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Obstructive Jaundice
OBSTRUCTIVE JAUNDICE
&
INTESTINAL OBSTRUCTION
PMS 2
Case Scenario
• A 78 years old, Chinese gentleman, a known case of
cholelithiasis in 2010 was admitted to the ward with a
...
Definition
• Yellowish discoloration of the skin or
sclera due to increase in circulating
bilirubin ( >50 umol/L).
• Three...
Investigation
Investigation ( Lab )
Investigation ( Imaging )
1) Ultrasonography – check for duct
dilatation, dilated gallbadder, present of
gallstone.
2) MRC...
Liver Function Tests
Ultrasound scan
Biliary dilatation
Gallstones Gallstones
Ix further to
exclude medical
cause
MRCP or ...
Management
General pre-operative measures
• AIM: reducing perioperative morbidity
(eg. Infection, massive haemorrhage
etc.)
• Oral ch...
• Ca and vitamin D supplements – slow
progression of osteoporosis. Used
with/without biphosphonate.
• Vitamin A supplement...
• Frequent IV hydration and catheterization of
urinary bladder – treating electrolytes
imbalance d/t nausea & vomiting & w...
Specific treatment
 Choledocholithiasis (CBD)
- Cholecystectomy, if present.
- Choledochotomy, usually supraduodenal
- T ...
- ERCP +/- sphincterotomy
A cholangiogram is done after the ampulla of
Vater has been identified and cannulated to
confirm...
Complications include perforation,
acute pancreatitis, and bleeding from
damage to a branch of the superior
pancreatico-du...
- Laparoscopic exploration of the
common bile duct
May be done through the cystic duct
(if the gall bladder has not been
p...
• Advantages
- Faster and better wound healing
- Better wound appearance
- Can acquire a whole and throughout
view of the ...
• Cholangiocarcinoma
- Classified into intra-hepatic tumours, (extra-
hepatic) hilar tumours and (extra-hepatic)
distal bi...
• Systemic therapy/palliative care
- The majority of patients with
cholangiocarcinoma present at an advanced
stage or have...
Other causes and treatment
• Biliary strictures – stenting,
choledochojejunostomy
• Klatskin tumor – radical resection or
...
Post-operative care
• Monitoring prothrombin time, bilirubin,
albumin, creatinine, electrolytes
• Fresh frozen plasma @ bl...
Complications
• Complications of obstructive jaundice
include sepsis especially cholangitis,
biliary cirrhosis, pancreatit...
Intestinal Obstruction
Case Scenario
 A 72 year old Malay gentleman presents to
Emergency Department with complaint of
abdominal pain.
 Six day...
Definition
• Impedance to the normal passage of
bowel content through the small
bowel or large bowel.
Classification of Intestinal Obstruction
Dynamic
• Peristalsis is working against
a mechanical obstruction.
• The obstruct...
Clinical Features
Small bowel Large bowel
Colicky pain
Vomiting
- bile – proximal obstruction
- feculent – distal obstruct...
Investigation
Investigation ( lab )
• Full blood count – Hb level,
• Renal profile – Creatinine level for
hydration status, hypokalemia
...
Investigation ( imaging )
1) Abdominal x-ray – Dilated bowels,
stack of coins appearance, string of
beads, mass/calcificat...
Management
• Admit the patient with high suspicious
of IO
– Acute abd pain + vomiting + constipation
+ abd distension
• Supportive ma...
– IV fluids
• To correct the electrolyte imbalance and also
rehydrate if patient is dehydrated
• Main electrolyte imbalanc...
Surgical Treatment
• Principles
– Manage segment at the site of obstruction
– Manage distended proximal bowel
– Manage und...
Small Bowel Obstruction
Causes of obstruction Surgical Procedure
Foreign bodies .e.g hair or gallstones Laparotomy: Remova...
Large Bowel
Causes of obstruction Surgical Procedure
Diverticulitis Laparotomy: Diverticulectomy
Colon Ca Laparotomy: Sing...
Adynamic Obstruction
 Paralytic Ileus
 Principles of Management
› Primary cause must be removed (infection,
uremia, hypo...
Pseudo-obstruction
 Small intestine pseudo-obstruction
› Treat underlying causes
› Use metoclopramide n erythromycin
 Co...
GI bleeding & Intestinal Obstruction
GI bleeding & Intestinal Obstruction
GI bleeding & Intestinal Obstruction
GI bleeding & Intestinal Obstruction
GI bleeding & Intestinal Obstruction
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GI bleeding & Intestinal Obstruction

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GI bleeding & Intestinal Obstruction

  1. 1. Obstructive Jaundice OBSTRUCTIVE JAUNDICE & INTESTINAL OBSTRUCTION PMS 2
  2. 2. Case Scenario • A 78 years old, Chinese gentleman, a known case of cholelithiasis in 2010 was admitted to the ward with a history of colicky pain at the right upper quadrant of abdomen for one day, associated with fever, vomiting and increasing malaise . • On examination, he had jaundice and tender hepatomegaly. • Lab investigation showed a total bilirubin of 151μmol/l. • Ultrasonography  showed multiple calculi seen within the gallbladder, largest measuring 1.1 cm. Gallbladder wall is thickened measuring 0.5 cm and there is presence of minimal pericholecystic collection.
