Surgical Jaundice investigations & management

This is a presentation by Md Shadman Shakib on the event of "Integrated Teaching of Jaundice" held on Dhaka Medical College on 6th September 2018

1. INVESTIGATIONS & MANAGEMENT OF SURGICAL JAUNDICE Md. Shadman Shakib 5 th yr MBBS student (K-71) Dhaka Medical College

2. Investigations To confirm diagnosis & exclude differentials 1. CBC with PBF Hb % - in malignancy PMN – in cholangitis PBF – in teenagers, it excludes: Hereditary Hemolytic Anemia Hereditary Spherocytosis

3. Investigations contd … 2.Liver Function Tests Serum Bilirubin- Conjugated (direct) hyperbilirubinemia is found in obstructive jaundice . In stone disease, S. bilirubin < 10 mg%, S. bilirubin >20 mg% suggests malignant obstruction

4. Investigations contd … Liver Enzymes SGPT (5-30 IU/L) – raised SGOT (5-40 IU/L)- raised Serum Alkaline Phosphatase - markedly raised , out of proportion to serum aminotransferases Serum – raised (more specific for hepatocytes)  

5. Investigations contd … 2. Liver Function tests contd … Prothrombine time (11-14 sec) – increased INR – elevated Serum Albumin - reduced Serum A:G ratio - altered

6. Investigations contd … 3. Imaging: USG of Hepatobiliary System & pancreas: can detect Site of obstruction Biliary dilatation & size of CBD Stone in biliary tree : choledocholithiasis Lesions in the wall of biliary tree: Cholangiocarcinoma Enlargement of the pancreatic head: Ca. head of pancreas

7. Investigations contd … 3. Imaging: Plain X-ray Abdomen – can detect radio-opaque gall stones in 10% cases

8. Investigations contd … 3. Imaging: CT scan of abdomen - to rule out malignancy in head of pancreas or in periampullary region.

9. Investigations contd … 3. Imaging: MRCP: Non invasive with excellent delineation of biliary tree

10. Investigations contd … 3. Imaging: ERCP: Detects calculi or malignant strictures Bile aspirates can be sent for cytological & microbiological examination Endoluminal brushings can be taken from strictures for cytological study

11. Investigations contd … 3. Imaging: Percutaneous Transhepatic Cholangiography Done when ERCP fails Useful for malignant stricture at the level of confluence of right & left hepatic duct or higher PTC is preferred to ERCP as successful drainage is more likely

12. Investigations contd … 4. Others: Urine tests Fouchet’s test: for bile pigments Hay’s test: for bile salts & urobilinogen in urine Supportive evidence: Tumour marker: a.CA 19-9 & b.CEA for carcinoma of pancreas

13. Investigations contd … For staging CECT of abdomen : detects local extension of tumour, LN status & liver metastasis Endoscopic Ultrasound: better delineates local extension of tumour & LN metastasis Diagnostic Laparoscopy & laparoscopic USG: defines operability & detects peritoneal deposits

14. Investigations contd … Investigations for GA fitness CBC Urine RME RBS Serum creatinine, Blood urea Serum electrolytes Chest X ray ECG, Echocardiography (if age > 40 yrs ) HBsAg , Anti HCV

15. Hazards & concerns Hypovolemia Coagulopathy: ↑ PT due to deficiency of vitamin K dependent clotting factors II , VII, IX, X. Hepatorenal syndrome & acute renal failure Drug toxicity: Analgesics, antibiotics, sedatives Effects on wound healing: Wound infection, Impaired wound healing, Anastomotic leakage.

16. Patient Preparation Preoperative: Correction of hypovolemia & raise glycogen storage: 5% / 10% DA, 5% DNS Correction of Anemia Transfusion of PCV or whole blood

17. Patient Preparation contd … Preoperative: Correction of Malnutrition Intake of glucose containing fluid High protein diet Bowel Preparation: Syp . Lactulose for clearance of urea splitting organism

18. Patient Preparation contd … Preoperative: Correction of Coagulopathy IV administration of Vitamin K (10 mg for 5 days) Correction of Co-Morbidities: Control DM, HTN , Asthma etc

19. Patient Preparation contd … Preoperative: Antibiotic Prophylaxis 2 nd generation cephalosporin + aminoglycosides Urethral catheterization To monitor urine output ( Should be >0.5 ml/kg/ hr )

20. Patient Preparation contd … Per-operative: Correction of Coagulopathy: If PT, INR is not corrected preoperatively, FFP should be used in OT To maintain Kidney perfusion: IV 20% Mannitol during operation

21. Treatment According to cause

22. Treatment contd … Choledochoilithiasis If CBD stone <10 mm: ERCP along with endoscopic sphinchterotomy & retrieval of stone with Dormia basket followed by laparoscopic cholecystectomy If ERCP is not successful, options are: Biliary stenting ESWL

23. Treatment contd … ERCP

24. Treatment contd … Choledochoilithiasis If CBD stone >10 mm: Open cholecystectomy with choledocholithotomy or Laparoscopic cholecystectomy with choledocolithotomy

25. Treatment contd … Lap cholecystectomy choledocholithotomy

26. Treatment contd … 2. Ca. of the head of the pancreas, Periampullary carcinoma, Cholangiocarcinoma: If the tumour is resectable : pylorus preserving pancreatico-duodenectomy or classical whipple’s operation.

27. classical whipple’s operation.

28. Treatment contd … 2. Ca. of the head of the pancreas, Periampullary carcinoma, Cholangiocarcinoma: If the tumour is irresectable : palliative triple bypass or stenting in CBD & duodenum These operations are combined with adjuvant chemotherapy

29. Deuodenal stent placed by ERCP Biliary stent placed by ERCP Treatment contd …

30. Treatment contd … 3. Klatskin tumour : Hepatic plate dissection with excision of tumour followed by hepatico-jejunostomy or Palliative percutaneous transhepatic biliary drainage

31. Treatment contd … 4. Biliary stricture: Biliary Stenting or Roux- en -Y Hepaticojejunostomy

32. Treatment contd … 5 . Choledochal cyst: Radical excision or mucosal resection with Hepaticojejunostomy

33. Treatment contd … 6. Parasitic infestation Removal by ERCP 7. Biliary atresia Extrahepatic: Kasai’s operation , Intrahepatic: Liver transplantation

34. Post operative jaundice Definition: Presence of elevated bilirubin with or without clinical icterus appearing in the post operative period. Causes: Pre-hepatic: due to excessive hemolysis or a resolving hematoma. Hepatic: from hepatic ischemia, viral infection or drug toxicity. Post-hepatic : retained bile duct stone or bile duct injury .

35. Post operative jaundice Management: Depends upon the underlying cause with specific intervention. Prognosis: Jaundice will resolve in weeks to months if the underlying causes are resolved.

36. Acknowledgement Department of Surgery , DMCH References: Bailey & Love’s Short Practice of Surgery 27 th edition ,CRC Sabiston textbook of surgery 20 th edition,Elsevier RCS Course Manual UpToDate , Wolters Kluwer