Surgical Jaundice

KEHINDE Adeleke
 Outline of Discussion
Definition
Epidemiology
Classification
Pathophysiology
Clinical evaluation
Management
 Definition
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 0.2-1.2
mg/dL. Jaundice may not be clinically
recognizable until levels are at least 3 mg/dL.
Jaundice is not a diagnosis.
Surgical jaundice is any jaundice amenable to
surgical treatment. Majority are due to
extrahepatic biliary obstruction.
Not all obstructive jaundice is surgical jaundice
e.g hepatitis and not all surgical jaundice is due
to obstruction e.g congenital spherocytosis
 Epidemiology
RACE
The racial predilection depends on the
cause of the biliary obstruction.
Gallstones are the most common cause of
biliary obstruction.
Persons of Hispanic origin and Northern
Europeans have a higher risk of gallstones
compared to people from Asia and Africa.
Native Americans (particularly Pima
Indians)have a lifetime chance of
developing gallstones as high as 80%.
SEX
Women are much more likely to
develop gallstones than men.
This increased risk is likely caused by
the effect of estrogen on the liver,
causing it to remove more cholesterol
from the blood and diverting it into
the bile.
 Pathophysiology
To better understand these disorders, a brief discussion
of the normal structure and function of the biliary tree is
needed.
Bile is the exocrine secretion of the liver and is produced
continuously by hepatocytes. It contains cholesterol and
waste products, such as bilirubin and bile salts, which aid
in the digestion of fats. Half the bile produced runs
directly from the liver into the duodenum via a system of
ducts, ultimately draining into the common bile duct
(CBD). The remaining 50% is stored in the gallbladder.
In response to a meal, this bile is released from the
gallbladder via the cystic duct, which joins the hepatic
ducts from the liver to form the CBD. The CBD courses
through the head of the pancreas for approximately 2 cm
before passing through the ampulla of Vater into the
duodenum
 Biliary obstruction refers to the blockage of
any duct that carries bile from the liver to
the gallbladder(intrahepatic) or from the
gallbladder to the small
intestine(extrahepatic).
This can occur at various levels within the
biliary system.
The major signs and symptoms of biliary
obstruction result directly from the failure of
bile to reach its proper destination.
The failure of biliary flow may be due to
biliary obstruction by mechanical means or
by metabolic factors in the hepatic cells.
 For the sake of simplicity, the primary
focus of this presentation is mechanical
causes of biliary obstruction, further
separating them into intrahepatic and
extrahepatic causes.
The discussion of intracellular/metabolic
causes of cholestasis is very complex,
the pathogenesis of which is not always
clearly defined. Therefore, these causes
are mentioned but are not discussed in
detail.
 Intrahepatic cholestasis generally occurs at
the level of the hepatocyte or biliary
canalicular membrane. Causes include
hepatocellular disease (eg, viral hepatitis,
drug-induced hepatitis), drug-induced
cholestasis, biliary cirrhosis, and alcoholic
liver disease.
In hepatocellular disease, interference in
the 3 major steps of bilirubin metabolism,
ie, uptake, conjugation, and excretion,
usually occurs. Excretion is the rate-limiting
step and is usually impaired to the greatest
extent. As a result, conjugated bilirubin
predominates in the serum.
 Extrahepatic obstruction to the flow of bile
may occur within the ducts or secondary to
external compression. Overall, gallstones
are the most common cause of biliary
obstruction. Other causes of blockage
within the ducts include malignancy,
infection, and biliary cirrhosis.
External compression of the ducts may
occur secondary to inflammation (eg,
pancreatitis) and malignancy. Regardless
of the cause, the physical obstruction
causes a predominantly conjugated
hyperbilirubinemia
 The lack of bilirubin in the intestinal
tract is responsible for the pale stools
typically associated with biliary
obstruction.
The cause of itching (pruritus)
associated with biliary obstruction is
not clear. Some believe it may be
related to the accumulation of bile
acids in the skin. Others suggest it
may be related to the release of
endogenous opioids.
 Causes