  3. 3. Definition • Yellowish discoloration of the skin or sclera due to increase in circulating bilirubin ( >50 umol/L). • Three type of jaundice which are :- • In surgery, we will anticipate mostly in post hepatic jaundice. Pre hepatic - Hemolytic jaundice eg. Spherocytosis, thalassemia, Gilbert syndrome Intra hepatic - Hepatocelluar carcinoma, chronic liver failure, cirrhosis Post hepatic - cholelithiasis, cholangitis, cholecystitis
  4. 4. Investigation
  5. 5. Investigation ( Lab )
  6. 6. Investigation ( Imaging ) 1) Ultrasonography – check for duct dilatation, dilated gallbadder, present of gallstone. 2) MRCP – non invasive investigation to give view on anatomy of biliary systems. 3) ERCP – invasive investigation and therapeutic for obstructive jaundice ( definitive ) 4) CT scan – non invasive investigation that can identify hepatic, bile duct and pancreatic tumors in jaundiced patients
  7. 7. Liver Function Tests Ultrasound scan Biliary dilatation Gallstones Gallstones Ix further to exclude medical cause MRCP or ERCP CT scan or MRCP Biliary stent or surgeryERCP/sphincterotomy or laparoscopic cholecystectomy as indicated Yes No No Yes No
  8. 8. Management
  9. 9. General pre-operative measures • AIM: reducing perioperative morbidity (eg. Infection, massive haemorrhage etc.) • Oral cholestyramine 2 to 8 gm – subsides pruritis (irritation of skin due to high concentration of bilirubin). Acts by binding bile salts in within the intestines • Vitamin K1 5 to 10 mg sc once/daily (2 to 3 days) – treat hypoprothrombinemia
  10. 10. • Ca and vitamin D supplements – slow progression of osteoporosis. Used with/without biphosphonate. • Vitamin A supplement – prevent deficiency, due to lacking of utilization of fat soluble vitamin A, caused by deficiency in bile secretion • Dietary fat – used to minimize the occurrence of steatorrhea.
  11. 11. • Frequent IV hydration and catheterization of urinary bladder – treating electrolytes imbalance d/t nausea & vomiting & wash out the deposition and high concentration of urobilinogen in the renal tubules • Mannitol 100 – 200 ml BD IV – forced natriuresis, preventing hepatorenal syndrome • Antibiotic prophylaxis – 3rd generation cephalosporin, immunosuppressed patients
  12. 12. Specific treatment  Choledocholithiasis (CBD) - Cholecystectomy, if present. - Choledochotomy, usually supraduodenal - T tube is used in certain conditions, to confirm the clearance of the duct by a postoperative cholangiogram. Usually removed after 2 weeks, when an epithelialzed tract has formed to avoid bile leak into the peritoneum
  13. 13. - ERCP +/- sphincterotomy A cholangiogram is done after the ampulla of Vater has been identified and cannulated to confirm anatomy and the presence of stones. An adequate sphincterotomy is undertaken and the duct cleared using a balloon catheter Success rate is about 90% with low complications.
  14. 14. Complications include perforation, acute pancreatitis, and bleeding from damage to a branch of the superior pancreatico-duodenal artery
  15. 15. - Laparoscopic exploration of the common bile duct May be done through the cystic duct (if the gall bladder has not been previously removed) or common duct via a choledochotomy Requires considerable laparoscopic expertise and is time consuming, more over it’s expensive due to the need of proper equipments
  16. 16. • Advantages - Faster and better wound healing - Better wound appearance - Can acquire a whole and throughout view of the body
  17. 17. • Cholangiocarcinoma - Classified into intra-hepatic tumours, (extra- hepatic) hilar tumours and (extra-hepatic) distal bile duct tumours. - Surgery is the only curative option for cholangiocarcinoma - Cholecystectomy, lobar or extended lobar hepatic and bile duct resection, regional lymphadenectomy are commonly being used
  18. 18. • Systemic therapy/palliative care - The majority of patients with cholangiocarcinoma present at an advanced stage or have associated co-morbidity that preclude surgery - Biliary endoprosthesis (stent) placement is a useful option for palliation of jaundice - Photodynamic therapy, radiation and chemotherapy are all available as palliative options
  19. 19. Other causes and treatment • Biliary strictures – stenting, choledochojejunostomy • Klatskin tumor – radical resection or palliative stenting • Carcinoma periampullary or head of pancreas – Whipple’s oepration or triple bypass or ERCP stenting
  20. 20. Post-operative care • Monitoring prothrombin time, bilirubin, albumin, creatinine, electrolytes • Fresh frozen plasma @ blood transfusion • Antibiotics • Care of T tube and drains • Observation for septicaemia, haemorrhage, pneumonia, pleural effusion, bile leak
  21. 21. Complications • Complications of obstructive jaundice include sepsis especially cholangitis, biliary cirrhosis, pancreatitis, coagulopathy, renal and liver failure
  22. 22. Intestinal Obstruction
  23. 23. Case Scenario  A 72 year old Malay gentleman presents to Emergency Department with complaint of abdominal pain.  Six day history of increasing abdominal pain in LLQ, colicky in nature.  Pain is dull and constant with nausea and vomiting  No bowel movements or flatus for the past six days.  Increasing abdominal distention with lack of appetite.  Over the past several days he has tried laxatives and enemas. Did not relieve his constipation.
