Obstructive Jaundice or Surgical Jaundice

Surgical Jaundice

1. OBSTRUCTIVE JAUNDICE

2. It is the jaundice that develops due to biliary obstruction, partial or complete or intermittent.

3. ETIOLOGY CONGENITAL: Biliary atresia Choledochal cyst INFLAMMATORY Acending cholangitis Sclerosing cholangitis OBSTRUCTIVE CBD Stones Biliary stricture Parasitic infestation NEOPLASTIC EXTRINSIC COMPRESSION OF CBD

4. 4. NEOPLASTIC Carcinoma head of pancreas Ca of periampullary region of pancreas Cholangiocarcinoma Klatskin tumour 5. EXTRINSIC COMPRESSION OF CBD Lymph nodes Tumours

5. COMMON CAUSES BENIGN: Choledocholithiasis Biliary stricture Choledochal cyst MALIGNANT: Ca head of pancreas Periampullary ca of pancreas Cholangiocarcinoma Klatskins tumour

6. CLASSIFICATION OBSTRUCTIVE JAUNDICE INTRAHEPATIC EXTRAHEPATIC

7. BENJAMINS CLASSIFICATION OF BILIARY OBSTRUCTION TYPE 1: COMPLETE OBSTRUCTION TUMOURS CBD LIGATION PRIMARY/ SECONDARY LIVER TUMOURS TYPE 2: INTERMITTENT OBSTRUCTION CHOLEDOCHOLITHIASIS, PERIAMPULLARY TUMOUR CHOLEDOCHAL CYST, BILE DUCT PAPILLOMA HEMOBILIA, DUODENAL DIVERTICULOSA

8. TYPE 3: CHRONIC COMPLETE OBSTRUCTION BILE DUCT STRICTURE; CONGENITAL TRAUMATIC; POST RADIOTHERAPY CHRONIC PANCREATITIS; CYSTIC FIBROSIS TYPE 4: SEGMENTAL OBSTRUCTION TRAUMATIC; SCLEROSING CHOLANGITIS CHOLANGIOCARCINOMA, INTRAHEPATIC BILIARY STONES (HEPATOLITHIASIS)

9. CLINICAL FEATURES SEVERE JAUNDICE PRURITIS, more on the back and forearm Loss of weight, loss of appetite Pain in the Right hypochondrium, palpable gallbladder, hydrohepatotic nodule palpable, smooth, soft, non tender liver COURVOISIERS LAW may suggest neoplastic/ inflammatory cause CHARCOTS TRIAD/ REYNAUDS PENTAD as presentation in cholangitis Steatorrhea (more fatty stool) due to improper absorption of fat soluble vitamins

10. EFFECTS OF OBSTRUCTIVE JAUNDICE IN LIVER: Enlarged green bile stained liver (HYDROHEPATOSIS) shows dilated intrahepatic biliary radicles. Once intraductal pressure increases, bile secretion reduces causing formation of white bile IN BILIARY TREE: Recurrent inflammation- cholangitis- fibrosis can occur IN BOWEL: Digestion impaired, reduced fat absorption due to absence of bile making stools bulky and fatty RETENTION OF BILE SALTS AND BILE PIGMENTS

11. Discolouration Yellowish discolouration occurs due to deposition of conjugated bilirubin in tissues. Serum bilirubin :- >2- eye discolouration >6- oral cavity >9- extremities

12. High coloured urine Occurs due to increase in soluble conjugated bilirubin in blood

13. Clay coloured stools Occurs due to decreased urobilinogen in gut, causing decreased stercobilinogen, causing clay coloured stools

14. Abdominal pain in Obstructive Jaundice GALL STONES Cause Biliary colic= Obstruction to outflow of bile causing Colicky pain in Right hypochondrium Radiating to Right tip of scapula Pain may be precipitated due to fatty meal because GB contracts causing outflow obstruction resulting in severe pain

15. 2) Gall stones + Pancreatitis Causes excruciating pain in epigastric region, due to inflammation and stretching of pancreatic capsule, radiating to back which worsens after meals 3) Periampullary obstruction/ Ca Head of Pancreas Due to Occlusion of pancreatic duct causing stasis of pancreatic juice. Due to Infiltration into Retropancreatic Nerve

16. Fever Occurs in gall stone disease

17. CHARCOTS TRIAD PAIN FEVER OBSTRUCTIVE JAUNDICE

18. RAYNAUDS PENTAD PAIN FEVER OBSTRUCTIVE JAUNDICE HYPOTENSION ALTERED SENSORIUM

19. Cause of Hematemesis Due to pancreatic cancer Duodenal erosion Splenic vein thrombosis  Splenomegaly Portal Hypertension  Esophageal varices Severe jaundice  Biliary cirrhosis  Portal Hypertension

20. Recent onset DM may signify Pancreatic involvement

21. PERIAMPULLARY CA/ HEAD OF PANCREAS CA

22. PERIAMPULLARY CA/ HEAD OF PANCREAS CA Due to obstruction to outflow  stagnation of bile in biliary radical  GB may be palpable

