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L17. Obstructive jaundice-1.pptx
- 1. Obstructive jaundice (1 hour) 13/05/2023MUHAS, Department of Surgery 1
- 2. Objectives By the endof this presentation, students should be able to: 1. Give an overview on obstructive jaundice, its aetiology and common causes in our setting. 2. Take a focused history and examine a patient presenting with obstructive jaundice. 3. Be familiar with common differentials of obstructive jaundice. 13/05/2023 MUHAS, Department of Surgery 2
- 3. Outline • Introduction • Aetiology •Clinical features • Investigations • Complications • Specific conditions (an overview) –Choledocholithiasis –Pancreatic cancer 13/05/2023 MUHAS, Department of Surgery 3
- 4. Introduction • Jaundice isthe yellowish pigmentation of the skin, the conjunctival membranes over the sclerae, and other mucous membranes caused by hyperbilirubinemia. • Jaundice is not a diagnosis • Total serum bilirubin values are normally 3.6 – 21.6 mmol/L (0.2-1.2 mg/dL). • Jaundice may not be clinically evident until levels are at least 54 mmol/L (3mg/dL). 13/05/2023 MUHAS, Department of Surgery 4
- 5. Introduction… • Surgical jaundiceis any jaundice amenable to surgical treatment. • Majority are due to extra-hepatic biliary obstruction. 13/05/2023 MUHAS, Department of Surgery 5
- 6. Overview on biliaryanatomy and bile physiology 13/05/2023 MUHAS, Department of Surgery 6
- 7. Aetiology Prehepatic causes Hemolysis, Gilbert’sdisease, Criggler-Najjar syndrome. Hepatic causes Hepatitis (viral, alcoholic, drug induced) Chronic hepatitis, liver cirrhosis, Dubin-Johnson syndrome. 13/05/2023 MUHAS, Department of Surgery 7
- 8. Aetiology… Posthepatic/Extrahepatic (Surgical jaundice) Common • Choledocholithiasis •Ca head of Pancreas • Malignant LNs at porta hepatis Uncommon • Ca ampulla of Vater • Chronic pancreatitis • Liver secondaries, cysts and abscesses. 13/05/2023 MUHAS, Department of Surgery 8
- 9. Aetiology… Rare • Benign strictures(iatrogenic, trauma) • Recurrent cholangitis • Mirrizzi’s syndrome • Primary sclerosing cholangitis • Ca of bile ducts (Klatskin tumour) • Biliary atresia (neonates) • Choledochal cyst (congenital) 13/05/2023 MUHAS, Department of Surgery 9
- 10. Clinical features • Jaundice –Onset - Sudden- Gall-stone obstruction - Gradual- Carcinoma – Progress - Relentless- Carcinoma, - Fluctuating- Stones, Ca Papilla • Pain : – Present- Gall stone. Usually colicky. Murphy’s sign – Moderate midepigastric, deep seated, radiating to the back or absent- Ca Bile duct, Ca Ampulla of Vater, Ca Head Pancreas (early) 13/05/2023 MUHAS, Department of Surgery 10
- 11. Clinical features… Murphy’s sign 13/05/2023MUHAS, Department of Surgery 11
- 12. Clinical features… • Fever& Chills: Cholangitis due to obstruction usually due to calculus • Pruritis: All forms of cholestatic jaundice • Weight Loss: Progressive loss e.g. in Ca Head pancreas • Stool: Pale, clay-coloured due to excess fat and absence of stercobilin • Urine: Dark due to excess bilirubin 13/05/2023 MUHAS, Department of Surgery 12
- 13. Clinical features… • Haemorrhage:Failure of absorption of Vit. K with impaired coagulation • Supraclavicular node: Virchow’s node indicates malignancy • Abdominal Scar: Previous surgery may suggest operative injury to bile duct • Hepatomegaly: Hard, nodular in metastases and hepatoma • Abdominal Mass: Suggests malignancy and may be associated with ascites • Diabetes: Sometimes precedes jaundice especially due to Ca head of pancreas. 13/05/2023 MUHAS, Department of Surgery 13
- 14. Clinical features… • GallBladder: May be palpable with Ca Head of pancreas. Non palpable with gall-stone obstruction (Courvoisier’s Law) Courvoisier’s law In the presence of jaundice, a palpable gallbladder is unlikely to be due to gallstone. More likely to be due to carcinoma eg. carcinoma head of pancreas 13/05/2023 MUHAS, Department of Surgery 14
- 15. Complications I. Ascending cholangitis •Charcot’s triad RUQ pain Fever Jaundice • Reynold’s pentad Charcot’s triad Hypotension Altered mental status Other complications II.Clotting disorders (Prolonged PT) III. Hepato-renal syndrome IV. Impaired wound healing V. Altered Drug metabolism (analgesics) Common bacteria in the biliary tract (KEEPS) Klebsiella Enterococcus E. coli, Enterobacter Proteus, Pseudomonas Serratia 13/05/2023 MUHAS, Department of Surgery 15
