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OBSTRUCTIVE JAUNDICE

OBSTRUCTIVE JAUNDICE. PROF P DARWIN PROF AND HEAD DEPT OF GENERAL SURGERY STANLEY MEDICAL COLLEGE. WHAT IS JAUNDICE ?. Yellowish pigmentation of the conjunctival membranes over the sclerae and other mucous membranes caused by increased levels of bilirubin in the blood >2 mg/dl.

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OBSTRUCTIVE JAUNDICE

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  1. OBSTRUCTIVE JAUNDICE PROF P DARWIN PROF AND HEAD DEPT OF GENERAL SURGERY STANLEY MEDICAL COLLEGE

  2. WHAT IS JAUNDICE ? • Yellowish pigmentation of the conjunctival membranes over the sclerae and other mucous membranes caused by increased levels of bilirubin in the blood >2 mg/dl

  3. Types of jaundice • Hemolytic jaundice • Obstructive jaundice - Intra hepatic - Extrahepatic - Extraluminal - Mural - Intraluminal

  4. BILIRUBIN METABOLISM

  5. Anatomy of biliary tree

  6. Bile Composition • Water (85%) • Bile salts (10%) - (Cholic, chenodeoxycholic, deoxycholic, and lithocholic acid) • Mucus • Pigments (3%)- bile pigments e.g bilirubin glucuronide • Fats (1%) - such as Phospholipids (lecithin) , cholesterol • 0.7% inorganic salts – Sodium, chloride Function of bile: Acts as emulsifying agent – lowers surface tension - facilitates the digestion of dietary

  7. Gall bladder - Functions • Absorption It rapidly absorbs sodium, chloride, and water • Secretion Mucus Glycoproteins – makes up the colorless "white bile" seen in hydrops of the gallbladder resulting from cystic duct obstruction Hydrogen ions – The acidification promotes calcium solubility, thereby preventing its precipitation as calcium salts.

  8. CHOLESTEROL GALL STONE FORMATION • The key to keep cholesterol in soluble form is by micelle formation( cholesterol+bile salts+lecithin). • Pathogenesis: • Incresed water absorbtion. • Increased cholesterol secretion. • Inflammation of gall bladder epithelium.

  9. CAUSES OF OBSTRUCTIVE JAUNDICE • Intra luminal: Gall Stone disease Flukes Tumour emboli from HCC • Mural: Congeital Congenital atresia Choledochal cyst InflammatorySclerosing cholangitis Neoplastic Cholangiocarcinoma Traumatic Stricture(traumatic/post surgical) • Extra luminal: Malignant Ca gall bladder Portahepatis nodes Periampullaryca Ca head of pancreas Benign Pancreatitis

  10. Case scenario • 40 yr old male presented with C/o Yellow discolouration of eyes – 20 days High coloured urine – 20 days Clay coloured stools – 20 days h/o abd pain – rthypochondrium – 2 weeks h/o Intense itching + h/o fever with chills – 3 days No h/o loss of weight / apetite WHAT NEXT ???

  11. CLINICAL FEATURES

  12. HISTORY • Jaundice • Dark Urine • Pale/Brown Stools • Pruritis • Fever with Chills • Anorexia • Weight Loss • Alcoholism • Drug Intake Anabolic steroid, Oral Contraceptive, Chlorpromazine, Erythromycin Estolate, Isoniazid, Methyl Dopa, Acetaminophen, Aspirin • Previous Biliary Surgery

  13. Physical Examination • Age/Sex • Eyes • Scratch marks • Signs of liver cell failure Testicular atrophy, gynecomastia, Vascular Spiders,Dupuytren’s Contracture, Parotid Enlargement,Palmar Erythema • Hepatomegaly: Unduly Firm Irregular,Nodular • Palpable Gall Bladder

  14. GALL BLADDER • In a patient with obstructive jaundice, presence of a smooth nontender distended Gallbladder rules out gall stone as an etiology - Courvoisier’s law Exceptions to the law: • Double impaction of gall stone in cystic duct and CBD - mucocele of GB

  15. SPLENOMEGALY • In obstructive jaundice of long standing, splenomegaly may be a manifestation of secondary biliary cirrhosis • In Ca. body and tail of Pancreas, splenomegaly may result from encroachment of the tumour on the splenic vein.

  16. INVESTIGATIONS

  17. Investigations • Routine Tests • Liver Profile • Ultrasound • CT Scan • MRCP/ERCP/PTC • Hepato Biliary Scintiscan • Endoscopic Ultrasound • Laparoscopy

  18. Obstructive Jaundice Lab Findings • Serum Bilirubin • Fecealstercobilinogen (incomplete obstruction) • Fecealstercobilinogenabsence (complete obstruction) • urobilinogenuria is absent in complete obstructive jaundice • bilirubinuria • ALP  • cholesterol 

  19. The role of Radiology Are the ducts dilated ? What is the level of obstruction ? What is the cause ? What is the best therapeutic approach ?

  20. ULTRASOUND IN OBSTRUCTIVE JAUNDICE • Sensitivity 70-95% • Specificity 87% • Limitations Fails to detect CBD Stones at ampulla in75-85 % of cases. OBESE patients.

  21. CT SCAN IN OBSTRUCTIVE JAUNDICE • Sensitivity and specificity similar to good quality Ultrasound. • Useful in Obese patients or Excessive bowel Gas. • Better at imaging lower end of common bile duct. • Stages and assess the operability of Tumours. • Identify the site and nature of obstruction. • More costly and exposure to Radiation.

