Surgical Jaundice Supervised by Dr. Jamal Hamdi
Dec 19, 2015
Surgical Jaundice
Supervised by Dr. Jamal Hamdi
Definition Of Jaundice
• yellow pigmentation of skin, mucous membrane or
sclera
• Jaundice clinically detected when serum bilirubin level ( 2.5
mg/dl)
• Normal serum bilirubin (0.2-1.0 mg/dl )
• caused by an excess of bile
pigments in plasma• It is a symptom not a
disease
Bilirubin Metabolism
Bilirubin is produced from the breakdown of haemoglobin in the reticuloendothelial system. 95% of the circulating bilirubin is unconjugated
and bound to albumin .
Bilirubin Metabolism
RES
Hepatic metabolism occurs in 3 phases:
- Uptake - Conjugation - excretion
Pathophysiology Of Hyperbilirubinemia
•Over production by RES
•Failure of hepatocellular uptake
•Failure of conjugation or excretion
•Obstruction of biliary excretion into intestine
Classification Of Jaundice
Posthepatic(obstructed)
surgical
Hepatic :
•Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome )
•Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc )
Prehepatic:•RBC disorders• ( Hereditary spherocytosis , SCA) •Auto-immune ( Mismatched blood transfusion ) •Infective ( Sepsis , Malaria )
Etiology Of Obstructive Jaundice
Common:
• Common bile duct stone.
• Cancer head of pancreas
Etiology Of Obstructive Jaundice
Less Common:
•Ampullary carcinoma
• Pancreatitis.
•Mirrizi syndromes.
•Sclorosing cholangitis.
•Cholangiocarcinoma
Approach To Jaundice Patient
History
Careful History is of very important value to guide the D\D toward the cause & the type of
jaundice
( PreHepatic , Hepatic , PostHepatic )
Approach To Jaundice Patient
History
Onset
Sudden ?
CBD stone
Hepatitis
Gradual ?
cirrhosis pancreatitis
cancer
Approach To Jaundice Patient
History
Pattern
fluctuating ? CBD stone
Ampullary carcinoma Hemolytic episodes
Progressive? Pancreatic carcinoma
Cholangiocarcinoma
Approach To Jaundice Patient
History
Pain
painless?
Malignancy
Painful? CBD stone
Pancreatic diseases
Approach To Jaundice Patient
History
Pruritis
Fatty dyspepsia
Steatorrhea
Dark urine , pale stool
Bleeding disorder
Other symptoms of obstructive jaundice
Approach To Jaundice Patient
History
RUQ pain , fever
Symptoms of anemia
Hx of SCD
G6PD deficiency ? Food related ?
Symptoms of malignancy
( weight loss & anorexia )
Approach To Jaundice Patient
History
Blood transfusion
Hx of drugs
Past Hx of surgery
Family Hx of jaundice & hemolytic disorders
Alcohol
Occupation & travel
Past Medical
Family Hx
Past Surgical Hx
Approach To Jaundice Patient
Physical Examination
General Appearance
Cachexia
Muscle Wasting
Yellow Discoloration
Stigmata of Chronic Liver
Disease
Palmar erythema clubbing .
flapping tremor. duputrine’s
contracture . Spider nevi
gynecomastia caput medosa
testicular atrophy
General Examination
Jaundice
Scratch marks
Pallor
Vital Signs
Approach To Jaundice Patient
Physical ExaminationAbdominal Discolration , scars
( collen’s , Grey Tuner )
RUQ pain
Murphy sign
Palpaple Gallbladder ( Courvoisier’s law )
Abdominal masses ( malignancy ) Hepatomegaly , splenomegaly ,
ascitis
PR : color of stool .
Abdominal Examination
Obstructive Jaundice
Invistigation
InvasiveImagingLaboratory
Exam
Obstructive Jaundice
Invistigation
Laboratory Exam Blood
LFT: Serum bilirubin (Direct / Indirect) , Albumin , ALT , AST , ALP, LDH ,
CBC , Electrolyte , Amylase
Urine
Urine analysis
Stool
The investigations will differentiate hepatocellular and obstructive jaundice
In most of the cases
Obstruction Hepatitis CirrhosisBilirubin
Alk phos / /
ALT/AST/ /
gGT /
PT (INR)
Invistigation
Obstructive Jaundice
Invistigation
ImagingNon-invasive
AXR
US
CT
MRI/MRCP
Invasive
ERCP
PTC
Operative cholangiogram
T-tube cholangiogram
Angiogram
Biopsy
Obstructive Jaundice
Invistigation
Imaging
Non-invasive
1- The presence of gall stones 2- the thickened wall of the gallbladder in acute or chronic inflammation 3- The Diameter of CBD more than 7mm is suggestive of presence of stones
Is the most useful initial study for
evaluation of intra/extrahepatic biliary dilatation.
