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OBSTRUCTIVE JAUNDICE
Presented by: Dr. Anum Arif
Resident 1 (Surgical Unit 2)
1
OBJECTIVES
1.
DEFINITION
2.
TYPES
3.
OBSTRUCTIVE
JAUNDICE
4.
CAUSES
5.
SIGN/SYMPTOMS
6.
DIAGNOSIS
7.
TREATMENT
2
1. DEFINITION
Jaundice is the yellow
discoloration of the sclera and
skin, as a result of raised serum
bilirubin and is usually
detectable clinically when the
bilirubin is greater than 3 .g/dl.
3
2. TYPES
1.
PREHEPTIC
2.
HEPATIC
3.
POST HEPATIC
JAUNDICE
TYPES
4
2. TYPES
1.
PREHEPTIC
2.
HEPATIC
3.
POST HEPATIC
JAUNDICE
TYPES
1. HEMOLYTIC DISEASES
• Intravascular and extravascular
hemolytic disease.
• Autoimmune hemolytic disease.
• Paroxymal nocturnal
hemoglobinuria
2. INEFFECTIVE ERYTHROPESIS
1. IMPAIRED OR ABSENT
CONJUGATION OF
BILIRUBIN.
2. HEREDITIARY DISORDERS.
3. ACQUIRED DISORDERS
1. INTRAHEPATIC-LIVER CELL
DAMAGE/BLOCAKGE OF
BILE CANALICULI
2. EXTRAHEPATIC-
OBSTRUCTION OF BILE
DUCTS
5
Features Prehepatic
(hemolytic)
Intrahepatic
Heptocellular
Post-hepatic
(Obstructive)
UCB ↑ ↑ Normal
CB Normal ↑ ↑
AST or ALT Normal ↑↑ Normal
ALPO Normal Normal ↑↑
Urine
Bilirubin
Absent Present Increased
Urobilinogen Increased Present Absent
Features Prehepatic
(hemolytic)
Intrahepatic
Heptocellular
Post-hepatic
(Obstructive)
Plasma
Albumin
Normal Decreased Normal or
decreased
PT Normal Increased Increased
but
correctted
by Vitamin K
OBSTRUCTIVE JAUNDICE
• Also called as surgical
jaundice.
• Most important in surgical
setting.
• Obstruction may be
intrahepepatic or extrahepatic.
8
CAUSES
9
CLASSIFICATION OF OBSTRUCTIVE JAUNDICE
# CLASSIFICATION DESCRIPTION
1. CONGENITAL
Biliary atresia
choledochal cyst
2. INFLAMMATORY
Ascending cholangitis
Sclerosing cholangitis
3. OBSTRUCTIVE
CBD stone
biliary stricture,
parasitic infestation
4. NEOPLASTIC
Carcinoma head of pancreas
Periampullary carcinoma
cholangiocarcinoma
Klatskin tumor
5.
EXTRINSIC COMPRESSION OF
CBD
Lymph node or tumor(Mirzzi’s syndrome)
10
CHOLEDOCHOLETHIASIS
11
CA PANCREAS
12DILATED CBD DUE TO CA PANCREAS
CA PANCREAS
13
CA HEAD OF PANCREAS
PRIMRY SCLEROSING CHOLANGITIS
14
HEPATOCELLULAR CARCINOMA
15HEPATOCELLULAR CARCINOMA
CHOLANGIOCARCINOMA
16
CHOLANGIOCARCINOMA
17
MIRZZI’S SYNDROME
18
CHOLEDOCHAL CYST
19
PARASITIC INFESTATION
20
BENJAMIN CLASSIFICATION
21
TYPE 1: COMPLETE OBSTRUCTION
Classical symptoms with biochemical changes:
• Ca. head of Pancreas
• Cholangiocarcinoma
• Parenchymal Liver diseases
22
TYPE II : INTERMITTENT OBSRUCTION
• Symptoms and typical biochemical changes
• But jaundice may or may not be present
o Choledocholithiasis
o Periampullary tumor
o Duodenal diverticula
o Choledochal Cyst
o Papillomas of the bile duct
o Parasitic infestation
o Hemobilia
23
TYPE III : CHRONIC INCOMPLETE OBSTRUCTION
With or without classical symptoms but pathological changes are present in bile duct and liver
o Strictures of the CBD
• Congenital
• Traumatic
• Sclerosing cholangitis
• Post radiotherapy
o Stenosed biliary enteric anastamosis
o Cystic fibrosis
o Chronic pancreatitis
o Stenosis of the Sphincter of Oddi
ERCP showing distal common bile duct
stricture
24
