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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLI

A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS. BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery. General Data: A.M. 35 –years- old Female Binondo, Manila.

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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLI

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  1. A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery

  2. General Data: A.M. 35 –years- old Female Binondo, Manila

  3. Chief Complaint: Yellowish discoloration of the eyes

  4. HISTORY OF PRESENT ILLNESS One month PTC= =RUQ pain, colicky, moderate to severe, radiating to R scapular area =no fever, no yellowish discoloration of skin and sclerae =no consult, no meds

  5. HISTORY OF PRESENT ILLNESS One week PTC =persistence of colicky right upper quadrant pain =yellowish discoloration of skin and sclerae =(+) light colored stool =(+) consult, HBT- UTZ done: Choledocholithiasis, Cholecystolithiais Advised OR, and was scheduled for operation

  6. Past Medical History • No hypertension • No diabetes • No PTB • No previous hospitalization • No allergies to foods and drugs

  7. Family History • unremarkable

  8. Personal and Social History • Unremarkable • Occasional alcoholic beverage drinker

  9. Physical Examination • General Survey: • Conscious, coherent, not in respiratory distress • Vital Signs BP = 110/ 60 mmHg CR = 81 bpm RR = 20 cpm Temp: 37 degrees Celsius

  10. Physical Examination • Skin: yellowish coloration of skin • HEENT: -Pink palpebral conjuctivae, icteric sclerae, no CLAD, no TPC, no NAD, supple neck. • Chest: • Symmetrical chest expansion, no retractions, • CBS

  11. Physical Examination • Heart normal rate, regular rhythm, no murmur • Abdomen Flat, NABS, soft, with Direct Tenderness RUQ, no organomegaly.

  12. Physical Examination • Extremities: • Full and equal pulses, no deformities, no cyanosis DRE: -light colored stool

  13. Salient Features • 1.35/Female • 2. RUQ pain • 3. Yellowish discoloration of the eyes, skin • 4. Light colored stool • 5. UTZ result of Hepatobiliary Tree: dilated CBD, normal liver, portal vein and tributaries are unremarkable, intrahepatic ducts not dilated, with an intraluminal echogenic focus exibiting acoustic shadowing

  14. NON OBSTRUCTIVE OBSTRUCTIVE JAUNDICE INTRAHEPATIC EXTRAHEPATIC INTRADUCTAL COMPRESSION OF BILIARY TRACTS HEMOLYSIS HEPATOCELLULAR

  15. OBSTRUCTIVE EXTRAHEPATIC INTRAHEPATIC GB/CBD stones Pancreatic Ca Primary Biliary Cirrhosis Sclerosing Cholangitis Pattern Recognition (90-95%) RUQ pain Clinical Jaundice CBD dilatation

  16. Initial Impression

  17. Para clinical Diagnostic Procedure • Do I need to perform a Para clinical diagnostic procedure? “No”

  18. Pretreatment Diagosis

  19. Pre Treatment Diagnosis Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis

  20. GOALS OF TREATMENT • Resolution of obstruction • Prevention of complication

  21. Treatment Options Meta-analysis ofendoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ, Clayton et.al. University of Athens 2006

  22. Management • OPEN CBDE • CHOLECYSTECTOMY, IOC

  23. Preoperative Preparation • Informed consent • Provide psychosocial support • Optimize patient’s condition • NPO for 6 hours • Preparation of OR materials

  24. Operative technique • Patient supine under GA • Asepsis/Anti-sepsis • Sterile drapes placed • Right paramedian incision carried down from skin to subcutaneous tissue, fascia and peritoneum entered • Intraoperative findings noted

  25. Operative Technique • Cystic artery identified, ligated and cut • Cystic duct identified, isolated and tagged • Gallbladder removed. Intraoperative findings noted. • French 5 feeding tube inserted into the cystic duct, IOC done, results noted • CBD opened logitudinally and explored

  26. Operative Technique • T-tube inserted and anchored • Hemostasis • Correct sponge and instruments count • Layer by layer closure • DSD

  27. Operative Findings • Intraoperative findings noted • GB is distended with thickened walls measuring 10x4cm; on opening up, it contained multiple stone measuring 0.2-0.3cm, cystic duct measures 0.5cm in diameter; CBD measured 12mm in diameter; on IOC, there was a filling defect on the distal CBD, there was visualization of both intrahepatic ducts. On CBDE, 8mm primary stone was noted at the distal common bile duct. Pancreas was normal. Liver was noted to be cirrhotic.