  22. CECT

  23. RADIONUCLIDE SCANNING • 99 TECHNETIUM IMINODIACETIC ACID (HIDA). • Taken up by Hepatocytes and actively excreted in to Bile. • Allows imaging of Biliary tree. • Failure to fill Gall Bladder- Acute Cholecystitis. • Delay of flow in to Duodenum –Biliary Obstruction

  24. MRCP • Replaces Diagnostic ERCP • No Radiation • More costly,Less Morbidity • Expert skill needed for interpretation

  25. ERCP • Allows Biopsy or Brush Cytology • Stone Extraction or Stenting

  26. PTC • Rarely required today • Performed with 22 G CHIBA Needle • Also allows biliary drainage and stenting

  27. ENDOSONOGRAPY • Endoscopic Sonography is accomplished with combination of a sonographic transducer and a fibroptic Endoscope • Directly visualize the cause of obstruction. • Assess the regional spread in Malignancy. • Evaluate Parenchymal, vascular and ductal abnormalities • Superior to US, CT and MRI • Sensitivity 97% Specificity 100% • Limitations: *Duodenal stenosis *Previous Gastric Surgery

  28. LAPAROSCOPY • Diagnostic Accuracy in Hcc 65% • Demonstrates the presence of cirrhosis • Liver Biopsy under laparoscopic control is safe • Target Biopsy is possible • Helps identifying invasion of Liver,Peritoneum and Mesentry by tumour

  29. Complications of Obstructive Jaundice • Ascending Cholangitis – Charcot’s triad, Reynold’s pentad • Clotting Disorders • Hepato renal Syndrome • Drug Metabolism impaired • Impaired wound Healing

  30. MANAGEMENT

  31. PREOPERATIVE MANAGEMENT-OBSTRUCTIVE JAUNDICE • Broad Spectrum Antibiotics Prophylaxis • ParenteralVit K/ fresh Frozen plasma • Preoperative Fluid Expansion • Anaemia,Hypoproteinaemia to be corrected.

  32. AIMS OF SURGICAL TREATMENT • TO CURE THE DISEASE • TO RELEIVE SYMPTOMS • TO IMPROVE THE QUALITY OF LIFE AND SURVIVAL

  33. CBD STONES - MANAGEMENT • ENDOSCOPIC SPHINCTEROTOMY AND STONE REMOVAL • CHOLECYSTECTOMY AND CHOLEDOCHOLITHOTOMY • T – TUBE DRAINAGE / CHOLEDOCHO DUODENOSTOMY • LAPAROSCOPIC / OPEN

  34. MALIGNANT OBSTRUCTION • PERIAMPULLARY TUMORS • CA.HEAD OF PANCREAS • GB CARCINOMA • CBD TUMORS • HILAR TUMORS

  35. MALIGNANCY • SURGERY - CURATIVE / PALLIATIVE • ENDOSCOPY • RADIOLOGY PALLIATIVE

  36. MALIGNANCY OPERABLE – ONLY SURGERY  ADJUVANT THERAPY INOPERABLE - BYPASS

  37. SURGERY • LOW LEVEL OBSTRUCTION - WHIPPLE’S • MID / HIGH LEVEL - EXCISION / HEPATICOJEJUNOSTOMY - HEPATECTOMY - TRANSPLANT

  38. Periampullarycancerstumours arising out of or within 2 cm of the papilla of Vater and include ampullary,bile duct and duodenal cancer. • Surgery remains the main stay of periampullary carcinoma • surgical resection of the tumor provides the only chance of cure

  39. Ca Head of Pancreas • Whipple’s Pancreatico-duodenectomyhas become extremely safe in large volume centres. • Newer chemo-radiation studies have shown improved survival • Pylorus-preserving pancreatico -duodenectomy has the advantage of sparing the pylorus, and thus normal gastric emptying.

  40. TRANSECTION OF THE PANCREAS AT NECK

  41. CONSTRUCTING A ROUX LOOP

  42. PANCREATICO-JEJUNOSTOMY

  43. HEPATICO JEJUNOSTOMY

  44. WHIPPLES PROCEDURE -SPECIMEN

  45. END RESULT OF WHIPPLE S PROCEDURE

  46. HILAR CHOLANGIO CARCINOMA (KLATSKIN TUMOR) Tumor arising from the common hepatic duct at the confluence. Treatment: SURGERY - Resection & Hepaticojejunostomy PALLIATION - Seg3 bypass / seg5 bypass ENDOSCOPIC - Stenting

  47. PALLIATIVE BYPASS • BILIARY ENTERIC ANASTAMOSIS AWAY FROM TUMOUR (SEG III BYE PASS ) • HEPATICO JEJUNOSTOMY IN CA. HEAD OF PANCREAS

  48. PALLIATIVE BILIARY DRAINAGE METHODS : • PTBD (Percutaneous transhepaticBiliary Drainage) • Endoscopic Drainage 1.Stenting 2.Naso Biliary Drain • Surgical Drainage

  49. COMPLICATIONS – PTBD • Sepsis • Haemobilia • Biliary Leak • Hemorrhage COMPLICATIONS of endoscopic drainage • Cholangitis • Pancreatitis • Haemorrhage

  50. SUMMARY • Patients need proper preoperative evaluation & preparation. • Whipples surgery is the optimum procedure for ca head of pancreas & periampullary carcinoma. • Hilarcholangiocarcinoma & ca gall bladder have dismal prognosis. • Benign diseases like biliary stricture needs management in expert hands.

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