1 / 53

Surgical Jaundice

Surgical Jaundice . Supervised by Dr. Jamal Hamdi. Definition Of Jaundice. yellow pigmentation of skin, mucous membrane or sclera Jaundice clinically detected when serum bilirubin level ( 2.5 mg/dl) Normal serum bilirubin (0.2-1.0 mg/dl ) caused by an excess of bile

verne
Download Presentation

Surgical Jaundice

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Surgical Jaundice Supervised by Dr. Jamal Hamdi

  2. Definition Of Jaundice • yellow pigmentation of skin, mucous membrane or sclera • Jaundice clinically detected when serum • bilirubin level ( 2.5 mg/dl) • Normal serum bilirubin • (0.2-1.0 mg/dl ) • caused by an excess of bile • pigments in plasma • It is a symptom not a disease

  3. Bilirubin Metabolism Bilirubin is produced from the breakdown of haemoglobin in the reticuloendothelial system. 95% of the circulating bilirubin is unconjugated and bound to albumin .

  4. Bilirubin Metabolism Hepatic metabolism occurs in 3 phases: - Uptake - Conjugation - excretion RES

  5. Pathophysiology Of Hyperbilirubinemia • Over production by RES • Failure of hepatocellular uptake • Failure of conjugation or excretion • Obstruction of biliary excretion into intestine

  6. Classification Of Jaundice • Prehepatic: • RBC disorders • ( Hereditary spherocytosis , SCA) • Auto-immune ( Mismatched blood transfusion ) • Infective ( Sepsis , Malaria ) • Hepatic : • Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome ) • Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc ) Posthepatic (obstructed) surgical

  7. Etiology Of Obstructive Jaundice • Common: • Common bile duct stone. • Cancer head of pancreas

  8. Etiology Of Obstructive Jaundice • Less Common: • Ampullary carcinoma • Pancreatitis. • Mirrizi syndromes. • Sclorosingcholangitis. • Cholangiocarcinoma

  9. Approach To Jaundice Patient History Careful History is of very important value to guide the D\D toward the cause & the type of jaundice ( PreHepatic , Hepatic , PostHepatic )

  10. Approach To Jaundice Patient History Onset Gradual ? cirrhosis pancreatitis cancer Sudden ? CBD stone Hepatitis

  11. Approach To Jaundice Patient History Pattern Progressive? Pancreatic carcinoma Cholangiocarcinoma fluctuating ? CBD stone Ampullary carcinoma Hemolytic episodes

  12. Approach To Jaundice Patient History Pain Painful? CBD stone Pancreatic diseases painless? Malignancy

  13. Approach To Jaundice Patient History • Other symptoms of obstructive jaundice • Pruritis • Fatty dyspepsia • Steatorrhea • Dark urine , pale stool • Bleeding disorder

  14. Approach To Jaundice Patient History • RUQ pain , fever • Symptoms of anemia • Hx of SCD • G6PD deficiency ? Food related ? • Symptoms of malignancy • ( weight loss & anorexia )

  15. Approach To Jaundice Patient History Past Medical • Blood transfusion • Hx of drugs • Past Hx of surgery • Family Hx of jaundice & hemolytic disorders • Alcohol • Occupation & travel Past Surgical Hx Family Hx

  16. Approach To Jaundice Patient • Physical Examination General Appearance Stigmata of Chronic Liver Disease General Examination Cachexia Muscle Wasting Yellow Discoloration Palmarerythema clubbing . flapping tremor. duputrine’s contracture . Spider nevi gynecomastia caput medosa testicular atrophy Jaundice Scratch marks Pallor Vital Signs

  17. Approach To Jaundice Patient • Physical Examination Abdominal Discolration , scars ( collen’s , Grey Tuner ) RUQ pain Murphy sign Palpaple Gallbladder ( Courvoisier’s law ) Abdominal masses ( malignancy ) Hepatomegaly, splenomegaly , ascitis PR : color of stool . Abdominal Examination

  18. Obstructive Jaundice • Invistigation • Laboratory Exam • Imaging • Invasive

  19. Obstructive Jaundice • Invistigation • Laboratory Exam • Blood • LFT: Serum bilirubin (Direct / Indirect) , Albumin , ALT , AST , ALP, LDH , • CBC , Electrolyte , Amylase • Urine • Urine analysis • Stool • The investigations will differentiate hepatocellular and obstructive jaundice • In most of the cases

  20. Invistigation

  21. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • AXR • US • CT • MRI/MRCP • Invasive • ERCP • PTC • Operative cholangiogram • T-tube cholangiogram • Angiogram • Biopsy

  22. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • 1- The presence of gall stones 2- the thickened wall of the gallbladder in acute or chronic inflammation 3- The Diameter of CBD more than 7mm is suggestive of presence of stones • Ultrasounde • Is the most useful initial study for evaluation of intra/extrahepaticbiliary dilatation.

