Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Obstructive jaundice

85,446 views

Published on

  • To get professional research papers you must go for experts like ⇒ www.WritePaper.info ⇐
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Hello! I can recommend a site that has helped me. It's called ⇒ www.HelpWriting.net ⇐ They helped me for writing my quality research paper.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • ⇒ www.HelpWriting.net ⇐ This service will write as best as they can. So you do not need to waste the time on rewritings.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • make your breasts bigger without surgery! NO PILLS NO CREAMS 100% NATURAL. FIND out more now! =>> https://t.cn/A6Li7BTH
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • boost your bust. increase your breast size by 2 cups, naturally and without surgery. ➢➢➢ https://t.cn/A6Li7dmy
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Obstructive jaundice

  1. 1. OBSTRUCTIVEJAUNDICEDr Fazal Hussain KhalilPost Graduate TraineeSBW KTH
  2. 2. OBJECTIVES• clinical presentation of surgical Jaundice• Review the Causes of Jaundice• Pathophysiology of obstructive jaundice• Important Investigations• Management
  3. 3. Case Scenario• 82 yr old male patient presents withprogressive jaundice, itching, loss of weight .
  4. 4. History of presenting illness• Gradually progressive jaundice• Recurrent episodes of itching• White stools for last 2 months• Dark yellow urine• Generalized weakness & fatigability- 6 months• Weight loss in last 1 year• Reduced appetite• No fever
  5. 5. H/o past illness• No h/o DM, HT, TB, Chest pain• No previous surgery(no history of cholelethiasis)Personal History• Decreased appetite with pale stools• Normal bladder habits but deep yellowish• Smoker – 25 yrs• Non-alcoholic
  6. 6. ExaminationGeneral Physical Examination:– Pulse 88/min,BP 110/70– anemia +, Jaundice ++– No Lymphadenopathy– Scratch marksPer abdomen– Soft non-tender– Gall bladder palpable– No free fluid
  7. 7. Routine Investigations• Hgb: 11.7• Hct: 35• WBC: 6000;• normal differential count• Platelet: 350,000• Serum Crea: 1.2 mg• Total bil: 20 mg;B1(unconj): 2 mgB2 (conj): 18 mg• Alkaline phosphatase: 990 U/L• CA 19-9: 350 units/ml• Total protein: 6.5 grams;• USG-Abd: solid mass in distal CBD, dilated CBD, Intrahepatic Biliarydistension and distended GB
  8. 8. • Ct abdomenCt abdomen show grossly dilatedintra and extrahepatic biliary channelsWith distended gall bladderAnd possibilty of periampullary massADVISE ERCP
  9. 9. Causes of obstructive jaundice
  10. 10. Causes of Obstructive JaundiceObstructive jaundice is caused by conditions that block the normalflow of bile from the liver into the intestines including:• Cholelithiasis (gallstones)• Cholangiocarcinoma• Carcinoma pancreas• Biliary stricture (mainly iatrogenic)• Cholangitis (inflammation of the common bile duct)• Congenital structural defects• Choledochal cysts(Cysts of the bile duct)• Lymph node enlargement• Pancreatitis• Parasitic infection• Trauma, including surgical complications
  11. 11. Most common cause of obstructivejaundice in our set up
  12. 12. Clinical classification Of ObstructiveJaundice(Benjamin Classification)
  13. 13. Type I : Complete obstructionClassical symptoms with biochemical changesTumors : Ca. head of PancreasLigation of the CBDCholangio carcinomaParenchymal Liver diseases
  14. 14. Type II : Intermittent obstruction• Symptoms and typical biochemical changes• But jaundice may or may not be present Choledocholithiasis Periampullary tumor Duodenal diverticula Choledochal Cyst Papillomas of the bile duct Intra biliary parasites Hemobilia
  15. 15. TYPE III : Chronic incomplete obstructionWith or without classical symptoms but pathologicalchanges are present in bile duct and liver Strictures of the CBDCongenitalTraumaticSclerosing cholangitisPost radiotherapy Stenosed biliary enteric anastamosis Cystic fibrosis Chronic pancreatitis ERCP showing distal common bile duct stricture Stenosis of the Sphincter of Oddi
  16. 16. TYPE IV : Segmental Obstructionone or more segment of intrahepatic biliary tract is obstructed Traumatic Sclerosing cholangitis Intra hepatic stones Cholangio carcinoma