- 16. Hepatorenal syndrome (HRS) •HRS is one of the many potential causes of AKI in patients with acute of chronic liver disease. • Affected patients usually have portal HTN due to cirrhosis. 13/05/2023 MUHAS, Department of Surgery 16
- 17. Portal Hypertension Splanchnic vasodilation Activationof renin-angiotensin-aldosterone system Decreased effective circulatory volume Renal vasocontriction HEPATORENAL SYNDROME 13/05/2023 MUHAS, Department of Surgery 17
- 18. CHOLEDOCHOLITHIASIS • These stonesdo form primarily in common bile duct • Almost all primary CBD stones are pigment type (brown stones). • Associated with bile duct stasis and infection (bacteria) • Soft, easily crumble when manipulated • Associated with biliary stricture, papillary stenosis or sphincter of Oddi dysfunction. 13/05/2023 MUHAS, Department of Surgery 18
- 19. Types of CBDstones I. Primary stones: These stones are formed in the CBD or within intrahepatic ducts. They are multiple, pigment stones or often mixed stones Various causes are: 1. Infections of biliary tree and infestation-parasites such as clonorchiasis. 2. Congenital-Caroli's disease or choledochal cyst. 3. Biliary dyskinesia-defective pathophysiology of biliary tree. 4. Other causes-diabetes, malnutrition 13/05/2023 MUHAS, Department of Surgery 19
- 20. CBD STONES … II.Secondary CBD stones: These stones originate from gallbladder and stay in CBD-usually supraduodenal portion then get enlarged to attain large size over a period of time. • These stones can give rise to cholangitis. 13/05/2023 MUHAS, Department of Surgery 20
- 21. Mechanisms • Stasis-bacteria secretebacterial glucuronidase which causes deconjugation of bilirubin diglucuronide. • Bilirubin gets precipitated as calcium salt. 13/05/2023 MUHAS, Department of Surgery 21
- 22. Clinical presentation • Biliarycolic (10-25%) • Jaundice • Rigors • Upper quadrant pain • Gallstone pancreatitits • Gallstone ileus (0.3-0.5%) • Others: empyema gallbladder, liver abscess, gall bladder perforation with bile peritonitis. 13/05/2023 MUHAS, Department of Surgery 22
- 23. Choledocholithiasis 13/05/2023 MUHAS, Departmentof Surgery 23
- 24. Mirrizzi’s syndrome 13/05/2023 MUHAS, Departmentof Surgery 24
- 25. MIRIZZI SYNDROME • TypeI:Compression of CBD without lumen narrowing. • Type II:Compression of CBD with lumen narrowing. • Type III:Compression causing CBD wall necrosis. • Type IV: Stone ulcerating into CBD resulting in cholecystocholedochal fistula. 13/05/2023 MUHAS, Department of Surgery 25
- 26. Pancreatic cancer • M> F, average age: 50-70yrs Risk Factors • Increased age • Smoking: 2-5x increased risk, most clearly established risk factor • High fat/low fibre diets, heavy alcohol use • Obesity • DM, chronic pancreatitis • Partial gastrectomy, cholecystectomy • Chemicals: betanaphthylamine, benzidine • African descent. 13/05/2023 MUHAS, Department of Surgery 26
- 27. Pancreatic Ca… Clinical features •Head of the pancreas (70%) – Weight loss, obstructive jaundice, steatorrhoea, vague constant mid-epigastric pain (may radiate to back) – Painless jaundice, Courvoisier’s sign • Body or tail of pancreas (30%) – Tends to present later and usually inoperable – Weight loss, vague mid-epigastric pain – <10% jaundiced – Sudden onset DM. 13/05/2023 MUHAS, Department of Surgery 27
- 28. Summary • CBD stonesare common cause of surgical jaundice. • We should be able to diagnosed and treat all complications of obstructive jaundice. 13/05/2023 MUHAS, Department of Surgery 28
- 29. References • Manipal surgery,4thed. • Schwartz’s principles of surgery 11th edition • Current surgical therapy 12th edition 13/05/2023 MUHAS, Department of Surgery 29
Editor's Notes
- #2 It is not a diagnosis ,u need to find the cause of obstruction
- #12 (+)Murphy’s sign is an inspiratory arrest with deep palpation along the right subcostal area
- #18 Arterial vasodilatation in the splanchnic circulation, triggered by portal HTN, Plays a central role in hemodynamic changes and decline in renal function in HRS. There is increased production or activity of vasodilators, mainly in the Splanchnic circulation, with nitric oxide thought to be most important. There is progressive rise in cardiac output and fall in SVR with RAAS and sympathetic nervous system response to hypotension
- #25 Mirizzi syndrome