This document discusses obstructive jaundice and Whipple's operation. It provides information on:
1) The physiological functions of the liver including glucose homeostasis, fat and protein metabolism, drug and hormone metabolism, bilirubin formation and excretion, and its role as a blood reservoir.
2) How obstructive jaundice affects liver function and can lead to endotoxemia, systemic alterations to circulatory homeostasis like hypotension, and effects on the renal system like hypoperfusion.
3) Considerations for anesthetic management for a patient undergoing Whipple's operation to address obstructive jaundice, given the liver's role and how its dysfunction impacts other organ systems.
1. Obs. JObs. J
Obstructive Jaundice – Whipple’s OperationObstructive Jaundice – Whipple’s Operation
Anesthetic ManagementAnesthetic Management
Munisha AgarwalMunisha Agarwal
ProfessorProfessor
Deptt. of AnaesthesiologyDeptt. of Anaesthesiology
& Intensive Care& Intensive Care
L N Hospital & MaulanaL N Hospital & Maulana
Azad Medical College DelhiAzad Medical College Delhi
2. Obs. JObs. J
Obstructive JaundiceObstructive Jaundice
Physiological functions of Liver ?Physiological functions of Liver ?
3. Obst. J
Physiological functions of LiverPhysiological functions of Liver
Glucose HomeostasisGlucose Homeostasis
Fat MetabolismFat Metabolism
Protein SynthesisProtein Synthesis
Drug & Hormone MetabolismDrug & Hormone Metabolism
Bilirubin formation &excretionBilirubin formation &excretion
Anti bacterial actionAnti bacterial action
Blood ReservoirBlood Reservoir
5. Obst. J
Glucose HomeostasisGlucose Homeostasis
Glycogen stores 75gm 24—48hrsGlycogen stores 75gm 24—48hrs
Anesthesia – gluconeogenesisAnesthesia – gluconeogenesis
Provide ext. source of glucoseProvide ext. source of glucose
6. Obst. J
Fat metabolismFat metabolism
Synthesis of lipo-proteins & cholesterolSynthesis of lipo-proteins & cholesterol
Oxidation of FA to ketone bodiesOxidation of FA to ketone bodies
7. Obst. J
Protein MetabolismProtein Metabolism
Deamination of AADeamination of AA
Formation of ureaFormation of urea
Plasma proteinsPlasma proteins
-- All except y globulin & factor VIIIAll except y globulin & factor VIII
- Albumin daily prod. 10—15g/d (3.5-5.5gm%)- Albumin daily prod. 10—15g/d (3.5-5.5gm%)
- liver disease- liver disease ↓↓ albalb ↑↑ globglob
Albumin ?Albumin ?
8. Obst. J
Protein synthesisProtein synthesis
Plasma O. P.Plasma O. P.
Drug bindingDrug binding
CoagulationCoagulation
HydrolysisHydrolysis
9. Obst. J
Drug bindingDrug binding
Drugs reversibly combine with AlbuminDrugs reversibly combine with Albumin
↓↓ albuminalbumin ↓↓ binding sitesbinding sites ↑↑ free drugfree drug
Albumin < 2.5gm%Albumin < 2.5gm%
Acute Hepatic dysfunction ?Acute Hepatic dysfunction ?
Coagulation ?Coagulation ?
10. Obst. J
Drug bindingDrug binding
Acute hepatic dysfunction - drug bindingAcute hepatic dysfunction - drug binding
not affectednot affected
T ½ AlbuminT ½ Albumin : 14 – 21 days: 14 – 21 days
CoagulationCoagulation : affected (2—6hrs): affected (2—6hrs)
Vitamin K dependent Coag. Factors?Vitamin K dependent Coag. Factors?