Causes of biliary obstruction can be

separated into intrahepatic and
extrahepatic.
intrahepatic causes are most
commonly hepatitis and cirrhosis,
Drugs e.g thiazides,
chlorpromazine,augmentin etc
Extrahepatic causes may be further
subdivided into intrinsic, intraluminal
and extrinsic
 Stone disease is the most common
cause of obstructive jaundice.Larger
stones can become lodged in the CBD
and cause complete obstruction, with
increased intraductal pressure
throughout the biliary tree.
Mirizzi syndrome is the presence of a
stone impacted in the cystic duct or the
gallbladder neck, causing inflammation
and external compression of the
common hepatic duct and thus biliary
obstruction.
 Of biliary strictures, 95% are due to
surgical trauma and 5% are due to
external injury to the abdomen or
pancreatitis or erosion of the duct by
a gallstone.
A tear in the duct causes bile leakage
and predisposes the patient to a
localized infection. In turn, this
accentuates scar formation and the
ultimate development of a fibrous
stricture.
 Of parasitic causes, adult Ascaris
lumbricoides can migrate from the
intestine up through the bile ducts,
thereby obstructing the extrahepatic
ducts.
Eggs of certain liver flukes (eg,
Clonorchis sinensis, Fasciola hepatica)
can obstruct the smaller bile ducts
within the liver, resulting in
intraductal cholestasis. This is more
common in Asian countries
 PSC is most common in men aged 20-
40 years, and the cause is unknown.
PSC is characterized by diffuse
inflammation of the biliary tract,
causing fibrosis and stricture of the
biliary system. It generally manifests
as a progressive obstructive jaundice
and is most readily diagnosed based
on findings from endoscopic
retrograde cholangiopancreatography
(ERCP).
 AIDS-related cholangiopathy manifests
as abdominal pain and elevated liver
function test results, suggesting
obstruction. The etiology of this
disorder in patients who are HIV-
positive is thought to be infectious
(cytomegalovirus, Cryptosporidium
species, and microsporidia have been
implicated). Direct cholangiography
often reveals abnormal findings in the
intrahepatic and extrahepatic ducts
that may closely resemble PSC.
 Biliary tuberculosis is extremely rare.
Histopathologic evidence of caseating
granulomatous inflammation with bile
cytology revealing M tuberculosis is
confirmatory. Polymerase chain reaction
is useful to expedite the diagnosis if
biliary tuberculosis is being considered
 Biliary obstruction associated with pancreatitis
is observed most commonly in patients with
dilated pancreatic ducts due to either
inflammation with fibrosis of the pancreas or a
pseudocyst.
Notably, intravenous feedings predispose
patients to bile stasis and a clinical picture of
obstructive jaundice. Consider this in the
evaluation of biliary obstruction.
Sump syndrome is an uncommon complication
of a side-to-side choledochoduodenostomy in
which food, stones, or other debris accumulate
in the CBD and thereby obstruct normal biliary
drainage
 Clinical Evaluation
History
Examination
Investigations
Treatment
 History
Patients commonly complain of pale stools, dark urine, yellowness of
the eye, and pruritus.
The following considerations are important:
Patients' age
Jaundice (duration ,onset, progresion,
Associated symptoms:
the presence of abdominal pain( location and characteristics of the
pain)
The presence of systemic symptoms (eg, fever, weight loss)
Symptoms of gastric stasis (eg, early satiety, vomiting, belching)
Change in bpwel habit:
History of anemia
Previous malignancy
Known gallstone disease
Gastrointestinal bleeding
Hepatitis
Previous biliary surgery
Diabetes or diarrhea of recent onset
Also, explore the use of alcohol, drugs, and medications
 Physical