  17. 17. Pathophysiology of obstructivejaundice
  18. 18. PATHOPHYSIOLOGY OFOBSTRUCTIVE JAUNDICEObstructive jaundice is a condition in which there is blockage of the flow of bileout of the liver. This results in an overflow of bile and its by-products into theblood, and bile excretion from the body is incompleteHepatic functionsProtein synthesis,Reticulo-endothelial functionHepatic metabolismCoagulation defect..increased prothrombin time(Decreased absroption of fat solube vitamins A,D,E,K(decreased factorXI ,XII ,platelets)Renal functionsRenal vasoconstrictionActivation of complement system causing peritubular and glomerular fibrin deposition leading totubular and cortical necrosisCardiovascular effectsDecreased peripheral vascular resistanceBradycardia due to direct effect of bile salts on SA nodeDecreased cardiac contractabilityDelayed wound healing due to defective synthesis ofcollagen
  19. 19. Investigations
  20. 20. ROUTINE• Haemoglobin usually decreased in case of malignancy• Rfts are usually derranged
  21. 21. BIOCHEMICAL PROFILE1.Conjugated bilirubin> increased2.Urine bilirubin +3.Urobilinogen will be absent4.S.ALK PHOSPH RAISED (most sensitive, levels are elevated in nearly 100 % of patients with extrahepatic obstruction except in some cases of intermittent obstruction.Values usually greater than 3 timesthe upper limit of reference range, and in most typical cases, they exceed 5 times the upper limit)5. GAMMA –GLUTAMYL TRANSPEPTIDASE(GGT) is a sensitive marker ofbiliary tract disease is raised6.5’nucleotidase is raised and its more specific7.ALT AST may rise8.Albumin decreased9.PT prolonged clotting factor decreased10.RFTs are usually impaired
  22. 22. Radiology• IMAGING GOALS To confirm the presence of an extrahepatic obstruction To determine the level of the obstruction, to identify the specificcause of the obstruction To provide complementary information relating to the underlyingdiagnosis (eg., Staging information in cases of malignancy). What is the best therapeutic approach
  23. 23. Ultrasound abdomen– More sensitive than CT for gallbladderstones and other pathology of gall bladder– Sensitive for dilated ducts (Dilation of theextrahepatic (>10 mm) or intrahepatic(>4 mm) bile ducts suggests biliaryobstruction.)– Liver parenchymal mass and mets– Portable, cheap, no radiation,– But it is operator dependant
  24. 24. ENDOSCOPIC ULTRASOUND (EUS)• EUS has been reported to have up to a 98%diagnostic accuracy in patients with obstructivejaundice• it allows diagnostic tissue sampling via EUSguided fine-needle aspiration (EUS-FNA)• The sensitivity of EUS for the identification offocal mass lesions in pancreas has been reportedto be superior to that of CT scanning, bothtraditional and spiral, particularly for tumorssmaller than 3 cm in diameter.• Compared to MRCP for the diagnosis of biliarystricture, EUS has been reported to be morespecific (100% vs 76%)
  25. 25. Ct scan• Main role in malignant conditionsmainly for localization of primarytumors and mets• Best for PancreaticCarcinoma(Highly sensitive for lesion>1mm)•Mainly done when ultrasound fail orwhen there is ductal dilation onultrasound•also to find level and cause ofobstruction•and in malignant conditions
  26. 26. MAGNETIC RESONANCECHOLANGIOPANCREATOGRAPHY (MRCP)• Noninvasive test to visualize the hepato biliarytree• Entire biliary tree and pancreatic duct can beseen• Best for Intra Hepatic stones andCHOLEDOCHAL CYST• SINGLE BEST FOR CHOLANGIOCARCINOMA• MRCP is better to determine the extent andtype of tumor as compared to ERCP
  27. 27. Endoscopic retrograde cholangiogram(ERCP• Its an invasive procedure andhas therapeutic potential.• Allows biopsy or brush cytology• Stone extraction or stentingCOMPLICATIONS Pancreatitis Cholangitis Hemorrhage SepsisCONTRAINDICATIONS Unfav anatomy Pseudocyst Rec a/c pancreatitis
  28. 28. Percutaneous TranshepaticCholangiogram (PTC)• PTC is indicated whenpercutaneous intervention isneeded and ERCP either isinappropriate or has failed.• Can be used to drain biliaryobstructions.
