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Similar to Obstructive jaundice (1)
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Obstructive jaundice (1)
- 2. Jaundice – Classification Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg% Jaundice is increased levels of SB > 1.0 mg% Over production of Bilirubin (Hemolytic) From hemolysis of RBC Impaired hepatic function (Hepatitic) Hepatocellular dysfunction in handling bilirubin Uptake, Metabolism and Excretion of bilirubin Obstruction to bile flow (Obstructive) Intrahepatic cholestasis Extrahepatic Obstruction (Surgical Jaundice) 2www.drsarma.in
- 3. Clinical Aspects of Jaundice Clinically detectable if SB is >3 mg% With edema and dark skin – Jaundice is masked What is special about the sclera ? – Rich Elastin Darkening of the urine – Differential Diagnosis Skin discoloration – Yellowish, - Carotinemia – Eyes N Mucosa – hard palate (in dark skinned) Greenish hue of skin and sclera - due Biliverdin – indicates long standing jaundice ( CA head pancreas ) Generalized Pruritus – Obstructive Jaundice – Why ? 3www.drsarma.in
- 4. Clinical History – Imp clues Duration of jaundice – Acute / Chronic Abdominal pain v/s painless jaundice Fever – Viral / bacteria /sepsis Scraches-Pruritus - obstructive Appetite – Hepatocellular / Malignancy Weight loss – Malignancy Colour of stools –chalky white –obstructive Family history – Hemolytic – Inherited dis. H/o transfusion Alcohol abuse, Medications – INH, EM, Largactil www.drsarma.in 4
- 5. Coloured Urine – Differ. Diagnosis Bilirubin in urine due to Jaundice (CB) Concentrated urine in dehydration Sulfasalazine use – for Ulcerative colitis Rifampicin, Pyridium and Thiamine use Red urine – Porphyria, Hemoglobin & Myoglobinuria, Hematuria Melanin excretion from Melanoma-black food www.drsarma.in 5
- 6. Fate of RBC 6 • RBC life span in blood stream is 90-120 days • Old RBCs are phagocytosed and/or lysed • Lysis occurs extravascularly in the RE system subsequent to RBC phagocytosis • Intravascular Hemolysis of young RBC • This is due to hemolytic diseases of RBC www.drsarma.in
- 7. E V Pathway for RBC Scavanging Liver, Spleen & Bone marrow Hemoglobin Globin Amino acids Amino acid pool Heme Bilirubin Fe2+ Excreted Phagocytosis & Lysis Through Liver 7www.drsarma.in
- 8. Bilirubin Metabolism - Summary 8www.drsarma.in
- 10. How to clinically evaluate the patient ? What tests will help us in D.D ? What imaging modalities will be useful ? How to monitor the progress ? 10 ALGORITHMIC APPROACH FOR JAUNDICE www.drsarma.in
- 12. Second Step : If SB > 1.0 mg 12www.drsarma.in
- 13. Third Step : If CSB is increased 13www.drsarma.in
- 15. What imaging we need • Ultrasonography – 98% Sp, 90% Sen. • For GB stones USG better than CT • For duct stones –only 40% seen in USG • PTC – Extrahepatic obstr. – drainage • ERCP – Distal biliary obstruction Dx.Rx. • MRCP – Most useful for duct stones www.drsarma.in 15
- 16. Post hepatic Obstructive Jaundice • Painful v/s painless • Obstruction can be – Intra Luminal -(stone), hydatit cysts worms – Luminal- Stricture (benign v/s cholangiocarcinoma), periampulary ca – Klatskin tumor – Extra luminal pancreatic cancer,. lymph nodes, choledocal cyst • Investigate & treat with – Radiology (US, CT, MRCP) – ERCP / PTC 16www.drsarma.in
- 17. • A Klatskin tumor (or hilar cholangiocarcinoma) is a cholangiocarcinoma (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts. It is named after Dr. Gerald Klatskin, an American physician working at Yale.
- 18. Acute Cholecystitis 17 GB wall is thickened and striated. Courtesy of Udo Schmiedl, M.D.www.drsarma.in
- 19. Magnetic Resonance Cholangio-Pancreatography (MRCP) Two stones in the common bile ductTwo stones in the common bile duct Courtesy of Udo Schmiedl, M.D.Courtesy of Udo Schmiedl, M.D.
- 20. Retrograde Cholangiogram - ERCP Bile leak from the cystic duct after cholecystectomy Courtesy of Michael
- 21. Primary sclerosing cholangitis (PSC) with stricture due to cholangiocarcinoma. Courtesy of Robert L. Carithers, Jr., M.D. Retrograde Cholangiogram - ERCP
- 22. Irregular dilation of intrahepatic and extrahepatic ducts. Courtesy of Charles Rohrmann, M.D. Retrograde Cholangiogram - ERCP
- 23. Primary Sclerosing Cholangitis Normal Extra hepatic BD Narrowed abnormal intra- heptic bile ducts.
- 24. 23 PRE-OPERATIVE MANAGEMENT OF OBSTRUCTIVE JAUNDICE 1. HIGH INTAKE OF GLUCOSE (BUILD UP LIVER GLYCOGEN STORE) 2. VITAMIN K (FAT SOLUBLE), 10mg IV OR IM 3. ANTIBIOTICS (BROAD SPECTURUM) 4. HYDRATION (PREVENT RENAL FAILURE) (5% DEXTROSE TO ENSURE 30 ml/HOUR URINE FLOW) 5. DIURESIS – MANNITOL- 200ML REGIMEN
- 25. 24 SURGICAL PROCDURES 1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET, BALLOON CATHETER)(STENT TO RELIEVE SYMPTOMS) 2. PERCUTANEOUS REMOVAL OF STONES BY BURHENNE METHOD (T- TUBE LEFT FOR SIX WEEKS AND THEN REMOVED, DILATION OF THE MATURE TRACT, STEERABLE CATHETER, AND THEN STONE BASKET) 3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE VERY ILL 4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR WITH OUT TRANSDUODENAL SPHINCTEROTOMY OR CHOLEDOCHODUODENOSTOMY 5. STENTING
- 29. 25 EXPLORATION OF THE CBD
- 32. • Physical examination findings typically include jaundice and right upper quadrant tenderness. • Charcot's triad is a set of three common findings in cholangitis: abdominal pain, jaundice, and fever.
- 33. Causes •OBSTRUCTION •GALL STONES 10-30% of cases •CA •TRAUMATIC-- ERCP