Jaundice 351

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in carotenoderma the pigment
is concentrated on the palms,
soles, forehead, and nasolabial
folds. Carotenoderma can be
distinguished from jaundice by the
sparing of the sclerae
The differential diagnosis for
yellowing of the skin is limited. In
addition to jaundice, it includes
Carotenoderma
The use of the drug Quinacrine
Excessive exposure to phenols
JAUNDICE
It is yellowish discoloration of
Skin, mucous membranes, sclera
Due to excess plasma bilirubin
Normal
range
5-17 m
mol/l
Clinically
obvious
50 mmol/l
(2.5mg/dl)
Is not a disease but rather a sign
that can
occur in many different diseases
E V Pathway for RBC Scavanging
Liver, Spleen &
Bone marrow
Phagocytosis & Lysis
Hemoglobin
Globin
Heme
Bilirubin
Amino acids
Fe2+
Through Liver
Amino acid pool
www.drsarma.in
Excreted
3
Bilirubin Production & Metabolism:
Conjugation of bilirubin in Hepatocyte
The remainder
comes from
prematurely
destroyed erythroid
cells in bone marrow
and from the
turnover of
hemoproteins such
as myoglobin and
cytochromes found
in tissues
throughout the
body.
Formation of Bilirubin Mainly in RES (Spleen)
About 70 to 80% of
the 250 to 300 mg
of bilirubin
produced each day
is derived from the
breakdown of
hemoglobin in
senescent red blood
cells
Excretion
Etiology Of Jaundice:
Increase of
production
Impaired of
Clearance
Direct Hyperbilirubiemia
Medical Causes
1-Alcoholic hepatitis
2-Drugs-Intravenously
administered
tetracycline, chlorpromazine
Hydrochloride, oral
contraceptives,
methyl testosterone, halothane,
azathioprine
3-Lymphomas
4-Primary biliary cirrhosis
5-Cholestasis of pregnancy (3rd
trimester)
6-Benign, recurrent intrahepatic
cholestasise
7-Post-operative jaundice (anoxia,
transfusions, etc.)
8-Sclerosing cholangitis
9-Pericholangitis
Surgical Causes
Very common (25 to 35 percent)
Choledocholithiasis
Carcinoma of head of pancreas
Common (5 to 10 percent)
Carcinoma of common duct
Stricture of common duct
Ampullary carcinoma
Uncommon (I to 5 percent)
Chronic pancreatitis
Sclerosing cholangitis
Lymphoma
Metastatic carcinoma
Primary liver cell carcinoma
Rare (less than I percent)
Post-bulbar ulcer
Hepatic artery aneurysm
Choledochal cyst
Biliary atresia
Duodenal diverticulum
hemobilia
Medical Causes
Anatomy of biliary system
Gall bladder Stone
Risk Factors
Gallstones are also associated with certain
medical conditions including:
1-Diabetes
2-Liver disease
3-Crohn's disease
4-Blood disorders like sickle-cell anaemia
5-Stomach surgery - gallstones are more
common if you have had surgery to remove
part of your stomach
Gall bladder Stone
Gall stones increase risk of
carcinoma of the gall bladder
Other symptoms are related to site of
movement of stone
The majority of cases
(approximately 80%)are
asymptomatic (silent) gall
stones , discovered accidentally
by abdominal sonar .
A gall stone
may impact
in the neck
of gall
bladder or
in the cystic
duct giving
biliary pain
or
cholecystitis
Obstruction of common
bile duct leading to pain &
jaundice
Biliary pain usually
occurs in the
epigastrium and right
hypochondrium
Pancreatitis.
Charcot’s Triad:
1-Pain
2-Jaundice
3-Fever
Obstruction of common bile
duct leading to pain &
jaundice
May Complicate to
Abdominal Ex:
1-Gall Bladder: in 80%Not Distended
When gall bladder be distended??
Murphy’s sign +ve
2-Liver:Enlarged?????
Reynold’s Pentad:
1-Pain
2-Jaundice
3-Fever
4-Altered Mental State
5-Shock
Treatment of Choledocholithiasis:
Preoperative Preparation:
Correct Clotting Dysfunction
Guard vs LCF
Guard vs RF
Chronic cholecystitis
Definitive Treatment:
Remove Source of Obstruction (stone)
Remove Source of Stone (Gall bladder)
Obstructive Jaundice
Treatment
3rd
Generation
Cephalosporin
Cholecystectomy
ERCP
Charcot’s Triad
Reynold’s Pentad
ttt
Of
Shock
Carcinoma of head of pancreas
Symptoms
Cachecxia
Criteria of obstructive jaundice
Pain which is common, characterized by starting as vague
(Lower abdomen or back)
Usually worsen in supine position & relived by lining
forward
It may be caused by:
A) Tumor invasion of splanchnic plexuses &
retroperitoneum
B) Obstruction of pancreatic duct
Digestive symptoms
Signs
Jaundice
Palpable liver
Palpable gall bladder
Tenderness
Ascites
Abdominal mass
In advanced cases:
Nodular liver
Enlarged supraclavicular
lymph node
Periumblical adenopathy
Courvoisier’s sign = painless,
palpable/distended gallbladder on
exam (think of CA)
Diagnosis & management of pancreatic cancer:
It depends on results of
Spiral CT
1) Resectable: ask yourself if operative candidate or not
a)YES :Explore for resection
b) NO: =NONOPERATIVE: Palliation, Biliary stent & Chemo/Radiotherapy
2) Unresectable: is it only Biliary or associated with duodenal obstruction
a)only Biliary:Endobiliary stent
b)Both: Operative palliation(Biliary bypass)
Gastrojejunostomy
Celiac plexus block
Whipple operation:
Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
– Advantage
• Detects choledocholithiasis, neoplasms, strictures, biliary
dilations
• Sensitivity of 81-100%, specificity of 92-100% of
choledocholithiasis
• Minimally invasive- avoid invasive procedure in 50% of
patients
– Disadvantage:
• cannot sample bile, test cytology, remove stone
• Contraindications: pacemaker, implants, prosthetic valves
– Indications
• If cholangitis not severe, and risk of ERCP high, MRCP useful
• If Charcot’s triad present, therapeutic ERCP with drainage
should not be delayed.
