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Obstructive Jaundice Dr. Mohammed H. Alarawi Consultant General surgeon Al- Iman General Hospital FRCS, ED – ABCS 1 Objectives • Case scenario • Definition of Jaundice • Bilirubin Biochemistry • Anatomy of the Hepatobiliary Tree • Types of Jaundice • OBSTRUCTIV Jaundice. • Clinical presentation • Laboratory investigations • Radiological investigations • Treatment options 2 Case Scenario 82 yr old male patient presents with progressive jaundice, itching, loss of weight . 3 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 • • • • • 4 H/o past illness – No h/o DM, HT, TB, – No past Surgical history • Personal History – Smoker – 25 yrs – Non-alcoholic 5 Physical Examination – Pulse 88/min, BP 110/70 –Afebrile – anemia +, Jaundice ++– – No Lymphadenopathy – Scratch marks • Abdomen – Soft non-tender– palpable gall bladder– No free fluid 6 Definition of Jaundice • = icterus • Yellowish pigmentation of the skin and other Tissues (Sclera, mucous membrane, deep tissue…)due to deposition of bile pigment(bilirubin) when serum level exceed 3mg/dl • Normal Total serum bilirubin is 0.3-1.9 mg/dl – Direct Bilirubin < 0.4 mg/dl 7 Bilirubin Biochemistry • 80% of Bilirubin is formed by the degradation of Heme from Red blood cell. • The reminder from Heme containing enzymes (cytochromes, catalase, peroxidase..) • Is potentially Toxic • Remains harmless by binding to albumin 8 Unconjugated Bilirubin (indirect bilirubin) • Insoluble in water • Tightly complex to albumin • Not filtered through renal glomeruli, is not excreted in urine • Toxic substance • The main form of bilirubin in the blood 9 Conjugated Bilirubin (Direct bilirubin) • Bilirubin must be conjugated before its excretion into bile • Bilirubin is conjugated with glucuronic acid by the enzyme glucuronyltransferase • This changes the bilirubin into a water soluble and thus facilitates rapid excretion • Can be filtered through renal glomeruli • Present in low concentration in the blood 10 Con’t 11 Anatomy of the Hepatobiliary Tree 12 Types of Jaundice A. Pre-hepatic B. Hepatic C. Post-hepatic (Obstructive)(cholestatic) I. Intrahepatic II. Extrahepatic Physiologic Jaundice??? 13 Pre-hepatic • Excess extra-hepatic production of bilirubin raising unconjagated form. – Haemolytic anemias – - Malariae 14 Hepatic jaundice liver disability to uptake, conjugate or excecrete bilirubin, raising unconjugated bilirubin Acute : • Viral hepatitis A, B, C.. • Other viruses: EBV, CMV • Drugs – Dose-dependant e.g. paracetamol – Idiosyncratic • • • • Toxins Autoimmune hepatitis Alcoholic hepatitis Tumours Chronic : • Viral hepatitis B, C • Chronic AI hepatitis • Genetic (Crigler–Najjar, Gilbert syndroms) • End-stage liver disease (of any cause) – – – – – Alcoholic Hepatitis B, C Autoimmune Haemochromatosis Wilson’s disease 15 Post hepatic (Obstructive Jaundice) Benign causes • Choledocholithiasis • Primary sclerosing cholangitis • Post-surgical stricture • Pancreatitis • Parasitic infections Malignant Causes • • • • • Carcinoma gall bladder Periampullary Carcinoma Cholangiocarcinoma Carcinoma of head of pancreas Obstruction due to metastatic LN Cholestatic jaundice • Cholestasis denotes a pathologic condition of impaired bile formation and or bile flow. – Extrahepatic cholestasis (biliary obstruction) frequently is amenable to surgical correction. – Intrahepatic cholestasis (Intrahepatic biliary tree diseases or hepatocellular secretory failure 19 What are the Causes of Cholestasis: Intrahepatic & Extrahepatic Intrahepatic cholestasis • • • • • • Cholestatic phase of AVH Alcoholic H Drug induced liver D Primary biliary cirrhosis Primary sclerosing cholangitis TPN Intrahepatic cholestasis • Cholestasis of pregnancy • Sepsis • Benign postoperative Cholestasis Drugs that lead to Cholestasis Jaundice • Estrogen • Tamoxifen • Anabolic steroid • Azathioprine • Chlorpromazine • Carbamazepine • Antibiotics- Erythromycin, Rifampicin Consequences of Cholestasis Retention of bile salt in liver • Decreased hepatocyte function • Decreased Kuffer cell activity • Decreased albumin & clotting factors synthesis • Decreased collagen synthesis, impaired wound healing Retention of bile constituents in serum • Jaundice, dark urine and Pruritis • CVS depression • Nephrotoxicity • Hypercholesterolemia, atheroma, Xanthoma Consequences of Cholestasis Absence of bile in Intestine • Escape of endotoxins into portal blood • Mal-absorption of fats and Vitamin A, D, E & K • Clay colored stools Clinical presentation of obstructive jaundice • • • • • • Jaundice, dark urine,pale stool, pruritus RUQ pain, Nausea and vomiting Fever Charcot Triad??? Skin xanthomas Symptoms related to intestinal malabsorption and nutritional deficiency of fat soluble vitamins History - age - sex - onset , duration - alcohol consumption - blood transfusion - drug abuse - medication - recent surgery(post op complication) - history of hemolytic disorders - weight loss, loss of appetite - pain ,fever ,fatty dyspepsia - dark urine, pale stool. - yellow discoloration(skin , sclera) - symptoms & signs of chronic liver disease 27 Courvoisier’s law If the CBD is obst. due to calculus , the GB is usually not distended owing to previous inflammatory fibrosis. If CBD is obstr. due to malignant growth, the GB becomes distended in order to reduce the press. in the biliary system. Laboratory Investigations • • • • Blood test (Hemoglobin, WBC, Platelets)? Coagulation Profile (PTT, INR,..)