12. Obst. J
CoagulationCoagulation
Deranged coagulationDeranged coagulation
↓↓ed synthesis of Clotting factorsed synthesis of Clotting factors
↑↑ed PT Vit. K deficiency d/t biliaryed PT Vit. K deficiency d/t biliary
obstructionobstruction absence of bile saltsabsence of bile salts
ThrombocytopeniaThrombocytopenia
↑↑ed Fibrinolysinsed Fibrinolysins
13. Obst. J
CoagulationCoagulation
Evaluate PT/ PTTK/ BTEvaluate PT/ PTTK/ BT
LFT grossly deranged before coagulationLFT grossly deranged before coagulation
abnormalities appearabnormalities appear
20%--30% activity required for normal20%--30% activity required for normal
coagulationcoagulation
TT1/2 of1/2 of clotting factors produced in liver isclotting factors produced in liver is
very short (in hrs)very short (in hrs)
Ac. Hep dysfunctionAc. Hep dysfunction Coag. Abn.Coag. Abn.
15. Obst. J
Drug metabolismDrug metabolism
Clearance of drugs from plasmaClearance of drugs from plasma
High HE ratio ~ Hepatic Blood Flow (HBF)High HE ratio ~ Hepatic Blood Flow (HBF)
Lidocain, Pethidine, FentanylLidocain, Pethidine, Fentanyl
low HE ratio ~microsomal enzymeslow HE ratio ~microsomal enzymes
~protein binding~protein binding
diazepam, thiop, pancuroniumdiazepam, thiop, pancuronium
17. Obst. J
Bilirubin formation & excretionBilirubin formation & excretion
Daily prod 250—350mg/dDaily prod 250—350mg/d
Interpretation of plasma &Interpretation of plasma &
urine bilirubinurine bilirubin
Categories of liverCategories of liver
dysfunctiondysfunction
1 unit BT ?1 unit BT ?
18. Obst. J
Blood ReservoirBlood Reservoir
10% of total blood volume10% of total blood volume
Available for Auto transfusion into centralAvailable for Auto transfusion into central
circulationcirculation
20. Obst. J
Hepatic Blood SupplyHepatic Blood Supply
25% to 30% of CO25% to 30% of CO
Dual supplyDual supply
Portal VPortal V (75%) 85% saturated(75%) 85% saturated
Hepatic AHepatic A (25%) 95%saturated(25%) 95%saturated
2/3 of oxygen used by liver2/3 of oxygen used by liver
21. Obst. J
Control of Liver Blood FlowControl of Liver Blood Flow
INTRINSICINTRINSIC
AUTOREGULATIONAUTOREGULATION
- Hepatic artery-80 mmHg- Hepatic artery-80 mmHg
- Portal vein – flow from spleen, intestine- Portal vein – flow from spleen, intestine
- resistance to vascular bed- resistance to vascular bed
Hepatic Arterial Buffer response.Hepatic Arterial Buffer response.
Extrinsic ?Extrinsic ?
27. Obst. J
Signs &SymptomsSigns &Symptoms
Prog sev jaundiceProg sev jaundice
Dark urineDark urine
Clay coloured stoolsClay coloured stools
PruritisPruritis
High fever+ chillsHigh fever+ chills
Biochemical hallmarksBiochemical hallmarks
28. Obst. J
Obstructive JaundiceObstructive Jaundice
Primary mechanism- Obst. of E.H. bilePrimary mechanism- Obst. of E.H. bile
duct.duct.
Bile duct pressureBile duct pressure --
Normal – 10-15 cm H2ONormal – 10-15 cm H2O
> 15 cm> 15 cm →→ bile flow decreasesbile flow decreases
> 30 cm> 30 cm →→ bile flow stopsbile flow stops
29. Obst. J
Pathophysiological consequencesPathophysiological consequences
CHOLESTASIS
Retention of bile solutes
In liver
Hepatocyte func ↓
Cyto-450 –metab
Protein synth-alb ↓
- clotting factors ↓
Bile constituents in serum
↑conju. Bilirubin
Serum bile acids—pruritus
Hypercholesterolemia-
Ahteromas, Xanthomas
Systemic effect-CVS/renal/ GIT
Absence of bile in intestine
Malabsorp steatorrhoea
↓ Vitamin A,D, E, K
Escape of endotoxins into
portal blood
Bile Acids are potent toxins
30. Obst. J
Endotoxemia in obstructive jaundiceEndotoxemia in obstructive jaundice
Bile salts are surfactants----disrupt endotoxins
Causes of endotoxemiaCauses of endotoxemia
Absence of bile in intestineAbsence of bile in intestine →→ intest.bact. Floraintest.bact. Flora
Breakdown of GI mucos. barrier-Breakdown of GI mucos. barrier- bact. translocationbact. translocation
↓↓Hepatic RES functionHepatic RES function →→ ↓↓clearance of endotoxinsclearance of endotoxins
Systemic Alterations – CVS ?Systemic Alterations – CVS ?