Upon physical examination, the patient may display signs of

jaundice (sclera icterus).
When the abdomen is examined, the gallbladder may be
palpable (Courvoisier sign). This may be associated with
underlying pancreatic malignancy.
Also, look for signs of weight loss, adenopathies, and occult
blood in the stool, suggesting a neoplastic lesion.
Note the presence or absence of ascites and collateral
circulation associated with cirrhosis.
A high fever and chills suggest a coexisting cholangitis.
Abdominal pain may be misleading; some patients with CBD
calculi have painless jaundice, whereas some patients with
hepatitis have distressing pain in the right upper quadrant.
Malignancy is more commonly associated with the absence of
pain and tenderness during the physical examination.
Xanthomata are associated with primary biliary cirrhosis (PBC).
Excoriations suggest prolonged cholestasis or high-grade biliary
obstruction
 Lab studies
Basic
FBC+ Blood film: aneamia,
infection,Hgbpathy
Serum E/U/Cr
Urinalysis : bilirubin present,
urobilinogen absent
Stool for ocult blood: ca ampula
Stool mcs for ova and parasites
Clotting profile: PT deranged
Hepatitis serology: HbsAg, HCV
pptk
LFT: see next slide
 Imaging
Plain radiographs are of limited utility to
help detect abnormalities in the biliary
system
Ultrasonography (USS):USS is the
procedure of choice for the initial
evaluation of cholestasis and for helping
differentiate extrahepatic from intrahepatic
causes of jaundice. Extrahepatic
obstruction is suggested by the presence of
dilated bile ducts, but the presence of
normal bile ducts does not exclude
obstruction that may be new or
intermittent.
 Traditional computed tomography (CT)
scan is usually considered more
accurate than US for helping
determine the specific cause and level
of obstruction.
Percutaneous transhepatic
cholangiogram: done esp if the
intrahepatic duct is dilated, outline the
biliary tree, locates stones and is
therapeutic for stent placement and
stone retrieval.
 ERCP is an outpatient procedure that
combines endoscopic and radiologic
modalities to visualize both the biliary
and pancreatic duct systems.
Endoscopic ultrasound (EUS) combines
endoscopy and US to provide remarkably
detailed images of the pancreas and
biliary tree. It uses higher-frequency
ultrasonic waves compared to traditional
US (3.5 MHz vs 20 MHz) and allows
diagnostic tissue sampling via EUS-guided
fine-needle aspiration (EUS-FNA)
 Magnetic resonance
cholangiopancreatography (MRCP) is
a noninvasive way to visualize the
hepatobiliary tree.
MRCP provides a sensitive
noninvasive method of detecting
biliary and pancreatic duct stones,
strictures, or dilatations within the
biliary system. It is also sensitive for
helping detect cancer.
 Treatment
Medical care:Treatment of the
underlying cause is the objective of
the medical treatment of biliary
obstruction. Do not subject patients
to surgery until the diagnosis is clear.
In cases of cholelithiasis in which
either the patient refuses surgery or
surgical intervention is not
appropriate give
 Ursodeoxycholic acid (10 mg/kg/d) works to
reduce biliary secretion of cholesterol. In turn,
this decreases the cholesterol saturation of bile.
Extracorporeal shock-wave lithotripsy may be
used as an adjunct to oral dissolution therapy. By
increasing the surface-to-volume ratio of the
stones, it both enhances dissolution of stones and
makes clearing the smaller fragments easier.
Contraindications include complications of
gallstone disease (eg, cholecystitis,
choledocholelithiasis, biliary pancreatitis),
pregnancy, and coagulopathy or anticoagulant
medications (ie, because of the risk of hematoma
formation).
 Bile acidbinding resins,
cholestyramine (4 g) or colestipol (5 g),
dissolved in water or juice 3 times a
day may be useful in the symptomatic
treatment of pruritus associated with
biliary obstruction.
VIT ADEK SUPPLEMENTS
Antihistamines may be used for the
symptomatic treatment of pruritus,
particularly as a sedative at night.
 Discontinuation of medications that
may be causing or exacerbating
cholestasis and/or biliary obstruction
often leads to full recovery. Similarly,
appropriate treatment of infections
(eg, viral, bacterial, parasitic) is
indicated.
 SURGERY..Preop care
The following are problems of a
jaundiced ptx and all must be taken
care of before surgery
Infection due to biliary stasis
Uncontrolled bleeding due to vit k def
Liver glycogen depletion
Dehydration
Hepatorenal syndrome
 Therefore;
Fluid resuscitation using dextrose alternate
with Saline. Encourage oral rehydration as well
Give broad spectrum antibiotics at induction of
anaesthesia to cover for G+,G- and anaerobes
Bowel prep
IM VitK 10mg daily until PT/PPTK
normlises( start 5days preop)
Monitor UO, catheterize night before surgery
You may consider given mannitol preop,intraop
and post op for diuresis to prevent hepatorenal
syndrome
 surgery
the need for surgical intervention depends
on the cause of biliary obstruction.
Cholecystectomy is the recommended
treatment in cases of choledocholithiasis .
(open or lap)
Open cholecystectomy is relatively safe,
with a mortality rate of 0.1-0.5 %.
Laparoscopic cholecystectomy remains the
treatment of choice for symptomatic
gallstones, partially because of the shorter
recovery period, decreased postoperative
discomfort, and improved cosmetic result.
 Ca head of pancres
Early stage: whipples operation, pancreatoduodenectomy+
pancreticojejunostomy+ gastrojejunostomy+ cholecystojejunostomy