TYPE IV : SEGMENTAL OBSTRUCTION
One or more segment of intrahepatic biliary tract is obstructed
o Traumatic
o Sclerosing cholangitis
o Intra hepatic stones
o Cholangio carcinoma
25
SYMPTOMS
• Yellowish discoloration of sclera
• Epigastric pain
• Fever
• Pruritis
• Loss of weight
• Loss of appetite
• Increased bleeding tendency
• Steatorrhoea or Dark stool
• Dark orange urine
26
SYMPTOMS
27
SIGNS
• Charcot’s triad
• Reynold’s pentad
• palpable and / or tender
gallbladder (Courvioser’s law)
• Hepatomegaly
• Spleenomegaly
• xanthomas
• xanthelasma
• scratch marks: excoriation
• finger clubbing
• loose, pale, bulky, offensive
stools
• dark orange urine
INVESTIGATIONS
• Serum Direct Bilirubin
• Feceal urobilinogen (incomplete
obstruction)
• Feceal urobilinogen absence
(complete obstruction)
• urobilinogenuria is absent in
complete obstructive jaundice
• bilirubinuria 
• ALP 
• cholesterol 
• (GGT) is a sensitive marker of biliary
tract disease and its raised
• 5’nucleotidase is raised and its more
specific
• ALT AST may rise
• Albumin decreased
• PT prolonged
• clotting factor decreased
• Tumor markers Ca19-9 and CEA raised
according to underlying cause.
29
RADIOLOGY
• IMAGING GOALS
• To confirm the presence of obstruction
• To determine the level of the obstruction
• cause of the obstruction
• To provide complementary information relating to the underlying
diagnosis (eg., Staging information in cases of malignancy).
• What is the best therapeutic approach?
30
• IMMAGING MODALITIES are:
• Ultrasound
• ERCP
• MRCP
• PTC
31
Ultrasound abdomen
• More sensitive than CT for gallbladder stones and other pathology of gall
bladder
• Sensitive for dilated ducts (Dilation of the extrahepatic (>10 mm) or
intrahepatic (>4 mm) bile ducts suggests biliary obstruction.)
• Liver parenchymal mass and mets
PortableThe sensitivity of EUS for the identification of focal mass lesions in
pancreas is superior to that of CT scanning
Cheap
no radiation,
• Operator dependant
33
Ultrasound showing gallbladder stonesEndoscopic ultrasound showing CBD
stone
34
Endoscopic retrograde cholangiogram (ERCP)
• invasive procedure
• Diagnostic and therapeutic
potential.
• biopsy
• brush cytology
• Stone extraction
• stenting.
COMPLICATIONS
 Pancreatitis
 Cholangitis
 Hemorrhage
 SepsiS
CT SCAN ABDOMEN
• Main role in malignant conditions
mainly for localization of primary
tumors and mets.
• Best for Pancreatic Carcinoma(Highly
sensitive for lesion >1mm.)
•Mainly done when ultrasound fail or
when there is ductal dilation on
ultrasound.
•level and cause of obstruction.
Carcinoma head of pancreas
MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
• Noninvasive test to visualize the hepato biliary
tree
• Entire biliary tree and pancreatic duct can be
seen
• Best for Intra Hepatic stones and
CHOLEDOCHAL CYST
• SINGLE BEST FOR CHOLANGIOCARCINOMA
• MRCP is better to determine the extent and
type of tumor as compared to ERCP
Percutaneous Transhepatic Cholangiogram (PTC)
• PTC is indicated when percutaneous
intervention is needed and ERCP either
is inappropriate or has failed.
• Can be used to drain biliary
obstructions.