31. Obst. J
Systemic alterationsSystemic alterations
Circulatory homeostasisCirculatory homeostasis
CHOLEMIACHOLEMIA →→ ●● vasodepressor effect on BVsvasodepressor effect on BVs
●● cardiodepressorcardiodepressor →→ LVFLVF
●● ↓↓ PVRPVR →→ ↓↓ BPBP →→ sympathsympath ++
renal & cerebral vasoconstrictionrenal & cerebral vasoconstriction
●● redistribution of TBVredistribution of TBV →→ trappingtrapping
of blood in splanc. Circulationof blood in splanc. Circulation →→
↓↓ effective BVeffective BV
●● NO - insensitive to vasoconstrictorsNO - insensitive to vasoconstrictors
↑↑ Hypotension & circulatory collapseHypotension & circulatory collapse
32. Obst. J
Renal systemRenal system
Mild renal vasoconstrictionMild renal vasoconstriction
Renal hypoperfusion( hypovolemia)Renal hypoperfusion( hypovolemia)
Refractoriness of tubules to ADHRefractoriness of tubules to ADH
EndotoxemiaEndotoxemia
33. Obst. J
Renal SystemRenal System
Renal vasoconstriction
Arterial hypotension
Nephrotoxic bile salt
& pigments
Endotoxins &
Inflammatory mediators
• Acute Renal FailureAcute Renal Failure
• Hepatorenal SyndromeHepatorenal Syndrome
34. Obst. J
Renal systemRenal system
OliguriaOliguria
Inability to excrete Na in urine( 10mmol/l)Inability to excrete Na in urine( 10mmol/l)
Functional changeFunctional change
Normal renal blood flowNormal renal blood flow
Treatment : Prevention-identify high riskTreatment : Prevention-identify high risk
patientspatients
Hepatorenal SyndromeHepatorenal Syndrome
37. Obst. J
PROBLEMSPROBLEMS
DUE TO DYSFUNCTION OF LIVER ITSELF :DUE TO DYSFUNCTION OF LIVER ITSELF :
- Low serum proteins- Low serum proteins
- Coagulopathy- Coagulopathy
- Drug metabolism and disposition- Drug metabolism and disposition
- Metabolic derangement - Hypoglycemia- Metabolic derangement - Hypoglycemia
- Electrolyte imbalance- Electrolyte imbalance
- Haematological - Anaemia- Haematological - Anaemia
–– ThrombocytopeniaThrombocytopenia
–– LeucopeniaLeucopenia
–– DICDIC
- Deficiency of fat soluble vitamins (A, D, E, K)- Deficiency of fat soluble vitamins (A, D, E, K)
- Increased serum cholesterol (atheromatous changes)- Increased serum cholesterol (atheromatous changes)
38. Obst. J
PROBLEMSPROBLEMS
DUE TO INVOLVEMENT OF OTHERDUE TO INVOLVEMENT OF OTHER
SYSTEMSSYSTEMS
CVS– TBVCVS– TBV ↓↓, PVR, PVR ↓↓,, ↑↑Circulatory collapseCirculatory collapse
Renal - pre renal azotemiaRenal - pre renal azotemia
- Hepatorenal failure- Hepatorenal failure
GIT - Hm gastritis & stress ulcersGIT - Hm gastritis & stress ulcers
Resp.–Resp.– Arterial HypoxemiaArterial Hypoxemia
- vulnerability to pulmonary infection- vulnerability to pulmonary infection
CNS – Hepatic encephalopathyCNS – Hepatic encephalopathy
Problems related to surgery ?Problems related to surgery ?
