MANAGEMENT • CHENODEOXYCHOLIC ACID &
URSODEOXYCHOLIC ACID ( INHIBITS ABSORPTION OF CHOLESTEROL FROM
GUT)
DISSOLUTION
THERAPY
• OPEN CHOLECYSTECTOMY• CHOLEDOCHOTOMY• OPEN
CHOLEDOCHODUODENOSTOMY• OPEN CHOLEDOCHOJEJUNOSTOMY
OPEN PROCEDU
RES
• LAPROSCOPIC CHOLECYSTECTOMY
LAPROSCOPIC
PROCEDURES
OPEN CHOLECYSTECTOMY
PREOPERATIVE PREPARATION :
DEHYDARTION CORRECTION (IV DEXTROSE 5%)
IV ANTIBIOTICS
PNEUMOPERITONEUM WITH CO2 GAS AT SUBUMBILICAL PORT
GRASPING THE GALL BLADDER & CALOT’S TRAINGLE VISUALISATION
PLACING CLIPS AROUND CYSTIC DUCT & ATRERY TO CUT
GALL BLADDER IS DISSECTED OFF THE LIVER
BLEEDING CHECK & WASH & REMOVE THE GAS
BILIARY STRICTURE
BILIARY STRICTURE CAUSES
POST OP. ( MOST COMMON )
INFLAMMATORY CBD STONES
PARASITES
PSC
MALIGNANT TRAUMATIC
BISMUTH CLASSIFICATION
MANAGEMENT ERCP CHOLEDOCHOJEJUNOSTOMY CHOLEDOCHODUODENOSTOMY ROUX EN Y HEPATICOJEJUNOSTOMY ( IDEAL )
TAKE HOME MESSAGES
CONGENITAL MALFORMATION OF BILIARY TREE MAY BE EITHER ILEANA OR NAMITHA
SCLEROSING CHOLANGITIS IS AUTOIMMUNE INFLAMMATION + DESTRUCTION = OBSTRUCTION
MIXED TYPE IS THE COMMONEST STONE LAPROSCOPIC > OPEN PROCEDURE T TUBE PALCEMENT (CHOLANGIOGRAM
DONE TWICE )
DON’T AFRAID OF BEING DIFFERENT! HUMAN BEING IS ALWAYS AFRAID OF “BEING DIFFERENT” ; NOT BECAUSE THEY ARE DIFFERENT, ITS BECAUSE HUMANS ARE “WEAKER THAN” DIFFERENT !
THANK YOU