  24. 24. Definition • Impedance to the normal passage of bowel content through the small bowel or large bowel.
  25. 25. Classification of Intestinal Obstruction Dynamic • Peristalsis is working against a mechanical obstruction. • The obstruction may be: 1. Intraluminal (Ex. impacted faeces, foreign bodies, bezoar, gallstones) 2. Intramural (Ex. malignant or inflammatory strictures) 3. Extramural (Ex. intraperitoneal bands and adhesions, hernias, volvulus or intussusception.) Adynamic • Peristalsis is absent (eg. Paralytic ileus) • May be present in a non- propulsive form (eg. Pseudo-obstruction)
  26. 26. Clinical Features Small bowel Large bowel Colicky pain Vomiting - bile – proximal obstruction - feculent – distal obstruction Constipation Abdominal distension Signs of dehydration Constipation/diarrhea Abdominal distension Colicky pain Vomiting Hematochezia/tenesmus Signs of dehydration
  27. 27. Investigation
  28. 28. Investigation ( lab ) • Full blood count – Hb level, • Renal profile – Creatinine level for hydration status, hypokalemia • Tumor marker ( if suspected )
  29. 29. Investigation ( imaging ) 1) Abdominal x-ray – Dilated bowels, stack of coins appearance, string of beads, mass/calcification. 2) Barium enema – large bowel 3) Barium meal – small bowel 4) Colonoscopy/sigmoidscopy
  30. 30. Management
  31. 31. • Admit the patient with high suspicious of IO – Acute abd pain + vomiting + constipation + abd distension • Supportive management – Nasogastric decompression • Ryles or Salem tube • On free drainage with 4 hourly aspiration or on continous or intermittent suction • To decompress area proximal to obstruction n also reduce risk of aspiration during induction of anaesthesia – Analgesics • IV Tramal
  32. 32. – IV fluids • To correct the electrolyte imbalance and also rehydrate if patient is dehydrated • Main electrolyte imbalance in IO is sodium n water loss • Use Hartmann’s solution or normal saline • Electrolyte imbalance is one of the causes of paralytic illeus – IV antibiotics • Is not mandatory except for surgical resection of small or large bowel • May use broad spectrum because of high risk of bacterial outgrowth (e.g. 3rd generation cephalosporin, ceftriaxone)
  33. 33. Surgical Treatment • Principles – Manage segment at the site of obstruction – Manage distended proximal bowel – Manage underlying causes of obstruction • Indications for early surgery – Obstructed or strangulated external hernia – Internal intestinal strangulation – Acute obstruction
  34. 34. Small Bowel Obstruction Causes of obstruction Surgical Procedure Foreign bodies .e.g hair or gallstones Laparotomy: Removal of foreign bodies Adhesions IV rehydration n nasogastric decompression, if failed go for Laparotomy: Lyse the adhesions Hernia Laparotomy: Removal of the gangrenous part and herniorraphy Disseminated Intraperitoneal Ca that obstruct small bowel Bypass the obstruction through laparomoty of endoscopy, to relieve symptoms
  35. 35. Large Bowel Causes of obstruction Surgical Procedure Diverticulitis Laparotomy: Diverticulectomy Colon Ca Laparotomy: Single stage resection n anastomosis Cecal Valvulus Surgical resection and anostomosis/ Cecotomy to recorrect the cecal position Sigmoid valvulus Decompression by rectal tube followed by resection of valvulus as it has high recurrence rate Fecal impaction Removal of feces by digit (if it is in rectum) Laparotomy if it is complete obstruction
  36. 36. Adynamic Obstruction  Paralytic Ileus  Principles of Management › Primary cause must be removed (infection, uremia, hypokalemia) › GI distension must be relieved by decompression › Maintain fluid n electrolyte balance › If resistant, use neostigmine (cholinergic stimulation) › If prolong n life threatening, use laparotomy to decompress n fine hidden causes
  37. 37. Pseudo-obstruction  Small intestine pseudo-obstruction › Treat underlying causes › Use metoclopramide n erythromycin  Colonic PO › Colonic decompression or flatus tube  Acute messenteric ischemia › Early phase  Embolectomy via ileocolic artery  Revascularization of Sup. Messenteric Art. › Late phase  Surgical resection of affected bowel

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