39. Obst. J
Problems related to surgeryProblems related to surgery
Whipple’s procedure---Carc. Head of pancWhipple’s procedure---Carc. Head of panc
Distal gastrectomy,PJ, HJ, GJDistal gastrectomy,PJ, HJ, GJ
Major surgery---long durationMajor surgery---long duration
Increased blood loss/fluid shiftsIncreased blood loss/fluid shifts
Wide incision---Roof top—warrants goodWide incision---Roof top—warrants good
postoperative analgesiapostoperative analgesia
Extensive monitoring reqd for favourableExtensive monitoring reqd for favourable
outcomeoutcome
41. Obst. J
Preoperative AssessmentPreoperative Assessment
OBJECTIVESOBJECTIVES
Assess the type and degree of liverAssess the type and degree of liver
dysfunction.dysfunction.
Assess effect on other system.Assess effect on other system.
To ensure – post operative facilities (High riskTo ensure – post operative facilities (High risk
patient).patient).
42. Obst. J
Preoperative AssessmentPreoperative Assessment
HistoryHistory
Clinical examinationClinical examination
Investigations ???Investigations ???
Unexplained jaundice of 4wks duration or longerUnexplained jaundice of 4wks duration or longer
will prove to be caused by obstruction in nearlywill prove to be caused by obstruction in nearly
75% patients75% patients
Blumgart LBlumgart L
43. Obst. J
Preoperative InvestigationsPreoperative Investigations
To know the pattern of disease :To know the pattern of disease :
S. Bilirubin S. Bilirubin
SGOT, SGPT SGOT, SGPT 90% predictive90% predictive
alk. phosphatase alk. phosphatase
44. Obst. J
Preoperative InvestigationsPreoperative Investigations
To judge the synthetic ability of liverTo judge the synthetic ability of liver
Serum albumin–Serum albumin– < 2·5 gm% - severe damage< 2·5 gm% - severe damage
Albumin/globulin ratioAlbumin/globulin ratio – reversed.– reversed.
Prothrombin timeProthrombin time –> 1·5 sec. Over control–> 1·5 sec. Over control
–– INR - > 1.3INR - > 1.3
(D/D – Par entral Vit. K – Obst. Jaundice)(D/D – Par entral Vit. K – Obst. Jaundice)
51. Obst. J
Anesthetic techniqueAnesthetic technique
Opioids –Opioids – Well toleratedWell tolerated
smaller dosessmaller doses
Morphine—ph-II reac.Morphine—ph-II reac.
fentanyl(DOC)fentanyl(DOC)
spasm of sphincter of Oddispasm of sphincter of Oddi
52. Obst. J
Anesthetic techniqueAnesthetic technique
Spasm of sphincter of OddiSpasm of sphincter of Oddi
Interpretation of operativeInterpretation of operative
cholangiography & biliary pressurescholangiography & biliary pressures
All patients do not show this responseAll patients do not show this response
Incidence of spasm is very lowIncidence of spasm is very low
Intraop manipulation of BD systemIntraop manipulation of BD system →→
spasmspasm
TreatmentTreatment
53. Obst. J
Anesthetic techniqueAnesthetic technique
Volatile AnestheticsVolatile Anesthetics
Useful & well toleratedUseful & well tolerated
Can be entirely eliminatedCan be entirely eliminated
Disadv- CVS instabilityDisadv- CVS instability →→ vasodilationvasodilation →→ ↓↓perf.perf.
Press.Press. →→ ↓↓ blood velocityblood velocity →↑→↑ oxygen extractionoxygen extraction
→→ ↓↓ HBF & oxygen supplyHBF & oxygen supply
Isoflurane—best maint. of HBF & oxygenIsoflurane—best maint. of HBF & oxygen
IPPV ?IPPV ?
54. Obst. J
Anesthetic techniqueAnesthetic technique
IPPV –IPPV –
- Maintain eucapnia- Maintain eucapnia
- Liver low pr.tissue bed- Liver low pr.tissue bed
- Avoid large V- Avoid large VTT & high airway& high airway
pressurespressures
55. Obst. J
Anesthetic techniqueAnesthetic technique
Maintenance of BV and Renal functionMaintenance of BV and Renal function
MannitolMannitol
FrusemideFrusemide
DopamineDopamine
Adequate blood/component replacementAdequate blood/component replacement