Surgical Jaundice investigations & management
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This document discusses the investigations and management of surgical jaundice. It outlines the various laboratory tests, imaging studies, and other diagnostic evaluations used to confirm the diagnosis and identify the underlying cause of obstructive jaundice. This includes liver function tests, ultrasound, CT, MRCP, ERCP, and in some cases biopsy or tumor markers. The document then reviews the treatment approaches for common causes like gallstones, pancreatic cancer, and bile duct cancers. These involve endoscopic or surgical procedures to relieve the obstruction like ERCP, cholecystectomy, bile duct exploration, bypass procedures, and resection when possible. Postoperative jaundice is also discussed.
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Surgical Jaundice investigations & management
- 1. NVESTIGATIONS & MANAGEMENT OF SURGICAL JAUNDICE Md. Shadman Shakib 5 th yr MBBS student (K-71) Dhaka Medical College
- 2. Investigations To confirm diagnosis & exclude differentials 1. CBC with PBF • Hb% - in malignancy • PMN – in cholangitis PBF – in teenagers, it excludes: • Hereditary Hemolytic Anemia • Hereditary Spherocytosis
- 3. Investigations contd… 2.Liver Function Tests • Serum Bilirubin- Conjugated (direct) hyperbilirubinemia is found in obstructive jaundice. • In stone disease, S. bilirubin < 10 mg%, • S. bilirubin >20 mg% suggests malignant obstruction
- 4. Investigations contd… • Liver Enzymes • SGPT (5-30 IU/L) – raised • SGOT (5-40 IU/L)- raised • Serum Alkaline Phosphatase- markedly raised, out of proportion to serum aminotransferases • Serum 𝜸 𝑮𝒍𝒖𝒕𝒂𝒎𝒚𝒍 𝒕𝒓𝒂𝒏𝒔𝒇𝒆𝒓𝒂𝒔𝒆 – raised (more specific for hepatocytes)
- 5. Investigations contd… 2. Liver Function tests contd… • Prothrombine time (11-14 sec) – increased • INR – elevated • Serum Albumin- reduced • Serum A:G ratio- altered
- 6. Investigations contd… 3. Imaging: • USG of Hepatobiliary System & pancreas: can detect • Site of obstruction • Biliary dilatation & size of CBD • Stone in biliary tree : choledocholithiasis • Lesions in the wall of biliary tree: Cholangiocarcinoma • Enlargement of the pancreatic head: Ca. head of pancreas
- 7. Investigations contd… 3. Imaging: • Plain X-ray Abdomen – can detect radio-opaque gall stones in 10% cases
- 8. Investigations contd… 3. Imaging: • CT scan of abdomen - to rule out malignancy in head of pancreas or in periampullary region.
- 9. Investigations contd… 3. Imaging: MRCP: • Non invasive with excellent delineation of biliary tree
- 10. Investigations contd… 3. Imaging: ERCP: • Detects calculi or malignant strictures • Bile aspirates can be sent for cytological & microbiological examination • Endoluminal brushings can be taken from strictures for cytological study
- 11. Investigations contd… 3. Imaging: Percutaneous Transhepatic Cholangiography • Done when ERCP fails • Useful for malignant stricture at the level of confluence of right & left hepatic duct or higher • PTC is preferred to ERCP as successful drainage is more likely
- 12. Investigations contd… 4. Others: Urine tests • Fouchet’s test: for bile pigments • Hay’s test: for bile salts & urobilinogen in urine Supportive evidence: • Tumour marker: a.CA 19-9 & b.CEA for carcinoma of pancreas
- 13. Investigations contd… For staging • CECT of abdomen: detects local extension of tumour, LN status & liver metastasis • Endoscopic Ultrasound: better delineates local extension of tumour & LN metastasis • Diagnostic Laparoscopy & laparoscopic USG: defines operability & detects peritoneal deposits
- 14. Investigations contd… Investigations for GA fitness • CBC • Urine RME • RBS • Serum creatinine, Blood urea • Serum electrolytes • Chest X ray • ECG, Echocardiography (if age > 40 yrs) • HBsAg, Anti HCV
- 15. Hazards & concerns • Hypovolemia • Coagulopathy: ↑ PT due to deficiency of vitamin K dependent clotting factors II , VII, IX, X. • Hepatorenal syndrome & acute renal failure • Drug toxicity: Analgesics, antibiotics, sedatives • Effects on wound healing: Wound infection, Impaired wound healing, Anastomotic leakage.
