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  1. 1. Jaundice Robert Shirinov MD
  2. 2. Pathophysiology <ul><li>Jaundice is a syndrome that is recognised clinically when the serum bilirubin exceeds 40.0 mmol/l (the upper limit of normal = 17.0(mmol/ l). </li></ul>
  3. 3. Categories of Jaundice <ul><li>Haemolytic </li></ul><ul><li>Hepatocellular - in hepatocellular disease, clinical jaundice indicates substantive encroachment of liver function/ hepatic reserve and carries a poor prognosis. </li></ul><ul><li>Cholestatic or obstructive - cholestatic jaundice may be intrahepatic (hepatocellular disease) or extrahepatic (large bile duct obstruction, also referred to as surgical jaundice). </li></ul>
  4. 4. Obstructive Jaundice <ul><li>Gallstones </li></ul><ul><li>Pancreatic and Biliary Malignancy </li></ul><ul><li>Hepatic metastases </li></ul><ul><li>Bile duct strictures </li></ul>
  5. 5. Gallstones <ul><li>Gallstones are very common. The prevalence in the Western Hemisphere is 18.5%, with a female:male ratio of 2:1. </li></ul><ul><li>The current accepted classification recognises three main types of gallstone: </li></ul><ul><li>Cholesterol stones </li></ul><ul><li>essentially metabolic stones (preceded by biliary sludge) that form in the gallbladder </li></ul><ul><li>account for 75% of gallstones in the West. </li></ul><ul><li>Black pigment stones </li></ul><ul><li>consist of bilirubin polymers with varying amounts of cholesterol (3– 25%) in a matrix of organic material, and form in the gallbladder </li></ul><ul><li>account for 25% of stones in the West (commoner in Far Eastern countries) </li></ul><ul><li>can be associated with haemolytic states </li></ul><ul><li>are associated with infection in less than 20% of cases. </li></ul><ul><li>Brown pigment stones </li></ul><ul><li>form in the bile ducts (primary ductal stones) </li></ul><ul><li>associated with obstructive lesions and infections of the biliary tract </li></ul><ul><li>bacteria are present in the crevices and pits of these amorphous soft stones which consist of calcium bilirubinate and palmitate bound in a matrix of organic material. </li></ul>
  6. 6. Symptomatic gallstones diseases <ul><li>chronic cholecystitis </li></ul><ul><li>acute biliary colic/ acute obstructive cholecystitis </li></ul><ul><li>jaundice due to large bile duct obstruction </li></ul><ul><li>cholangitis and septicaemia </li></ul><ul><li>acute gallstone-associated pancreatitis </li></ul><ul><li>biliary fistulous disease </li></ul><ul><li>gallstone ileus </li></ul><ul><li>carcinoma of the gallbladder. </li></ul>
  7. 7. Risks of Surgery for large duct bile obstruction. <ul><li>infections (cholangitis, septicaemia, wound infections ) </li></ul><ul><li>bleeding (non-coagulant acarboxyl derivatives of vitamin K dependent factors) </li></ul><ul><li>renal failure </li></ul><ul><li>liver failure </li></ul><ul><li>fluid and electrolyte abnormalities </li></ul>
  8. 8. Pancreatic Malignancy <ul><li>Clinical picture of both pancreatic and biliary cancer is dominated by jaundice (from large bile duct obstruction) and itching. </li></ul><ul><li>Weight loss and recent onset of diabetes are important clinical features of pancreatic adenocarcinoma. </li></ul><ul><li>Pancreatic cancer </li></ul><ul><li>Annual deaths from pancreatic cancer range from 10±2/ 100 000 in males and 5±1/100 000 in females. </li></ul><ul><li>Risk factors for pancreatic cancer include: </li></ul><ul><li>smoking (strongest) </li></ul><ul><li>chronic pancreatitis </li></ul><ul><li>familial predisposition </li></ul><ul><li>cystic fibrosis. </li></ul>
  9. 9. Periampullary Tumors <ul><li>These include cancers of: </li></ul><ul><li>the ampulla of Vater </li></ul><ul><li>the distal common bile duct </li></ul><ul><li>the peri-Vaterian duodenum. </li></ul><ul><li>The prognosis depends on whether it is a periampullary cancer (5-year survival after treatment is approximately 40%) or cancer of the head (ductal adenocarcinoma) where 5- year survival after resection is less than 5%. </li></ul>
  10. 10. Biliary Tumors <ul><li>Carcinoma of the gallbladder is the commonest malignancy of the biliary tract and accounts for 3–4% of all gastrointestinal malignancies. It is a disease of old age and carries a uniformly poor prognosis. Gallstones are present in 75-90% of cases. </li></ul><ul><li>Presentation is with jaundice and/or acute cholecystitis. </li></ul>included in peri-ampullary tumours Distal from distal common hepatic duct, cystic duct and its confluence with the common bile duct Middle from right and left hepatic ducts, hilar confluence and proximal common hepatic ducts Proximal from minor hepatic ducts, often multicentric and usually classified with primary liver tumours Intrahepatic cholangiocarcinomas Bile duct cancers