23. Features of palpable GB Globular mass Moves with respiration Upper limit merges with lower border of liver Intraabdominal STEP DOWN SIGN

24. COURVOISIERS LAW In obstructive jaundice, If Gall Bladder is palpable, not because of stone but because of malignancy

25. Exceptions to Courvoisiers Law Double stone impaction (in Cystic duct and CBD duct) Oriental Cholangiohepatitis Mirizzi syndrome – stone in Hartmann pouch Hilar tumour/ Klatskin tumour Mucocele

26. Intermittent jaundice in Periampullary carcinoma Components of Periampullary ca: Tumour from Ampulla of Vater Adenoma arising from duodenal mucosa Tumour arising from duct Tumour arising from pancreas Occlude lumen of duct Bile stasis Gall bladder hugely distended

27. Pain in Biliary radicle Cause avascular necrosis of tumour Opening created Tumour sloughs out WAXING AND WANING OF JAUNDICE May also have features of GOO, Cachexia

28. Due to deposition of bile salts in subcutaneous tissue  cause release of histamine from mast cells  severe itching  Scratch marks over trunk and limbs

29. STONE DISEASE

30. Features Silent Travel Obstruct Navigate Escape STONE

31. CHEMICAL NATURE OF STONES Cholesterol Calcium Mixed

32. TYPES BASED ON SITE Primary- Formed in CBD. Soft friable stones Secondary- formed In gall bladder and migrated Residual/ Missed stones – During surgery, Stones missed and presenting within 2 years of surgery Recurrent stones- Stones arising >2 years after surgery

33. CLINICAL FEATURES Patient will have biliary colic Jaundice Charcots triad Raynauds Pentad

34. Understanding behind Courvoisiers law Due to obstruction of stone  Bile stasis occure  Inflammed GB  Contracts  GB NOT PALPABLE But in empyema/ Mucocele of GB, it may be palpable

35. PORTA HEPATIS

36. FEATURES Features of malignancy, but no waxing and waning of jaundice Progressive jaundice VGP + Visible Epigastric mass

37. INVESTIGATIONS Urine bile salts and pigments (Hay’s and Fouchet’s ) LFT ( Sr. Bilirubin, Direct highly elevated, SGOT, SGPT, ALP highly elevated) Coagulation Profile (PT elevated due to defective absorption of fat soluble vitamins ADEK ) Viral Markers

38. 5. USG ABDOMEN Gold standard Can know level and cause of instruction Look for intrahepatic and extrahepatic biliary radical dilatation Texture of GB Thickness of GB wall Pericholecystic collection Tumour >2 cm can be diagnosed by USG Node in Porta hepatis POD Secondaries Minimal Free fluid in abdomen

39. 6. PANCREATIC PROTOCOL CT = CECT Should assess operability (SMA occlusion is an indicator of inoperability) 2 Phases – Arterial and Venous phase Cleavage must be present between tumour and Fibrofatty tissue No vascular enhancement

40. 7. ENDOULTRASONOGRAM Used to stage the disease Findings: Ductal anomaly Parenchymal anomaly Vascular anomaly Intravascular USG is a newer modality where EUS is introduced through Femoral Artery

41. 8. ERCP AND MRCP Therapeutic indication of ERCP Sphicetrotomy Inoperable tumour, fresh biopsy + metallic stenting = DOUBLE STENT (pancreatic duct and CBD) Features suggestive of Malignancy in ERCP and MRCP Double duct sign- dilatation of pancreatic and CBD Egg Crample sign- Dye spray into parenchyma

42. PREOP PREP Rehydrate patient – Correct electrolytes Check urine output Correct aneamia Correct hyponatremia Give Synthetic Vit K INJ IM for 3-5 days. If no improvement, FFP given Antibiotics Neomycin- to sterilize gut Lactulose Preop stenting done if Sr. Bilirubin >20 mg/ dL

43. WHIPPLE PROCEDURE Pancreaticoduodenectomy TOC in Malignancy If inoperable, TRIPLE BYPASS done Structures removed : GB CBD Duodenum + head of pancreas Part of proximal jejunum Distal Stomach Continuity maintained by TRIPLE ANASTOMOSIS

44. TOC IN STONE DISEASE ERCP Sphincerotomy Stone retrieval Lap Cholecystectomy (OR) Open cholecystectomy + CBD exploration

45. If duct dilated- must anastomose with duodenum If duct not dilated- keep T TUBE Post op allow T tube to drain bile for 6 days Clamp T tube Do T tube cholangiogram on 6 th -11 th day Dye injected  enters duodenum Good result  Remove T tube

46. TREATMENT OF PORTA HEPATIS Signs of Inoperability: Ascites Vascular invasion POD deposit Supraclavicular node Treatment = PALLIATIVE BYPASS Anterior gastrojejunostomy Cholecystojejunostomy Jejunojejunostomy (to relieve jaundice) (OR) Bypass+ ERCP metallic stent