- 16. Patient Preparation Preoperative: • Correction of hypovolemia & raise glycogen storage: • 5% / 10% DA, 5% DNS • Correction of Anemia ▪ Transfusion of PCV or whole blood
- 17. Patient Preparation contd… Preoperative: • Correction of Malnutrition • Intake of glucose containing fluid • High protein diet • Bowel Preparation: • Syp. Lactulose for clearance of urea splitting organism
- 18. Patient Preparation contd… Preoperative: • Correction of Coagulopathy ▪ IV administration of Vitamin K (10 mg for 5 days) • Correction of Co-Morbidities: • Control DM, HTN , Asthma etc
- 19. Patient Preparation contd… Preoperative: • Antibiotic Prophylaxis • 2nd generation cephalosporin + aminoglycosides • Urethral catheterization • To monitor urine output ( Should be >0.5 ml/kg/hr)
- 20. Patient Preparation contd… Per-operative: • Correction of Coagulopathy: ▪ If PT, INR is not corrected preoperatively, FFP should be used in OT • To maintain Kidney perfusion: • IV 20% Mannitol during operation
- 22. Treatment contd… 1. Choledochoilithiasis • If CBD stone <10 mm: ERCP along with endoscopic sphinchterotomy & retrieval of stone with Dormia basket followed by laparoscopic cholecystectomy • If ERCP is not successful, options are: • Biliary stenting • ESWL
- 24. Treatment contd… 1. Choledochoilithiasis • If CBD stone >10 mm: • Open cholecystectomy with choledocholithotomy or • Laparoscopic cholecystectomy with choledocolithotomy
- 25. Treatment contd… Lap cholecystectomy choledocholithotomy
- 26. Treatment contd… 2. Ca. of the head of the pancreas, Periampullary carcinoma, Cholangiocarcinoma: • If the tumour is resectable: • pylorus preserving pancreatico-duodenectomy or • classical whipple’s operation.
- 28. Treatment contd… 2. Ca. of the head of the pancreas, Periampullary carcinoma, Cholangiocarcinoma: • If the tumour is irresectable: • palliative triple bypass or • stenting in CBD & duodenum • These operations are combined with adjuvant chemotherapy
- 29. Deuodenal stent placed by ERCP Biliary stent placed by ERCP Treatment contd…
- 30. Treatment contd… 3. Klatskin tumour: • Hepatic plate dissection with excision of tumour followed by hepatico-jejunostomy or • Palliative percutaneous transhepatic biliary drainage
- 31. Treatment contd… 4. Biliary stricture: • Biliary Stenting or Roux-en-Y Hepaticojejunostomy
- 32. Treatment contd… 5. Choledochal cyst: • Radical excision or mucosal resection with Hepaticojejunostomy
- 33. Treatment contd… 6. Parasitic infestation • Removal by ERCP 7. Biliary atresia • Extrahepatic: Kasai’s operation, • Intrahepatic: Liver transplantation
- 34. Post operative jaundice Definition: Presence of elevated bilirubin with or without clinical icterus appearing in the post operative period. Causes: • Pre-hepatic: due to excessive hemolysis or a resolving hematoma. • Hepatic: from hepatic ischemia, viral infection or drug toxicity. • Post-hepatic: retained bile duct stone or bile duct injury.
- 35. Post operative jaundice Management: • Depends upon the underlying cause with specific intervention. Prognosis: • Jaundice will resolve in weeks to months if the underlying causes are resolved.
- 36. Acknowledgement Department of Surgery, DMCH References: • Bailey & Love’s Short Practice of Surgery 27th edition ,CRC • Sabiston textbook of surgery 20th edition,Elsevier • RCS Course Manual • UpToDate , Wolters Kluwer