  11. 11. Bile duct strictures <ul><li>a - distal bile duct stricture b - stricture of anomalous duct c - low stricture at common hepatic duct d - mid common hepatic duct stricture e - high stricture f - obliteration at duct confluence </li></ul><ul><li>Bile duct strictures can be malignant (cholangiocarcinomas ) or benign. The vast majority are the result of iatrogenic injury during cholecystectomy </li></ul><ul><li>Lesions require expert surgery because of the possible serious consequences which include: </li></ul><ul><li>recurrent cholangitis </li></ul><ul><li>hepatic fibrosis </li></ul><ul><li>secondary biliary cirrhosis </li></ul><ul><li>portal hypertension </li></ul>
  12. 12. Hepatocellular Jaundice <ul><li>Hepatic Metastases </li></ul><ul><li>Hepatitis </li></ul><ul><li>Liver failure </li></ul><ul><li>Cirrhosis </li></ul>
  13. 13. Hepatic metastases <ul><li>90% of hepatic tumours are metastatic, mostly from primaries in the GI tract, lung and breast. The commonest, by far, are metastases from primary colorectal cancer and these account for the majority of deaths from this disease. </li></ul><ul><li>Morphology: </li></ul><ul><li>discretely nodular – single, multiple, unilobar or bilobar </li></ul><ul><li>miliary – widespread small seedling deposits </li></ul><ul><li>diffusely confluent – disease involving multiple segments or lobes </li></ul><ul><li>Only nodular disease is curable. Less than 5% of patients with hepatic metastases are suitable for hepatic resection. </li></ul>Clinically metastases can be: Occult Undetectable by current imaging tests at the time of resection of the primary detected at subsequent follow-up. Asymptomatic No symptoms or jaundice, although the alkaline phosphatase or gammaglutamyl transpeptidase may be elevated. Treatable, sometimes for cure. Symptomatic Large liver , jaundice, malignant ascites. Incurable and rarely treatable.
  14. 14. Hepatitis <ul><li>Hepatitis has numerous possible causes, grouped here under the following headings: </li></ul><ul><li>acute hepatitis </li></ul><ul><li>drug-induced liver disease </li></ul><ul><li>chronic hepatitis. </li></ul>
  15. 15. Liver failure <ul><li>Acute (fulminant) liver failure </li></ul><ul><li>Defined as severe encephalopathy occurring within 6–8 weeks of the onset of illness. </li></ul><ul><li>It is acute massive hepatocellular necrosis in a previously normal liver caused by drugs (e.g. acetaminophen, halothane etc.), viral infection (A, B, C) or poisoning (e.g. amanita phylloides). The disease carries a high mortality despite newer methods of hepatic support a </li></ul><ul><li>Chronic liver failure </li></ul><ul><li>arises on a background of cirrhosis and is often referred to as end-stage chronic liver disease. It is characterised by overt chronic encephalopathy with severe mental impairment, muscle wasting, fluid and salt retention, bleeding tendency and episodes of variceal haemorrhage.and liver transplantation. </li></ul>
  16. 16. Cirrhosis <ul><li>Micronodular </li></ul><ul><li>small regenerating nodules separated by thick fibrous septa, as encountered in alcoholic cirrhosis, malnutritional cirrhosis and cryptogenic cirrhosis (aetiology unknown). </li></ul><ul><li>Macronodular </li></ul><ul><li>nodules of variable size, with normal histological appearances within the larger nodules (diagnosis may be missed on liver needle biopsy). This is seen in post hepatitic cirrhosis. </li></ul><ul><li>Mixed picture </li></ul><ul><li>results from regeneration in a micronodular cirrhosis </li></ul>
  17. 17. Cirrhosis <ul><li>Irrespective of morphological type, disease severity in cirrhotic patients (and hence prognosis) is based on assessment of clinical condition and biochemical profile. </li></ul><ul><li>Aetiologically the cirrhosis may be: </li></ul><ul><li>cryptogenic (cause unknown) </li></ul><ul><li>post hepatitic (usually B or C) </li></ul><ul><li>alcoholic </li></ul><ul><li>primary biliary cirrhosis. </li></ul><ul><li>Two severity scores are commonly used: </li></ul><ul><li>Child-Pugh score/grading (modified from the initial Child- Turcotte) </li></ul><ul><li>Paul Brousse Hospital classification system. </li></ul><ul><li>Although not included in either classification, muscle wasting is an important feature of advanced liver disease. </li></ul>
  18. 18. Severity Scores <ul><li>Child-Pugh classification of disease severity in cirrhotic patients </li></ul>* In the original Child-Turcotte classification, nutrition was used but this has been substituted with prothrombin activity. The bilirubin has to be adjusted for patients with primary biliary cirrhosis (A = 5-7, B = 8 –10, C = 11 or more) Advanced Minimal None Encephalpathy Refractory Controlled None Ascites < 40* 40 – 65 > 64 Prothrombin level % >6.0 4-6 <4.0 Bilirubin(mol/l) <3.0 3.0-3.5 >3.5 Albumin (g/dl) C B A Parameter
  19. 19. Paul Brousse Hospital classification system A = none of the criteria; B = 1 – 2 criteria; C = 3 or more criteria Number of criteria Parameter 2 Coagulation factor II and V < 40% 1 Coagulation factor II and V 40 – 60% 1 Clinical ascites 1 Encephalopathy 1 Hyperbilirubinaemia > 30mol/l 1 Albuminaemia < 3.0g/100ml
  20. 20. Diagnostic Protocol