Ultrasounde
Obstructive Jaundice
Invistigation
Imaging
Is the most useful initial study for
evaluation of intra/extrahepatic biliary dilatation.
Ultrasounde
Obstructive Jaundice
Invistigation
Imaging
Non-invasive
Determine the specific causes and level of obstruction
CT scan can only image calcified stones
CT Scan
Obstructive Jaundice
Invistigation
Imaging
CT Scan
Obstructive Jaundice
Invistigation
Imaging
Non-invasive
Routine investigation-base-line & may
show specked calcification in the region of
pancreas.
X-Ray
Obstructive Jaundice
Invistigation
Imaging
Non-invasive
Magnatic resonance cholangiopancreatography (MRCP)
Sensitive noninvasive method of detecting biliary and pancreatic duct stones
stricture or dilatations within the biliary system
MRCP
Obstructive Jaundice
Invistigation
ImagingInvasive
Useful for lesion distal to the bifurcation of the hepatic ducts (diagnostic )
ERCP has a (therapeutic) application because obstruction can potentially be relieved by the removal of stones , sphcterotomy and placement of stent and drains
ERCP
Obstructive Jaundice
Invistigation
Imaging
ERCP
Obstructive Jaundice
Invistigation
Imaging
ERCP
Obstructive Jaundice
Invistigation
ImagingInvasive
Percutaneous transhepatic cholangiogram (PTC )
Useful for lesions proximal to common hepatic duct
PTC
Obstructive Jaundice
Treatment
According To The Cause
Obstructive Jaundice
Treatment
• Relief of Obstruction
• Prevent Complication
• Prevent Recurrence
Goal of Treatment
Obstructive Jaundice
Treatment
• Defined as stones in the CBD
•intermittent obstruction of CBD
•Predisposes to Cholangitis & Acute Pancreatitis
•Elevated sr. bilirubin & Alk. Phos.
•Evaluation By : U\S , ERCP , CT
Jaundice caused by Gallstones
Obstructive Jaundice
Treatment
• Evaluation By : ERCP
•Primary diagnostic and therapeutic modality
•Sphincterotomy and stone extraction
•Placement of stent if stone extraction unsuccessful
• Mortality rate 1.5%
•ERCP
Jaundice caused by Gallstones
Obstructive Jaundice
Treatment
Open CBD Exploration
Indications
•Presence of multiple stones (more than 5) Stones > 1 cm
• Multiple intra hepatic stones
•Distal bile duct strictures
• Failure of ERCP
• Recurrence of CBD stones after sphincterotomy
Jaundice caused by Gallstones
Obstructive Jaundice
Treatment
CBD Exploration – Surgical Options
•Common bile duct exploration with T-tube decompression
• Choledochoduodenostomy
• Transduodenal sphincterotomy and sphincterplasty
•Roux-en-Y Choledocho jejunostomy
Jaundice caused by Gallstones
Obstructive Jaundice
Treatment
At the time of diagnosis, 52% of all patients have distant disease
26% have regional spread.
The relative 1-year survival is only 24%
the overall 5-year survival rate for this disease is less than 5%.
Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Surgical treatment
Carcinoma Head Of Pancreas
Non surgical treatment
(metal stents)
Non Resectabl
e
Resectable
Obstructive Jaundice
Treatment
resectability. ?
Resectable, unresectable ?
experience and technical skill of the surgeon And overall health of the
patient
Typically, extrapancreatic disease precludes curative resection, and
surgical treatment may be palliative at best.
Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Non-resectable pancreatic head
tumor
Obstructive Jaundice
Treatment
Non surgical treatment
Inoperable Patient :-
- Endoscopic expandable metallic stent
- Bypassed By Hepatojejunostomy
( Roux-en-Y)
Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
surgical treatment
Operable Patient :-
Whipple’s Operation
Pancreaticoduodenectomy
Curative ?
Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Is It Curative ??
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation
Traumatic stricture:-
by passed
Malignant stricture: -
resection with reconstruction by hepatico jejunostomy .
Sclerosing cholongitis:
Surgical excision
Per cuteneous dilation
Obstructive Jaundice
Treatment
Bile Duct Stricture
•Ascending cholangitis
•Clotting disorders
•Hepato-renal syndrome
•Drug Metabolism
•Impaired wound healing
Obstructive Jaundice
Complications Of Obstructive
Jaundice
Be Aware Of life threatening Complications
References
•Bailey & Love short practice of surgery
•Clinical Surgery By : A.Cuschieri
•Lecture Note : General Surgery 11th Edition
•http://www.radiologyassistant.nl/en/43848b63def9d
•http://emedicine.medscape.com/
Done By
•Abbas A. Damanhori
•Abdulmajeed Fairaq
•Abdulrahman R. Nazer
•Hassan Abu Rokbah