  28. Postoperative Diagnosis Obstructive Jaundice Secondary to Choledocholithiasis Cholelithiasis Operation Done Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy

  29. Postoperative Management • Adequate analgesia • Monitoring of VS and hydration. • DAT • Adequate monitoring: complications • Patient was discharged on the 5th post operative day • Follow up after a week.

  30. Final Diagnosis • Obstructive Jaundice Secondary to Choledocholithiasis • Cholelithiasis • S/P Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy

  31. COURSE IN THE WARD • 1st Hospital Day • NPO • Adequate Antibiotic • Adequate Analgesia • DWC

  32. COURSE IN THE WARD • 2nd-3rd Hospital Day • GL- Soft diet • Adequate Antibiotic • Adequate Analgesia • DWC

  33. COURSE IN THE WARD • 4th Hospital Day • DAT • Adequate Antibiotic • Adequate Analgesia • DWC

  34. COURSE IN THE WARD • 5th Hospital Day • Patient discharged

  35. PREVENTION AND HEALTH PROMOTION • Advise given to patient regarding • Possible complications • Proper wound care • OPD follow up after 7 days for removal of sutures • Anticipate complications • Avoid Recurrence • Avoid infection

  36. SHARING OF INFORMATI0N

  37. Common Bile Duct Stones • 10% of patients who present for Cholecystectomy • definitive treatment is cholecystectomy and ductal clearance either through open CBDE, Lap CBDE, ERCP. • Manuevers include administration of glucagon and flushing of ductal system,dilatation of the distal CBD, balloon catheter, basket extraction.

  38. Overview to Patient Management • CBD stones can be discovered preoperatively, intraop, post-op. • Treatment options: • ERCP=/-S • Lap CBDE • Lap Chole + ERCP • Open CBDE • almost same success rate

  39. Completion CBDE • T tube placement: • decompression of the duct, incase of residual obstruction • access for ductal imaging postop • access for removal of stone • left as early as 4 days up to 6 weeks • complicatios: bile leaks, peritonitis

  40. Post Cholecystectomy CBDE Problems • Early Problems • bile duct injury: laceration, cystic duct stump leak, liver bed leak • bile duct obstruction: retained stone • biliary pancreatitis • Late Problems • stricture • postcholecystectomy syndrome • GERD

  41. Questions #1 (MCQ) Which of the following is the main chemical component of pigment stones? A. CholesterolB. Calcium bilirubinate C. Calcium carbonateD. Calcium phosphate E: Calcium oxalate

  42. Questions #2 (MCQ) What is the most commonly isolated bacteria in the common duct of patient with primary stone? A. Escherichia coli B. Pseudomonas aeruginosa C. Klebsiella sp. D. Salmonella typhii E. Corynebacterium sp.

  43. Questions #3 (MCQ) Which of the following is the best indication for preoperative ERCP in patients with gallstones? A. Gallstone pancreatitis B. Obstructive jaundice C. History of jaundice D. Increased alkaline phosphatase to twice normal E. 1.6 cm common bile duct dilatation

  44. Questions (MCR) Direction: Write “A” if 1, 2, and 3 are valid statements. “B” if only 1 and 3 are valid statements. “C” if only 2 and 4 are valid statements. “D” if only 4 is a valid statement. “E” if all are valid statements.

  45. Questions #4 (MCR) The following are drainage procedure after open/laparoscopic CBDE. 1. Sphincteroplasty 2. Choledochojeunostomy 3. Choledochoduodenostomy 4. Choledochotomy

  46. Questions #5 (MCR) Correct statement about biliary scintigraphy using technetium 99m- labeled derivatives of iminoacetic acid (HIDA) include:

  47. Questions #5 (MCR) 1. Nonvisualization of GB is strong evidence of cystic duct obstruction. 2. The isotope is cleared by Kupffer’s cells 3. The GB in a fasting subject is normally visualized within 60 minutes of the dye injection 4. The scan is the preferred initial step in identifying common duct stones

  48. Journal Appraisal • Evaluation of primary duct closure vs T-tube drainage following choledochotomy Marwah Sanjay, Singh Ishwar, Godara Rajesh, Sen Jyotsana, Marwah Nisha, Karwasra RKDepartments of Surgery, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, IndiaYear : 2004  |  Volume : 23  |  Issue : 6  |  Page : 227-228

  49. Objective • To assess the benefits and harms of primary closure versus routine T-tube drainage in open common bile duct exploration for common bile duct stones.

  50. Design: • Randomized Control Trial

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