obstructive jaundice.pptx

obstructive jaundice

1. Obstructive jaundice Dr Suhas U

2. Jaundice occuring secondary to blockade of any duct that carries bile from liver to gallbladder or from gallbladder to small intestine.

3. TYPES A PREHEPATIC HEPATIC POSTHEPATIC HAEMOLYSIS OBSTRUCTIVE OR SURGICAL

4. ANATOMY

5. Causes Causes in lumen Causes in wall Causes from outside Benign Malignant

6. In the lumen CBD Stones ( m/c ) Stones in pancreatic duct Biliary atresia Hydatid cyst of biliary tree Ova / cysts In the wall Periampullary carcinoma Choledochal cyst Stenosis at papilla Cholangiocarcinma Klatkin’s tumour Stricture bile duct

7. From outside Ca head pancreas Chronic pancreatitis Lymph nodes

8. 1 . Congenital :Biliary atresia , choledochal cyst. 2 . Inflammatory :Ascending cholangitis , sclerosing cholangitis . 3. Obstructive :CBD stones, biliary stricture, parasitic infestation. 4. Neoplastic :Carcinoma of head or periampullary region of pancreas, cholangiocarcinomas , Klatskintumour . 5. Extrinsic compression of CBD by lymph nodes or tumours.

9. Benign

10. Symptoms PAIN YELLOW DISCOLOURATION SKIN &M.M. DARK URINE [TEA COLOUR] CLAY COLOUR STOOL ITCHING FEVER IF CHOLANGITIS SUPERVENE LOSS OF APPETITE LOSS OF WEIGHT IN MALIGNACY

11. Signs LOSS OF Wt. IN MALIGNANCY TOXIC IN CHOLANGITIS, [ CHARCOT`S TRIAD ,;PAIN, FEVER ,JAUNDICE, REYNALD’S PENTAD - SHOCK & CONFUSION ] YELLOW DISCOLOURATION OF SKIN,M.M. TROISIER`S SIGN. VIRCHOW`S NODE TENDER R.U.Q.[IN CHOLANGITIS] COURVOISIER` LAW[IN CA.HEAD OF PAN.] ABDOMINAL MASS ASCITES[IN MALIGNANCY]

12. Investigations Blood investigations - CBC , LFT, RFT, serology , prothrombin time , anitmicrobial antibody, tumour markers Urine for bilirubin Imaging – invasive / non invasive

13. LFT Increased conjugated bilirubin AST/SGOT Intracellular Type 2 specific Less specific ALT/SGPT Specific to liver Intracellular Mild elevation – obstructive jaundice Severe elevation – cholangitis

14. Alkaline phosphotase Membrane bound enzyme Apical part of hepatocytes Osteoblasts , kidney, salivary glands, Hepatic origin – increased GGT , 5’-nucleotidase

15. GGT Liver , biliary tract, pancreas diseases with duct obstruction Extreme sensitivity limits its use Serology To rule out hepatitis

16. Prothromin time ratio (INR) Factors I,II,V,VII,VIII,IX,X,XIII – liver Factors II,VII,IX,X- vitamin K dependent

17. Imaging – non ivasive USG abdomen 1 st modality of investigation IHB diameter – 2mm CHD - <4mm CBD - <5-7mm Differentiate extrahepatic from intrahepatic causes Limitations – specific cause and exact level, CBD stones , obese

18. CT abdomen with contrast More accurate and specific cause and level Limited value in CBD stones , radiation exposure, expensive

19. MRCP/ MRI Sensitive non invasive test biliary , pancreatic stones ,strictures, dilatation Extent of disease No need of contrast Less risk compared to ERCP Limitations – contraindications to MRI

20. Imaging – invasive ERCP Lesions distal to bifurcations of hepatic ducts With cholangioscopy to biopsy Therapeutic intervention can be planned Limitations – proximal to obstruction , altered anatomy Complications -

21. PTC Lesions proximal to CHD Fluoroscopic guidance , iodine based contrast Liver is punctured to enter pheripheral IHB Complications – allergic reaction , peritonitis,sepsis , cholangitis , subhrenic abscess , Accuracy – 90%, Reserved for use if ERCP failed / altered anatomy precludes access to ampulla .. Drainage

22. Treatment Stabilisation Surgery

23. Preoperative management Prevention of renal failure Correction of coagulation status Prevention of cholangitis Preoperative biliary drainage

24. Renal failure Causes Vomiting Inadquate oral intake Bile salt induced diuresis Fasting for investigations Prevention Adequate IV hydration Bile salts administration Dopamine / diuretics Biliary drainage

25. Coagulation failure Malabsorption of vit K and hence its dependent factors Parenteral Vit K administration and reasses Abnormal INR – CLD- freeze dried plasma (clotting factors)

26. Cholangitis m/c in stones Instrumentation Gut failure Bacterial translocation Decreaed Kupffer cell activity Monomicrobial vs polymicrobial Gram negatives – E.coli , klebsiella , proteus Antibiotics – III gen cephalosporins with anaerobic coverage

27. Jaundice Level of jaundice – risk factor External or internal drainage Normal physiology restored with internal. Complications of bacterial colonisation with both precludes its use.

28. Treatment

29. Stones CBD stones ERCP with removal m/c method Failures – large , intrahepatic , multiple stones, altered anatomy , impacted stones CBD exploration + darinage – laparoscopic / open Laparoscopic – transcystic / trsnsductal Open CBD exploration

30. Stones Intrahepatic stones Percutaneous stone extraction with roux en Y hepaticojejunostomy Pancreatic duct stones ERCP+sphicterotomy +stone removal + stents

31. Acute cholangitis Adequate hydration IV antibiotics Endoscopic / percutaneous stone removal unsuccessful Open CBD exploration with T tube drainage

32. Primary sclerosing cholangitis Choleretic agents – UDCA Immunosuppressive therapy Symptomatic – balloon dilatation of dominant strictures Orthotopic liver transplantation

33. Biliary strictures ERCP+ sphincterotomy + baloon dilatation + stent placement unsuccessful Roux en Y proximal biliary to jejunal anastomosis

34. Choledochal Cysts Type I – simple excision + cholecystectomy + Roux en Y HJ Type II – simple excision Abnormal ABPJ – roux en Y HJ Type III - transduodenal excision Type IV – extrahepatic – type I intrahepatic – partial hepatectomy Type V – partial hepatectomy / liver transplantation

35. Gallbladder cancer Polyps >1cm – open cholecystectomy Cancer detected following cholecystectomy T1a – sufficient T1b/T2 – radical cholecystectomy GB carcinoma preoperatively Advanced locoregional disease Diagnostic laparoscopy with proceed Advanced disease at presentation Palliation for jaundice , pain , intestinal obstruction

36. Cholangiocarcinoma Distal – pancreaticoduodenectomy Proximal – en bloc resection of CBD + hepatic parenchyma + regional nodal tissue Bismuth collaret classification I and II – CBD resection + cholecystectomy + Roux en Y II – partial hepatic resection III and IV – complex resection , reconstruction of portal vein, hepatic artery Palliation – unresectable / uncurable disease

37. IV fluids and antibiotics ERCP with stent placement Pancreaticoduodenectomy / whipple’s When malignancy cannot be ruled out Chronic pancreatitis

38. WHIPPLE`S OPERATION Pancreatico-duodenoctomy Ca head pancreas/ P eriampellulary Ca

39. BENJAMIN CLASSIFICATION

40. Thank you