? Hepatic profile Hepatitis profile 29 Laboratory Investigations Hepatic Profile: AST (10-40) ALT (10-40) Alkaline phosphatase (40-100 U/L) Albumin (35-50 g/L) Total bilirubin (5-20 umol/L) Direct bilirubin (<5 umol/L) Indirect bilirubin (<12 umol/L) 30 AST & ALT • AST found in liver, cardiac muscle, skeletal muscles, kidneys, brain, pancreas • ALT found in liver, skeletal muscle • Used as indicator of liver cell injury • ALT is more specific 31 Alkaline Phos. • Can come from liver, bone, placenta and intestine Used mainly as indicator of ductal causes: partial obstruction of bile ducts, primary biliary cirrhosis, sclerosing cholangitis • Elevated in all patients with extra hepatic obstruction with values greater 3-5 times the normal 32 GGT • Very sensitive for hepatobiliary disease. • Mainly it increases in ductal injury • In case of increase in Alkaline Phosp . GGT is a good test to exclude the Bone source of ALP High Alkaline Phosph. Normal GGT Bone is more likely High Alkaline Phosph . High GGT Hepatic source is more likely 33 • Serum conjugated bilirubin – > 50% of total: more suggestive of post hepatic than hepatic jaundice • ALP • cholesterol • Fecal urobilinogen (incomplete obstruction) and absent (complete obstruction) • Urobilinogenuria is absent in complete obstructive jaundice with bilirubinuria. Case scenario Con’t • Hb: 11.7• Hct: 35• WBC: 6000; Plt: 350,000 • Serum Creat: 1.2 mg• Total bil: 20 mg;B1(unconj): 2 mgB2 (conj): 18 mg• Alkaline phosphatase: 990 U/L• Total protein: 6.5 grams; • CA 19-9: 350 units/ml 35 Radiology – Determine: • • • • • Extrahepatic obstruction level of obstruction Cause of obstruction Staging Best therapeutic approach 36 Radiology • Ultrasound – Best imaging for biliary tree – non-invasive, cheap, high accuracy esp in gallstones and biliary dilatation. – Disadvantege: distal bile duct may be obscured by bowel gas 37 Radiology • Ultrasound – Best imaging for biliary tree – non-invasive, cheap, high accuracy esp in gallstones and biliary dilatation. – Disadvantege: distal bile duct may be obscured by bowel gas 38 ENDOSCOPIC ULTRASOUND (EUS) • 98%diagnostic accuracy in obstructive jaundice • It allows diagnostic tissue sampling (EUS-FNA) • High sensitivity for identification of focal pancreatic mass, SUPERIOR to CT. • More specific to biliary stricture compared to MRCP. 39 • CT : – Main role in malignancies for primary and metastatic tumors • MRCP: – Non invasive to visualize the hepato biliary tree. • ERCP: – invasive, therapeutic (biopsy, brush cytology, Stone extraction or stenting) – Complications: Pancreatitis, Cholangitis, Hge, Sepsis – limitations: Unfaverable anatomy 40 • PTC indications: – when ERCP either is inappropriate or has failed. – Drainage of biliary obstructions. • Oral Cholecystography (OCG): • useful with symptomatic patients with negative US • HIDA Scan: useful in acute cholecystitis • Diagnostic Laparoscopy • Angiography: Rule out abnormal vascular anatomy • Tumor markers- CA19-9 , CEA 41 ERCP MRCP 42 Scenario case con’t • USG-Abd: solid mass in distal CBD, dilated CBD, Intrahepatic Biliary distension and distended GB • CT abdomen show grossly dilated intra and extra hepatic biliary channels With distended gall bladder And possibility of periampullary mass ADVISE ERCP 43 44 Treatment options for obstructive jaundice Depends on the cause and severity . • Antibiotic therapy (if indicated for infection) . ERCP, allows treatment of some bile duct problems including removal of gallstones causing obstruction • Intravenous fluids , pain medications and Nutritional support . • Surgery to repair anatomical defects or create alternative pathways for the flow of bile • Treatment for cancer, which may include surgery, chemotherapy, or radiation therapy 45 What are the Surgical Procedures done for Obstructive Jaundice? Ca GB: Radical Cholecystectomy with wedge resection and CBD excision Cholediocholithiasis: ERCP removal, mechanical lithotripsy , shock wave laser or CBD exploration Cholangio Ca: Liver resection and or local excision of the lesion or Whipple or stenting by ERCP or PTC Biliary Stricture: Hepaticojejenostomy/ Periampullary Ca: Whipple’s Procedure Chronic Pancreatits with head Mass: Whipple/ bilio-enteric anastmosis Whipple’s Procedure Pancreaticojejunostomy- end to end Hepatico-jejunostomy – end to side Gastrojejunostomy – end to side Feeding Jejunostomy Preoperative preparation • Oral H2 antagonist • Vit. K or FFP • Perioperative broad spectrum antibiotics • Rehydration and adequate diuresis • Furosemide/ Mannitol • Catheterization & CVP monitoring Postoperative management - Correct Fluid & Electrolyte imbalance Correct hypothermia Achieve CVS stability Adequate analgesia & chest physiotherapy Antibiotics + H2 receptor antagonist Maintain urine output Replace blood and blood products