SUPPORTIVE MANAGEMENT
• Preoperative biliary decompression (ERCP or PTC)
• Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop
diuretics to prevent hepatorenal syndrome/ renal failure(12 to 24 hours prior to
surgery)
• catheterization to monitor output
• Broad spectrum antibiotic prophylaxis with 3rd generation cephalosporins
• Parenteral vitamin K +/- fresh frozen plasma
• Need careful fluid balance to correct dehydration
• Correction of hypokalemia and other electrolyte imbalance.
• Cholestyramine and antihistamine for symptomatic relief of pruritis
39
DEFINITVE MANAGEMENT DEPENDS ON THE
CAUSE
40
CHOLOEDOCHOLITHISIS
• Ideally ERCP follwed by laproscopic
Cholecystectomy.
• 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
2. Ca HEAD OF PANCREAS
• Whipple resection:
• Removal of head & neck of pancreas,
duodenum, distal 40% of stomach, lower
CBD, GB, upper 10 cm of jejunum, regional
L.Ns and reconstruction through
gastrojejunostomy,choledochojejunostmy
and pancreaticojejunostomy
• If not operable then we go for ?????biliary
drainage
42
CARCINOMA GALLBLADDER
• if involving cbd then whipple resection is done
• And in case of inoperable cases Endoscopic / Radiological stenting is done
4)CHOLEDOCHAL CYST
 Surgical excision of the cyst with
 Reconstruction of the
extra hepatic biliary tree
 Biliary drainage is accomplished by
 Choledocho–jejunostomy
with a Roux – en – Y anastamosis
44
5) Cholanchiocarcinoma
Surgery depends on the stage of tumor and may involve
• Removal of the bile ducts
In Stage 1 tumor ,just the bile ducts containing the cancer are removed.
• Partial liver resection
If the tumor has begun to spread into the liver, the affected part of the
liver is removed, along with the bile ducts.
• Whipple procedure
If the tumor is larger and has spread into nearby structures, whipples
proceedure is done.
• Inoperable cases it may be possible to relieve the blockage through
stents via ERCP or PTC.
CHOLEDOCHOLITHISIS
Treatment of choice is stone extraction through ERCP
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
7)STRICTURE
• Treated by endoscopic stenting.
• Therefore, surgery should probably be reserved for those patients
with complete ductal obstruction or for those in whom endoscopic
therapy has failed.
• Surgery with Roux-en-Y choledochojejunostomy or
hepaticojejunostomy is the standard of care.
8)STRICTURE OF SPINCHTER OF ODDI
• Endoscopic or operative sphincterotomy
48
SUMMARY
49
TAKE HOME MESSAGE
50

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Obstructive jaundice 19_9_2014

  • 1. OBSTRUCTIVE JAUNDICE Presented by: Dr. Anum Arif Resident 1 (Surgical Unit 2) 1
  • 3. 1. DEFINITION Jaundice is the yellow discoloration of the sclera and skin, as a result of raised serum bilirubin and is usually detectable clinically when the bilirubin is greater than 3 .g/dl. 3
  • 5. 2. TYPES 1. PREHEPTIC 2. HEPATIC 3. POST HEPATIC JAUNDICE TYPES 1. HEMOLYTIC DISEASES • Intravascular and extravascular hemolytic disease. • Autoimmune hemolytic disease. • Paroxymal nocturnal hemoglobinuria 2. INEFFECTIVE ERYTHROPESIS 1. IMPAIRED OR ABSENT CONJUGATION OF BILIRUBIN. 2. HEREDITIARY DISORDERS. 3. ACQUIRED DISORDERS 1. INTRAHEPATIC-LIVER CELL DAMAGE/BLOCAKGE OF BILE CANALICULI 2. EXTRAHEPATIC- OBSTRUCTION OF BILE DUCTS 5
  • 6. Features Prehepatic (hemolytic) Intrahepatic Heptocellular Post-hepatic (Obstructive) UCB ↑ ↑ Normal CB Normal ↑ ↑ AST or ALT Normal ↑↑ Normal ALPO Normal Normal ↑↑ Urine Bilirubin Absent Present Increased Urobilinogen Increased Present Absent
  • 7. Features Prehepatic (hemolytic) Intrahepatic Heptocellular Post-hepatic (Obstructive) Plasma Albumin Normal Decreased Normal or decreased PT Normal Increased Increased but correctted by Vitamin K