  29. 29. Other investigations• Oral Cholecystography (OCG)>>> useful when patient has symptoms of cholelithiasis,but a negative ultrasound.• also is useful for counting the number of stones present.• HIDA SCAN- useful in a/c cholecystitis,• DIAGNOSTIC LAPAROSCOPY-• ANGIOGRAPHY- abnormal vasc.anatomy• Tumor markers- CA19-9 , CEA
  30. 30. Management of ObstructiveJaundice
  31. 31. ManagementPerioperative management of obstructivejaundice• Preoperative biliary decompression improves postoperative morbidity(usually cause increased hemorrhage & infections and is mainly Indicated in severe jaundiceor when there are signs of impending liver failure.Endoscopic internal drainage preferredover per-cutaneous external drainage• Intravenous admistration of 5% dextrose saline followed by 10%mannitol orloop diuretics to prevent renal failure(12 to 24 hours prior to surgery)• catheterization to monitor output• Broad spectrum antibiotic prophylaxis• Parenteral vitamin K +/- fresh frozen plasma• Need careful post operative fluid balance to correct dehydration• Correction of hypokalemia• Cholestyramine and antihistamine for symptomatic relief of pruritis
  32. 32. Treatment of Obstructive Jaundice isbased on the cause1) Cholelithiasis (gallstones)Ideally ERCP follwed by laproscopicCholecystectomyOr open cholecystectomy withCBD exploaration
  33. 33. 2) Ca Head of Pancreas / Periampullary Carcinoma/malignancyof lower 3rd of CBDa) Whipple resection (pancreaticoduodenectomy) is mainly done whichinvolves removal ofhead & neck of pancreas, duodenum, distal 40% of stomach, lower CBD, GB,upper 10 cm of jejunum, regional L.Nsand reconstruction through gastrojejunostomy,choledochojejunostmy andpancreaticojejunostomyb) If not operable then we go for Endoscopic sphincterotomy + stenting withPercutaneous transhepatic biliary drainage
  34. 34. 3) Ca gall bladdera) if involving cbd then whipple resection is doneb) And in case of inoperable cases Endoscopic / Radiological stenting is done4) Choledochal cyst Surgical excision of the cyst with Reconstruction of theextra hepatic biliary tree Biliary drainage is accomplished by Choledocho–jejunostomywith a Roux – en – Y anastamosis Long term follow up is necessary because of complicationslike cholangitis , lithiasis , anastomotic stricture
  35. 35. 5) CholanchiocarcinomaSurgery depends on the stage of tumor and may involve• Removal of the bile ductsIf the tumor is at a very early stage (Stage 1), just the bile ducts containingthe cancer are removed. The remaining ducts in the liver are then joinedto the small bowel, allowing the bile to flow again.• Partial liver resectionIf the tumor has begun to spread into the liver, the affected part of theliver is removed, along with the bile ducts.• Whipple procedureIf the tumor is larger and has spread into nearby structures, the bile ducts,part of the stomach, part of the small bowel (duodenum), the pancreas,gall bladder and the surrounding lymph nodes are all removed• If surgery to remove the tumour is not possible, it may be possible torelieve the blockage through stents through ERCP or PTC
  36. 36. 6)Choledocholithiasis (stones in the CBD)a)Treatment of choice is stone extraction through ERCPb) Mechanical lithotripsy – through modified dormia basketc)Through shock waves laser technologyd)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
  37. 37. 7)Strictures are usually treated by endoscopic stentingwhich is comparable to that of surgery, with similarrecurrence rates. Therefore, surgery should probably bereserved for those patients with complete ductal obstructionor for those in whom endoscopic therapy has failed. Surgerywith Roux-en-Y choledochojejunostomy orhepaticojejunostomy is the standard of care with good orexcellent results in 80 to 90% of patients.8) Stenosis of the Sphincter of Oddi endoscopic oroperative sphincterotomy will yield good results
  38. 38. Prognostic factors( Pitt’s score)Parameters• Type ofobstruction(malignant orbenign)• Age > 60 yrs• S.Alb< 3gm/dl• S.Bil > 10mg%• S.Alk P > 100 IU• S.Creatinine >1.3mg%• TLC >10000/mm3• Hematocrit < 30%Factors MortalityUpto 2 0%3 4%4 7%5 44%6 67%8 100%
  39. 39. Thank You

×