PREPARATION OF A PATIENT WITH JAUNDICE FOR SURGERY(1).pptx

General Surgery presentation on surgical jaundice.

1. PREPARATION OF A PATIENT WITH JAUNDICE FOR SURGERY BY DR. EJIOFOR LAWRENCE SUPERVISOR: DR. KABANG

2. OUTLINE Introduction Epidemiology Relevant anatomy Pathophysiology Problems of jaundiced patient History Physical examination Investigations Pre-operative care Conclusion References

3. INTRODUCTION Jaundice is yellowish discolouration of the skin and mucous membrane. Clinically, when serum bilirubin >40µmol/l OR > 2mg/dl. Obstructive jaundice is usually due to mechanical obstruction of the extra hepatic biliary tract. Surgery is the mainstay of treatment.

4. EPIDEMIOLOGY Incidence: 5 cases per 1000 people Gall stones: Native Americans, Hispanics and Europeans > Africans and Asians. Malignant causes: Africa, East Asia, Northern India, South America. Gall stones affect females more than males

5. RELEVANT ANATOMY

6. PATHOPHYSIOLOGY The pathophysiology is that of obstructed bile secretion into the duodenum with deficiency of bile salts in the gut and impairment in bilirubin metabolism. Consequently, there is fat (+ vit K) malabsorption with pale bulky stools and bleeding problem Systemic accumulation of bilirubin resulting in jaundice, dark urine, renal and hepatic toxicity.

7. PATHOPHYSIOLOGY CONTD Deposition of bile salts in the skin causing itching. Also, CBD obstruction predispose to third space fluid loss and ascending cholangitis infection.

8. PROBLEMS OF A JAUNDICED PATIENT Infection: ascending cholangitis Uncontrolled bleeding Liver glycogen depletion Dehydration Severe pruritus Hepatorenal syndrome Hepatic failure in extreme cases

9. HISTORY Biodata: name, age, sex, occupation Common PC: yellowness of eyes, abdominal swelling, complaints related to complications e.g itching , dark urine HPC: symptom analysis Jaundice: mode of onset, duration, progression, associations, itching, steatorrhea, pale/clay colored stool, dark colored urine, fever, bleeding problem, symptoms suggestive of DM

10. HISTORY CONTD Abdominal pain: site, duration, mode of onset, severity, nature, radiation, alleviating factors, aggravating factors Ask about other GIT symptoms like: nausea, vomiting, hematemesis, dyspeptic symptoms, change in bowel habit, rectal bleeding, melena, tenesmus If malignancy is suspected, ask about symptoms complicating malignancy: unusual weakness and easy fatigability, weight loss with anorexia, bone pains

11. HISTORY CONTD Analysis of aetiology /risk factors Gall stones: fair, fertile, fat, females of forty to fifty years Hx of weight gain, high calorie diet Pariety , pregnancy and OCP use Sickle cell disease Malignant disease ( e.g pancreas cancer): cigarette smoking, chronic pancreatitis, h x of DM

12. HISTORY CONTD Analysis of differential diagnoses Other post hepatic jaundice: Biliary stricture- hx of upper GIT and biliary surgeries Helminthiasis- ask for evidence of worm infestation: clonorchis , ascaris ; passage of worms Abdominal tuberculosis- drenching night sweat Rule out pre-hepatic (hemolytic) jaundice: Ask about hemoglobinopathies , Hb genotype and other blood dyscrasias

13. HISTORY CONTD Rule out causes of hepatic jaundice (hepatocellular pathogenesis): Viral hepatitis Drugs Alcohol use

14. PHYSICAL EXAMINATION General: Depth of jaundice, dehydration, pale, scratch marks, fever, left supraclavicular lymph node enlargement (metastatic cancer), features of CLD Abdomen: Distension/localized swelling, abdominal scars, tenderness, palpable gall bladder, hepatomegaly, splenomegaly (hemolytic), ascites, pelvic masses ( blummer’s shelf), Sister Joseph’s nodule. Other systems: CVS, RS

15. INVESTIGATIONS Basic: Urinalysis Stool for occult blood Stool for cyst/ova and parasite LFT Clotting profile Serologies FBC + Blood film

16. INVESTIGATIONS CONTD Abdominal USS Others: Barium meal and follow through Contrast enhanced CT scan of the abdomen Percutaneous Transhepatic Cholangiogram (PTC) Endoscopic Retrograde Cholangio - Pancreatogram (ERCP) Magnetic Resonance Cholangiopancreatography (MRCP)

17. INVESTIGATIONS CONTD Pre-operation investigations: Chest X-ray and ECG for patient >40 years; for cardiac and pulmonary evaluation FBS E/U/Cr; to assess fluid-electrolytes and renal status GxM blood; but make sure clotting profile is normal before surgery

18. PRE-OPERATIVE CARE OF A JAUNDICED PATIENT Admit some days prior to surgery; at least 3 days Antibiotics against Gr+, Gr- and Anaerobes; could be oral or IV initially but give IV antibiotics at induction of anaesthesia . Antibiotics of choice include IV ceftriaxone 1g 12 hourly and IV metronidazole 500mg TDS. I V vitamin K 10 mg daily, may increase dose until PT/PTTK normalize. Give I V Vit K 10mg daily 5 days pre-op and post-op (aim is to achieve INR<= 1.3 up to 2.

19. PREPARATION CONTD Adequate hydration (4L) to achieve 2-3 times the normal urine output. This should be done with glucose rich fluid to prevent hypoglycemia. Can be oral or IV ( 10 % D/S OR 10% D/W) initially but commence IVF 5% D/W at 100ml/ hr on the night before surgery. Monitor urinary output +/- catheterization (pass catheter night before surgery) . Hourly monitoting of glucose level.

20. PREPARATION CONTD Oral suspension cholestyramine 4g 6 hourly is given in case of pruritus. Some surgeons give 500ml of 10% mannitol OR 1g/kg in 3 divided doses (immediate pre-op, repeat intra-op and post-op) to enhance diuresis and prevent hepatorenal syndrome. Bowel preparation using suspension lactulose is also indicated.

21. CONCLUSION All jaundiced patients have mild to severe pathophysiological changes depending on the severity of the hyperbilirubinemia. Optimization is an important aspect in managing all moderate to severe jaundice .

22. REFERENCES BAJA’s Principle and Practice of Surgery including Pathology in the Tropics, 5 th ed. 2015, vol II. Bailey and Love, Short Practice of Surgery, 25 th ed. 2008. Moore, Keith L., et al. Clinically Oriented Anatomy. 8 th ed., Lippincot Williams and Wilkins, 2017. Clarke D. L et al. The current standard of care in the preprocedural management of the patient with obstructive jaundice. Ann. R. Coll Surg. Engl 2006; 88:610-616.