  • 8. OBSTRUCTIVE JAUNDICE • Also called as surgical jaundice. • Most important in surgical setting. • Obstruction may be intrahepepatic or extrahepatic. 8
  • 10. CLASSIFICATION OF OBSTRUCTIVE JAUNDICE # CLASSIFICATION DESCRIPTION 1. CONGENITAL Biliary atresia choledochal cyst 2. INFLAMMATORY Ascending cholangitis Sclerosing cholangitis 3. OBSTRUCTIVE CBD stone biliary stricture, parasitic infestation 4. NEOPLASTIC Carcinoma head of pancreas Periampullary carcinoma cholangiocarcinoma Klatskin tumor 5. EXTRINSIC COMPRESSION OF CBD Lymph node or tumor(Mirzzi’s syndrome) 10
  • 12. CA PANCREAS 12DILATED CBD DUE TO CA PANCREAS
  • 13. CA PANCREAS 13 CA HEAD OF PANCREAS
  • 22. TYPE 1: COMPLETE OBSTRUCTION Classical symptoms with biochemical changes: • Ca. head of Pancreas • Cholangiocarcinoma • Parenchymal Liver diseases 22
  • 23. TYPE II : INTERMITTENT OBSRUCTION • Symptoms and typical biochemical changes • But jaundice may or may not be present o Choledocholithiasis o Periampullary tumor o Duodenal diverticula o Choledochal Cyst o Papillomas of the bile duct o Parasitic infestation o Hemobilia 23
  • 24. TYPE III : CHRONIC INCOMPLETE OBSTRUCTION With or without classical symptoms but pathological changes are present in bile duct and liver o Strictures of the CBD • Congenital • Traumatic • Sclerosing cholangitis • Post radiotherapy o Stenosed biliary enteric anastamosis o Cystic fibrosis o Chronic pancreatitis o Stenosis of the Sphincter of Oddi ERCP showing distal common bile duct stricture 24
  • 25. TYPE IV : SEGMENTAL OBSTRUCTION One or more segment of intrahepatic biliary tract is obstructed o Traumatic o Sclerosing cholangitis o Intra hepatic stones o Cholangio carcinoma 25
  • 26. SYMPTOMS • Yellowish discoloration of sclera • Epigastric pain • Fever • Pruritis • Loss of weight • Loss of appetite • Increased bleeding tendency • Steatorrhoea or Dark stool • Dark orange urine 26
  • 28. SIGNS • Charcot’s triad • Reynold’s pentad • palpable and / or tender gallbladder (Courvioser’s law) • Hepatomegaly • Spleenomegaly • xanthomas • xanthelasma • scratch marks: excoriation • finger clubbing • loose, pale, bulky, offensive stools • dark orange urine
  • 29. INVESTIGATIONS • Serum Direct Bilirubin • Feceal urobilinogen (incomplete obstruction) • Feceal urobilinogen absence (complete obstruction) • urobilinogenuria is absent in complete obstructive jaundice • bilirubinuria  • ALP  • cholesterol  • (GGT) is a sensitive marker of biliary tract disease and its raised • 5’nucleotidase is raised and its more specific • ALT AST may rise • Albumin decreased • PT prolonged • clotting factor decreased • Tumor markers Ca19-9 and CEA raised according to underlying cause. 29
  • 30. RADIOLOGY • IMAGING GOALS • To confirm the presence of obstruction • To determine the level of the obstruction • cause of the obstruction • To provide complementary information relating to the underlying diagnosis (eg., Staging information in cases of malignancy). • What is the best therapeutic approach? 30
  • 31. • IMMAGING MODALITIES are: • Ultrasound • ERCP • MRCP • PTC 31
  • 32. Ultrasound abdomen • More sensitive than CT for gallbladder stones and other pathology of gall bladder • Sensitive for dilated ducts (Dilation of the extrahepatic (>10 mm) or intrahepatic (>4 mm) bile ducts suggests biliary obstruction.) • Liver parenchymal mass and mets PortableThe sensitivity of EUS for the identification of focal mass lesions in pancreas is superior to that of CT scanning Cheap no radiation, • Operator dependant
  • 33. 33
  • 34. Ultrasound showing gallbladder stonesEndoscopic ultrasound showing CBD stone 34
