OBSTRUCTIVE JAUNDICE- Problem Oriented Approach.pptx

Here discussing various cases of Obstructive jaundice namely Choledocholithiassis, Biliary atresia, Carcinoma Pancreas, Periampullary Carcinoma and Cholangiocarcinoma.

1. OBSTRUCTIVE JAUNDICE DR.B.SELVARAJ MS;Mch;FICS ; Professor of Surgery Manipal University College Malaysia Melaka 75150 Malaysia JAUNDICE- Surgical Perspective

2. OBSTRUCTIVE JAUNDICE Definition & Importance Anatomy of Biliary system Causes of obstructive jaundice Choledocholithiasis Biliary Atresia Carcinoma Head of the Pancreas Periampullary Carcinoma Cholangio Carcinoma Quick recap/Conclusion LEARNING OBJECTIVES

3. OBSTRUCTIVE JAUNDICE Definition: Obstructive jaundice is a medical condition characterized by the obstruction of normal bile flow from the liver to the small intestine, leading to the accumulation of bilirubin in the bloodstream. Bilirubin is a yellow pigment formed during the breakdown of red blood cells. Implications of Untreated Obstructive Jaundice: It can lead to progressive liver damage with impaired bile secretion and digestion Definition & Importance Timely Diagnosis for Effective Intervention : Early diagnosis allows for prompt intervention, preventing potential complications and improving the chances of successful treatment. Multidisciplinary Approach: The need for a collaborative approach involving various healthcare professionals, including gastroenterologists, hepatologists, surgeons, and radiologists, to ensure comprehensive care.

4. OBSTRUCTIVE JAUNDICE ANATOMY OF BILIARY SYSTEM

5. OBSTRUCTIVE JAUNDICE CAUSES • Intraluminal causes: - Choledocholithiasis - Clonorchis sinensis - Ascariasis • Mural causes: - Biliary atresia - Malignant stricture-Cholangiocarcinoma - Benign stricture- Scelerosing cholangitis • Extramural Causes: - Ca Head of Pancreas - Periampullary Carcinoma - Portal Lymph node

6. CHOLEDOCHOLITHIASIS Etiopathogenesis Clinical Features- S&S Diagnosis- Workup Treatmen t - Primary stones-5% - Secondary stones- 95% - Additional stones may be located in the GB . - Stones may pass into the duodenum asymptomatically . - Biliary colic occurs when the ducts partially obstructed. - Complete obstruction causes duct dilation and jaundice . -Eventually results in Ascending & suppurative cholangitis - Stone in ampulla of Vater can cause Gall stone pancreatitis. - RUQ pain -Nausea/Vomiting - Episodic/intermittent jaundice -High color urine -Pale color stool -Charcot’s triad in ascending cholangitis - RUQ pain -Jaundice - Fever -Reynold’s pentad in suppurative cholangitis - RUQ pain, Jaundice, fever, hypotension and altered mental status. - GB not palpable- Courvoisier’s law - LFT: Total Bilirubin is increased. - Direct-conjugated bilirubin is > Indirect unconjugated bilirubin - ALP and GGT both elevated -USG hepatobiliary may show GB stones and dilated CBD - MRCP-shows stones in biliary ducts - ERCP- Gold standard- both diagnostic and therapeutic. Stone extraction can be done. -EUS- can also shows stone in the biliary ducts - Blood Culture and sensitivity in Cholangitis patients -ERCP, Sphincterotomy and stone extraction -Followed by Open or Lap Chole - In ERCP failure- open Choledocholithotomy -Ascending cholangitis can still be treated with broad spectrum high antibiotics alone. -In Suppurative cholangitis pus can be drained by naso -biliary drain or PTBD-Percutaneous intra hepatic biliary drain.

7. CHOLEDOCHOLITHIASIS ERCP STONE EXTRACTION

8. BILIARY ATRESIA Etiopathogenesis Clinical Features- S&S Diagnosis- Workup Treatmen t - Congenital Obliteration of biliary system both extra and intra hepatic -Exact cause not known -Because of back pressure there is portal tract edema, bile duct proliferation, and portal and periductular inflammation and hepatocyte injury and eventually cirrhosis - Progressively increasing jaundice from neonatal period -High color urine - Pale color stool-acholic stool - Itching - Hepatosplenomegaly - Features of liver failure in late cases. - LFT: Total Serum bilirubin will be elevated, with the direct > indirect bilirubin -ALP & GGT both are elevated -Hepatobiliary scintigraphy- HIDA scan- will show uptake into the liver without excretion. -A liver biopsy provides definitive dx--can be done percutaneously, or part of an exploration with cholangiography. - Extrahepatic bile duct is excised and segment of jejunum is sewn into the fibrotic porta hepatis in a portoenterostomy or Kasai procedure. - The bile then drains from the liver via the small hepatic biliary ductules . - Liver transplantation for those who do not develop bile flow or who ultimately develop fibrosis of the intrahepatic bile ducts .

