Surgical Jaundice

Presented by : Nur Insyirah Abdullah 080100331

Jaundice

Jaundice is the yellowish pigmentation of the skin, the conjunctival membranes over the sclerae and other mucous membranes caused by hyperbilirubinemia

Total serum bilirubin values are normally 0.21.2mg/dL. Jaundice may not be clinically recognizable until levels are at least 3 mg/dL

Surgical Jaundice

Surgical jaundice is any jaundice amenable to surgical treatment. Majority are due to extrahepatic biliary obstruction (obstructive jaundice).

However not all obstructive jaundice is surgical jaundice and not all surgical jaundice is due to obstruction.

Bile is formed in the liver. It contains of cholesterol,bilirubin,bile acid and lethicin which aids in emulsifies fat. It then passes into the common hepatic duct,then carries into the gallbladder to be store.

Pathophysiology

In response to a meal,bile is release from gallbladder into the CBD.the CBD then passing through the ampulla of Vater into duodenum

Biliary obstruction refer to the blockage to any of the duct that carries the bile from the liver to the gallbladder (intrahepatic) or from the gallbladder to the duodenum (extrahepatic).

Obstructive jaundice

Posthepatic obstructive jaundice occurs because of obstruction of the extrahepatic biliary tree. Extrahepatic obstructive jaundice can be further subdivided into intrinsic (in the wall) , extrinsic (outside the wall) and intraluminal (in the lumen) causes.

Intraluminal

Causes of obstructive jaundice

Gallstones ,parasites Sclerosing cholangitis,cholangiocarcinoma, Mirizzi syndrome,benign stricture Portal lymphadenopathy Ampullary cancer

Intrinsic

Extrinsic

Pancreatic cancer
Duodenal cancer Chronic pancreatitis

Presentation

Jaudice

Abdominal pain
Pale stool Pruritus Tendency to bleed

Clinical approach

History

Physical examination
Investigation Management

History

Jaundice= intermittent or progressive and features of obstructive jaundice

Gallstone= pain related to gallstones

Itching Risk factors = viral hepatitis (blood tranfusion,tattoo,IVDU,sexual exposure) LOA & LOW = cholangiocarcinoma and pancreatic cancer or 2nd liver metastasis Previous biliary surgery and hx of IBD (sclerosing cholangitis)

Fhx,SocialHx, DrugHx

Physical examination

Jaundice= sclera,skin,mucous membrane Skin= scratch marks (pruritus) Stigmata of CLD Ascites Hepatomegaly

Splenomegaly
Palpable gallbladder (Courvoisier's law)

Investigation - lab

FBC
LFT

Alkaline phosphatase (ALP) elevated High total,conjugated bilirubin

Coagulation profile= prolonged PT (due to poor absorption of vitamin, high INR K>>>extrinsic factors 2,7,9,10) Urinalysis= bilirubin present, urobilinogen absent Renal profile= urea, electrolytes, creatinine

Investigation - imaging

Ultrasound may show dilated ducts and site of obstruction,gallstones in the bladder CT scan more sensitive

MRCP ( Magnetic Resonance CholangioPancreatography)

ERCP (Endoscopic Retrograde CholangioPancreatography) PTC (percutaneous transhepatic cholangiogram)

Management

Check PT,correct clotting problem with parenteral vit K,give mannitol and iv fluid to preent hepatorenal syndrome,prophylactic antibiotics

Then subsequent tx is according to the cause

The most common cause is gallstone

Choledocholithiasis

Explore duct at time of cholecystectomy (open or lap) Remove at ERCP

Traumatic stricture

By pass via Roux lop of intestine anastomosed to proximal dilated duct

Whipple's operation (pancreatico duodenectomy)

Carcinoma of the head of pancreas or ampulla of Vater

Cholangiocarcinoma

Stenting combined with radiotherapy

Choledochal cyst

Excision of cyst with Roux-en-Y choledochojejunostomy