  • 35. Endoscopic retrograde cholangiogram (ERCP) • invasive procedure • Diagnostic and therapeutic potential. • biopsy • brush cytology • Stone extraction • stenting. COMPLICATIONS  Pancreatitis  Cholangitis  Hemorrhage  SepsiS
  • 36. CT SCAN ABDOMEN • Main role in malignant conditions mainly for localization of primary tumors and mets. • Best for Pancreatic Carcinoma(Highly sensitive for lesion >1mm.) •Mainly done when ultrasound fail or when there is ductal dilation on ultrasound. •level and cause of obstruction. Carcinoma head of pancreas
  • 37. MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) • Noninvasive test to visualize the hepato biliary tree • Entire biliary tree and pancreatic duct can be seen • Best for Intra Hepatic stones and CHOLEDOCHAL CYST • SINGLE BEST FOR CHOLANGIOCARCINOMA • MRCP is better to determine the extent and type of tumor as compared to ERCP
  • 38. Percutaneous Transhepatic Cholangiogram (PTC) • PTC is indicated when percutaneous intervention is needed and ERCP either is inappropriate or has failed. • Can be used to drain biliary obstructions.
  • 39. SUPPORTIVE MANAGEMENT • Preoperative biliary decompression (ERCP or PTC) • Intravenous admistration of 5% dextrose saline followed by 10%mannitol or loop diuretics to prevent hepatorenal syndrome/ renal failure(12 to 24 hours prior to surgery) • catheterization to monitor output • Broad spectrum antibiotic prophylaxis with 3rd generation cephalosporins • Parenteral vitamin K +/- fresh frozen plasma • Need careful fluid balance to correct dehydration • Correction of hypokalemia and other electrolyte imbalance. • Cholestyramine and antihistamine for symptomatic relief of pruritis 39
  • 40. DEFINITVE MANAGEMENT DEPENDS ON THE CAUSE 40
  • 41. CHOLOEDOCHOLITHISIS • Ideally ERCP follwed by laproscopic Cholecystectomy. • 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
  • 42. 2. Ca HEAD OF PANCREAS • Whipple resection: • Removal of head & neck of pancreas, duodenum, distal 40% of stomach, lower CBD, GB, upper 10 cm of jejunum, regional L.Ns and reconstruction through gastrojejunostomy,choledochojejunostmy and pancreaticojejunostomy • If not operable then we go for ?????biliary drainage 42
  • 43. CARCINOMA GALLBLADDER • if involving cbd then whipple resection is done • And in case of inoperable cases Endoscopic / Radiological stenting is done
  • 44. 4)CHOLEDOCHAL CYST  Surgical excision of the cyst with  Reconstruction of the extra hepatic biliary tree  Biliary drainage is accomplished by  Choledocho–jejunostomy with a Roux – en – Y anastamosis 44
  • 45. 5) Cholanchiocarcinoma Surgery depends on the stage of tumor and may involve • Removal of the bile ducts In Stage 1 tumor ,just the bile ducts containing the cancer are removed. • Partial liver resection If the tumor has begun to spread into the liver, the affected part of the liver is removed, along with the bile ducts. • Whipple procedure If the tumor is larger and has spread into nearby structures, whipples proceedure is done. • Inoperable cases it may be possible to relieve the blockage through stents via ERCP or PTC.
  • 46. CHOLEDOCHOLITHISIS Treatment of choice is stone extraction through ERCP 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
  • 47. 7)STRICTURE • Treated by endoscopic stenting. • Therefore, surgery should probably be reserved for those patients with complete ductal obstruction or for those in whom endoscopic therapy has failed. • Surgery with Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the standard of care.
  • 48. 8)STRICTURE OF SPINCHTER OF ODDI • Endoscopic or operative sphincterotomy 48