Late surgey: bypass surgery

Cholangiocarcinoma:
hepatodochojejunostomy
Cancer ampulla of vater: whipples
operation
Chronic pancreatitis: subduodenal
exploration, sphincterectomy, insertion of
stent
Liver transplantation may be considered
in appropriate patients.
 Prevention
In patients with risk factors for
developing any of the conditions that
lead to biliary obstruction, awareness of
the signs and symptoms can improve
chances for early diagnosis and
improved outcome.
Diet: Reduce intake of saturated fats,
High intake of fiber has been linked to a
lower risk for gallstones.
Gradual and modest weight reduction
may be of value in patients who are at
risk.
 Activity:Regular exercise may reduce
the risk of gallstones and gallstone
complications
Estrogens cause an increase in the risk
for formation of gallstones and may
need to be avoided in patients with
known gallstones or a strong family
history of stone disease.
 Complications

The complications of cholestasis are

proportional to the duration and
intensity of the jaundice.
High-grade biliary obstruction begins
to cause cell damage after
approximately 1 month and, if
unrelieved, may lead to secondary
biliary cirrhosis.
 Acute cholangitis is another complication
associated with obstruction of the biliary
tract and is the most common
complication of a stricture, most often at
the level of the CBD. Bile normally is
sterile. In the presence of obstruction to
flow, stasis favors colonization and
multiplication of bacteria within the bile.
Concomitant increased intraductal
pressure can lead to the reflux of biliary
contents and bacteremia, which can
cause septic shock and death.
 Biliary colic that recurs at any point after a
cholecystectomy should prompt evaluation for possible
choledocholithiasis.
Failure of bile salts to reach the intestine results in fat
malabsorption with steatorrhea. In addition, the fat-
soluble vitamins A, D, E, and K are not absorbed,
resulting in vitamin deficiencies.
Disordered hemostasis with an abnormally prolonged PT
may further complicate the course of these patients.
Cholestyramine and colestipol, used to treat pruritus,
bind to bile salts and can exacerbate these vitamin
deficiencies.
Persistent cholestasis from any cause may be
associated with deposits of cholesterol in the skin
(cutaneous xanthomatosis) and, occasionally, in bones
and peripheral nerves.
 Conclusion
There are certain signs and symptoms common to all
jaundiced patients (yellow skin, itching).
Specific items from the history and physical examination
along with blood work can help the clinician classify jaundice
into obstructive and nonobstructive jaundice.
Surgical or other mechanical intervention almost exclusively
is restricted to cases of obstructive (posthepatic) jaundice.
Imaging evaluation of the gallbladder and biliary system
plays an important role in the evaluation of obstructive
jaundice by locating the site and disclosing the nature of the
obstruction.
Ultrasound imaging usually is the first step for suspected
biliary stone disease.
The physicians level of suspicion about benign versus
malignant causes of obstructive jaundice will lead to different
radiologic tests and interventions.
Treatment is tailored to the cause of obstruction.
Thank you