9. BILIARY ATRESIA

10. BILIARY ATRESIA

11. CA Head of Pancreas Etiopathogenesis Clinical Features- S&S Diagnosis- Workup Treatmen t - Exact cause not known -Risk factors are Cigarette smoking, Increased age. Chronic pancreatitis, increased saturated fat intake, exposure to non chlorinated solvents -Genetic risk factors- Chronic familial relapsing pancreatitis, Familial breast cancer BRCA2, Gardener syndrome, HNPCC , Peutz-Jegher’s syndrome - Tumor in the head of Pancreas cause extrinsic compression of distal CBD causing Obstructive jaundice. - Painless progressive jaundice -High color urine - Pale color stool-acholic stool - Itching - Nausea/vomiting - Loss of weight and loss of appetite -Palpable GB- “Courvoisier’s Law” - - LFT: Total Serum bilirubin will be elevated, with the direct > indirect bilirubin -ALP & GGT both are elevated -ERCP- Dual duct sign -USG Abd : can detect only huge tumors -Triple phase CT abdomen: is sensitive to pickup even small hypodense lesions and for staging -EUS- EUS guided pancreatic biopsy - Resectable tumors- tumors confined to pancreas- Whipple’s operation or Pancreatoduodenectomy - Borderline tumors- Neoadjuvant chemoradio and then surgery - Unresectable tumors- only palliative by pass surgeries Biliary obstruction: Biliary enteric bypass, Endoscopic biliary stent placement. Radiographic transhepatic stent placement. GOO- Gastroenteric bypass, Endoscopically placed duodenal stent

12. CA Head of Pancreas

13. Periampullary Carcinoma Etiopathogenesis Clinical Features- S&S Diagnosis- Workup Treatmen t - A malignant tumor arising in the last centimeter of the common bile duct. - can arise from 1 of 4 epithelial types: Terminal CBD, Duodenal mucosa, Pancreatic duct and Ampulla of Vater - Ampullary adenocarcinomas have two principal histologic forms: intestinal and pancreaticobiliary - Pancreaticobiliary tumors follow a more aggressive course - Painful intermittent jaundice because of partial necrosis of tumor -High color urine - Silver color stool-because of mixing of blood oozing from the tumor with acholic stool - Itching - Nausea/vomiting - Loss of weight and loss of appetite -Palpable GB- “Courvoisier’s Law” - Upper GI bleed & heme positive stools—May occur due to ulceration of ampullary mass (less common) - - LFT: Total Serum bilirubin will be elevated, with the direct > indirect bilirubin -ALP & GGT both are elevated - CA 19-9 and CEA Serum tumor markers elevated - CT scan often demonstrates a mass -ERCP- to evaluate the ductal architecture further -EUS- EUS guided biopsy -PET-CT scans can detect metastases - Resectable tumors: Whipple’s operation or Pancreatoduodenectomy - Followed by adjuvant chemotherapy - Unresectable tumors- only palliative by pass surgeries Biliary obstruction: Biliary enteric bypass, Endoscopic biliary stent placement. Radiographic transhepatic stent placement.

14. Periampullary Carcinoma

15. Cholangio Carcinoma Etiopathogenesis Clinical Features- S&S Diagnosis- Workup Treatmen t - A malignant tumor arising from intrahepatic or extrahepatic bile ducts - Extrahepatic is perihilar or distal duct. Perihilar is Klatskin tumor which is very common - Risk factors are Primary scelerosing cholangitis or liver flukes like Clonorchis sinensis - Painful progressive jaundice because of slow narrowing of the duct -High color urine - Pale color stool - Itching - Nausea/vomiting - Loss of weight and loss of appetite -Palpable GB- “Courvoisier’s Law” - - LFT: Total Serum bilirubin will be elevated, with the direct > indirect bilirubin -ALP & GGT both are elevated - In prolonged obstruction PT is elevated because of VitK malabsorption - USG shows biliary duct dilatation and larger hilar lesions - CT scan often demonstrates a mass -ERCP- shows site of obstruction and for brush cytology&palliative stenting -EUS- EUS guided biopsy-FNAC -PET-CT scans can detect metastases - Majority of tumors are unresectable and complte surgical excision is not possible. - So, only the following palliative treatment only can be done - ERCP and stenting - PDT-Photodynamic Therapy -Radiation therapy -Chemotherapy -Radiofrequency ablation - Targeted therapy with Futibatinib & Pemigatinib

16. Cholangio Carcinoma TYPES Intra-Hepatic Mass KLATSKIN TUMOUR

17. CAUSES Etiopathogenesis Clinical Features-S&S DIAGNOSIS TREATMENT Choledocholithiasis Formation of gall stones in the CBD. Primary/Secondary Painful intermittent jaundice, nausea and vomiting LFT USG and CECT MRCP and ERCP ERCP stone extraction Cholecystectomy- open and Lap, Choledocholithotomy Biliary Atresia Congenital absence or closure of bile ducts Neonatal jaundice Dark urine Pale stools MRCP and HIDA scan Intraop cholangiography Liver biopsy Kasai’s portoenterostomy Liver transplant Carcinoma Head of Pancreas Malignant tumor in the head of the Pancreas Painless progressive jaundice, Weight loss Nontender GB palpable Courvoisier’s law CECT and MRI ERCP- Duval duct sign EUS guided pancreatic biopsy Whipple’s Pancreato duodenectomy Triple bypass Adjuvant Chemoradio Peri Ampullary Carcinoma Tumors near the ampulla of Vater Painless intermittent jaundice, Silver color stool, FOBT + ve CECT and MRI ERCP- Biopsy FOBT + ve Whipple’s Pancreato Duodenectomy Adjuvant Chemoradio Cholangio Carcinoma Cancer of the bile ducts Intra and Extrahepatic Progressive jaundice Dark color urine Pale stools, Itching CECT and MRI ERCP EUS guided FNAC Surgical resection if possible Adjuvant Chemoradio OBSTRUCTIVE JAUNDICE- Quick Recap