Endoscopic retrograde cholangiopancreatography
(ERCP)
-Gold standard for diagnosis of CBD stones, pancreatitis,
tumors, sphincter of Oddi dysfunction
-Advantage
•Therapeutic option when CBD stone identified
•Stone retrieval and sphincterotomy
-Disadvantage
•Complications: pancreatitis, cholangitis, perforation of
duodenum or bile duct, bleeding
•Diagnostic ERCP complication rate 1.38% , mortality
rate 0.21%
MRCP
• purely diagnostic .
• rapid, accurate and non•
•
•
invasive
Safe :
no contrast material
administration
no radiation.
alternative to diagnostic
ERCP.
MRCP avoids the
complications of ERCP
• Case 1: Normal MRCP. Note good delineation of
normal caliber pancreatic and bile ducts. Fluid in
stomach and duodenum also demonstrated.
• Case 2: MRCP. Large common hepatic
duct stone (asterisk) within dilated bile
ducts. Note multiple gallstones
Surgical treatment
• Endoscopic biliary drainage
– Endoscopic sphincterotomy with stone
extraction and stent insertion
• CBD stones removed in 90-95% of cases
• Therapeutic mortality 4.7% and morbidity
10%, lower than surgical decompression
•
Surgery
– Emergency surgery replaced by non-operative
biliary drainage
– Once acute cholangitis controlled, surgical
exploration of CBD for difficult stone removal
– Elective surgery: low M & M compared with
emergency survey
– If emergent surgery, choledochotomy carries
lower M&M compared with cholecystectomy
with CBD exploration
ERCP
•
ERCP(theraputic)
Choledocholithiasis
• Choledocholithiasis develops in
10-20% of patients with
gallbladder disease
• At least 3-10% of patients
undergoing cholecystectomy
will have CBD stones
– Pre-op
– Intra-op
– Post-op
Pre-op diagnosis & management
– Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP
• High risk (>50%) of choledocholithiasis:
– clinical jaundice, cholangitis,
– CBD dilation or choledocholithiasis on ultrasound
– Tbili > 3 mg/dL correlates to 50-70% of CBD stone
• Moderate risk (10-50%):
– h/o pancreatitis, jaundice correlates to CBD stone in 15%
– elevated preop bili and AP,
– multiple small gallstones on U/S
• Low risk (<5%):
– large gallstones on U/S
– no h/o jaundice or pancreatitis,
– normal LFTs
-Treatment:
•ERCP
•Surgery
Intra-op diagnosis and management
• Diagnosis: intraoperative cholangiography (IOC)
– Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and
common hepatic duct diameter, presence or absence of filling defects.
– Detect CBD stones
– Potentially identify bile duct abnormalities, including iatrogenic injuries
– Sensitivity 98%, specificity 94%
– Morbidity and mortality low
•
Treatment
-Open CBD exploration
Most surgeons prefer less invasive techniques
-Laparoscopic CBD exploration
•via choledochotomy: CBD dilatation > 6mm
•via cystic duct (66-82.5%)
•CBD clearance rate 97%
•Morbidity rate 9.5%
•Stones impacted at Sphincter of Oddi most difficult to extract
-Intraoperative ERCP
Early years: Open CBD exploration &
Introduction of endoscopic sphincterotomy
• 1889, 1st CBD exploration by Ludwig
Courvoisier, a Swiss surgeon
– Kocherization of duodenum and short
longitudinal choledochotomy
– Stones removed with palpation, irrigation with
flexible catheters, forceps,
– Completion with T-tube drainage
– For many years, this was the standard
treatment for cholecystocholedocholithiasis
• 1970s, endoscopic sphincterotomy (ES)
-Gained wide acceptance as good, less
invasive,
effective alternative
-In patients with CBD stones who have
previously undergone cholecystectomy, ES is
the method of choice
PTC Radiology
• Diagnostic and theraputic
• Performed with 22G
Chiba Needle
• Complication:
-Bacteremia
-Haemorrhage
-Contrast reaction
-Pneumothorax
-Intrahepatic
arterioportal fistula
-Bile leakage
PTC
Percutaneous access to
the biliary tree, through the
CBD, if possible, and into
the duodenum.
Downsides:
• External drainage
• Procedural risks:
– Coagulopathy
– ascites
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