  23. Obstructive Jaundice • Invistigation • Imaging • Ultrasounde • Is the most useful initial study for evaluation of intra/extrahepaticbiliary dilatation.

  24. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Determine the specific causes and level of obstruction • CT scan can only image calcified stones CT Scan

  25. Obstructive Jaundice • Invistigation • Imaging CT Scan

  26. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Routine investigation-base-line & may • show specked calcification in the region of • pancreas. X-Ray

  27. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Magnatic resonance cholangiopancreatography (MRCP) • Sensitive noninvasive method of detecting biliary and pancreatic duct stones stricture or dilatations within the biliary system MRCP

  28. Obstructive Jaundice • Invistigation • Imaging • Invasive • Useful for lesion distal to the bifurcation of the hepatic ducts (diagnostic ) • ERCP has a (therapeutic) application because obstruction can potentially be relieved by the removal of stones , sphcterotomy and placement of stent and drains ERCP

  29. Obstructive Jaundice • Invistigation • Imaging ERCP

  30. Obstructive Jaundice • Invistigation • Imaging ERCP

  31. Obstructive Jaundice • Invistigation • Imaging • Invasive • Percutaneoustranshepaticcholangiogram (PTC ) • Useful for lesions proximal to common hepatic duct PTC

  32. Obstructive Jaundice • Treatment According To The Cause

  33. Obstructive Jaundice • Treatment Goal of Treatment • Relief of Obstruction • Prevent Complication • Prevent Recurrence

  34. Obstructive Jaundice • Treatment • Defined as stones in the CBD • intermittent obstruction of CBD • Predisposes to Cholangitis & Acute Pancreatitis • Elevated sr. bilirubin & Alk. Phos. • Evaluation By : U\S , ERCP , CT Jaundice caused by Gallstones

  35. Obstructive Jaundice • Treatment • Evaluation By : ERCP • Primary diagnostic and therapeutic modality • Sphincterotomy and stone extraction • Placement of stent if stone extraction unsuccessful • Mortality rate 1.5% • ERCP Jaundice caused by Gallstones

  36. Obstructive Jaundice • Treatment • Open CBD Exploration • Indications • Presence of multiple stones (more than 5) Stones > 1 cm • Multiple intra hepatic stones • Distal bile duct strictures • Failure of ERCP • Recurrence of CBD stones after sphincterotomy Jaundice caused by Gallstones

  37. Obstructive Jaundice • Treatment • CBD Exploration – Surgical Options • Common bile duct exploration with T-tube decompression • Choledochoduodenostomy • Transduodenalsphincterotomy and sphincterplasty • Roux-en-Y Choledochojejunostomy Jaundice caused by Gallstones

  38. Obstructive Jaundice • Treatment • At the time of diagnosis, 52% of all patients have distant disease • 26% have regional spread. •  The relative 1-year survival is only 24% • the overall 5-year survival rate for this disease is less than 5%.  Carcinoma Head Of Pancreas

  39. Obstructive Jaundice • Treatment Resectable Non Resectable Carcinoma Head Of Pancreas Surgical treatment Non surgical treatment (metal stents)

  40. Obstructive Jaundice • Treatment • resectability. ? • Resectable, unresectable ? •  experience and technical skill of the surgeon And overall health of the patient •  Typically, extrapancreatic disease precludes curative resection, and surgical treatment may be palliative at best.  Carcinoma Head Of Pancreas

  41. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas

  42. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor

  43. Obstructive Jaundice • Treatment • Non surgical treatment • Inoperable Patient :- • - Endoscopic expandable metallic stent • Bypassed By Hepatojejunostomy • ( Roux-en-Y) Carcinoma Head Of Pancreas

  44. Obstructive Jaundice • Treatment • surgical treatment • Operable Patient :- • Whipple’s Operation • Pancreaticoduodenectomy • Curative ? Carcinoma Head Of Pancreas

  45. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Is It Curative ??

  46. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  47. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  48. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  49. Obstructive Jaundice • Treatment • Traumatic stricture:- • by passed • Malignant stricture: - • resection with reconstruction by hepaticojejunostomy . • Sclerosingcholongitis: • Surgical excision • Per cuteneous dilation Bile Duct Stricture

  50. Obstructive Jaundice • Complications Of Obstructive Jaundice • Ascending cholangitis • Clotting disorders • Hepato-renal syndrome • Drug Metabolism • Impaired wound healing Be Aware Of life threatening Complications

More Related