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Surgical Jaundice

Surgical Jaundice. Supervised by: Dr:Bager. Presented by: Shurouq. Objectives :-. Definition . Bilirubin Pathophysiology Classefication of jaundice Causes Approach a jaundice pt Management. Definition :-.

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Surgical Jaundice

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  1. Surgical Jaundice Supervised by: Dr:Bager Presented by: Shurouq

  2. Objectives:- • Definition . • Bilirubin Pathophysiology • Classefication of jaundice • Causes • Approach a jaundice pt • Management

  3. Definition:- -Jaundice ( hyperbilirubinemia ) is a yellowish discoloration of the skin & sclera due to accumulation of the pigment bilirubin in the blood & tissue. -Bilirubin level has to exceeds 35-40 Mmol/L before jaundice is clinically apparent.

  4. Bilirubin Pathophysiology

  5. Classefication:- • Prehepatic jaundice (hemolytic jaundice = acholuric jaundice) • Hepatic jaundice ( disturbed conjugation or uptake) . • Post-hepatic jaundice (disturbed excretion )= surgical/ obstructive.

  6. Causes:- • 1- prehepatic Jaundice:- (hemolytic/acholuric) • Hereditary spherosytosis • Hereditary non-spherosytosis anemias • Sickle cell anemia • Thalasemia • Acquired hemolytic anemia • Incompatible blood transfusion • Sever sepsis • Drugs(chloropromazine,paracetamol,methyldopa,repeated exposure to halothane)

  7. 2) Hepatic Jaundice:- • Viral hepatitis • Hepatotoxins • Cirrhosis • Familial neonatal hyperbilirubinemia • Gilbert’s familial hyperbilirubinemia • Criglar-Najjar’s familial jaundice • Dubin-jhonson syndrom

  8. 3)Post-hepatic Jaundice:- • -Intrahepatic(without mechanical obstruction): • Cirrhosis. • Viral (chronic active hepatitis). • Certain drugs (methyltestosteron). • Primary biliary cirrhosis. • Parentral or enteric feeding with synthetic nutrition.

  9. -Extrahepatic(surgical-obstructive): • Intraductal>>> gall stones , foreign body (broken T-tube , parasites (hydatid , liver flukes). • Wall>>> congenital atresia , traumatic stricture , sclerosing cholangitis , tumor of bile duct . • Extraductal>>> pancreatic head cancer , ampullary cancer , pancreatitis , L.N metastasis . • N.B>>>>>> commonest in surgical jaundice are • gall stones & pancreatic carcinoma

  10. How to approach a jaundiced patient ?

  11. 1) History:- • Personal data>>> age, sex, occupation . • HPI>>> yellow discoloration of skin and sclera , abdominal pain (details) , fever , nausea , vomiting , chills , dark urine , pale stool ,itching , diarrhea , steatorrhea , contact with viral hepatitis patients. • Hx of blood transfusion. • PMHx , PSHx , Medications • FHx of anemia , splenectomy or gall stones

  12. 2) Examination:- • General condition of patient & color. • Vitals. • Hand(clubbing , palmar errythema , duputeryn contractures , flapping tremors>>liver stigmata) • Face & neck >>jaundice , pallor ,L.N • Chest>>spider nevi , gynecomastia • Genetalia>>>testicular atrophy • Lower limbs >>> edema

  13. -Abdominal Ex:- • Inspection>>>scars , distended veins , diverted umbilicus , pigmentations • Palpation>>> tenderness, masses , liver , spleen & gallbladder (murphy’s) . • Percussion>>> ascitis • Auscultation>> venous hums

  14. 3) Investigations:- • A) LAB:- • CBC>> Hb , WBC , PLT. • Chemistry>> electrolytes, albumin,haptoglobin LFT(transaminases.ALP.GGT.5-Nucleotidase) , Bilirubin , Amylase ,BUN. • Coagulation profile , pt , ptt • Urine & Stool. • Serology >> hepatitis , tumor markers , kazoni test

  15. B) Imaging:- • x-ray: - galls tones 10% • - gas in biliary tree • 2. U/S (1st line): • -intra/extra hepatic ducts • - gall bladder • -CBD • -pancrease • -liver parynchyma

  16. 3. CT: better reolution than U/S in: .demonstrating pancreatic lesions .obese pt .intrahepatic lesions(tumor,abcess,cyst) .pt with excess bowel gas shadow 4. ERCP/MRCP(if intrahepatic ducts are not dilated) PTC(if intrahepatic ducts are dilated)

  17. 4.PTC: • If dilated intrahepatic ducts on ct • ideal for demonstrating anatomy above extrahepatic obstruction • Contraindications:- • -coagulopathy,prolonged pt & ptt , plt below 40,000 • -peri/intra hepatic sepsis • -ascitis • -disease of right lower lung or pleura • Complications:- • -bile peritonitis -bilothorax -pneumothorax • -sepsis -hemobilia -bleeding

  18. 5.ERCP/MRCP:- • If no dilated intrahepatic ducts on ct • Visualize >>>upper GIT , ampullary region , biliary & pancreatic ducts • Complications:- • -traumatic pancreatitis • -biliary sepsis • 6.HIDA(unreliable if bilirubin more than 20 mg/dl). • 7.Liver Bx

  19. 4) Management:- • -It includes:- • Establishing the cause of jaundice • Assesment of patient general condition • Staging patient with tumor • Appropriate treatment which maybe surgical, endoscopic , radiological

  20. **Preoperative management:- -includes:- 1-correction of metabolic abnormalities 2-improvement of general condition 3-institution of general measures designed to minimize the incidence of complications assosciated with prolonged or sever cholestasis (infection , renal failure , Liver failure , fluid & electrolytes abnormalities )

  21. Drugs & anasthetics agents metabolism & conjugation • Hypokalemia • Viral screen • Prophylactic Antibiotics • Coagulation disorder (prolonged PT)>>I.M phytomenadione 10-20 mg • Renal failure>>adequate hydration & preoperative induction of natriuresis / diuresis • (I.V 5% dextrose/12-24 h prior to surgurey – followed by osmotic diuretic (mannitol) or loop diuretic (furosemide) I.V at time of induction

  22. Pt undergoing surgurey>>>catheterization & measure urine output hourly • Liver failure in pt with preexisting chronic hepatocelullar disease or with complete large duct obstruction • -if jaundice sever> 150Mmol/L or pt with signs of impending liver failure >>period of decompression before surgurey is indicated • -other prophylactic measures against encephalopathy includes correction of hypokalemia , restricted use of sedatives , hypnotics & potent analgesics & prompt ttt of infections.

  23. Treatment of some conditions • Gall stone with a CBD stone • Pancreatic carcinoma • Cholangitis • Bile duct stricture

  24. 1)Gall stone with a CBD stone:- -ERCP for CBD stone , 1-2 days after proceed for choecystectomy 2)Benign traumatic stricture:- Damaged area should be bypasses & choledojejunostomy is done (Roux-en-Y).

  25. 3)pancreatic cancer:- a)Resectional surgurey>>whipple’s operation b)Palliative surgurey>>aim to relieve ..biliary obstruction& duodenal obstruction  endoscopic or radiologic stenting(biliary bypass & gastrojejunostomy) .. Painceliac plexus block , splanchnicectomy c) Palliative therapy d) Chemotherapy / radiotherapy .

  26. 4)Cholangitis:- -resuscitation >> I.V fluids , blood culture ,systemic AB -endoscopic decompression (sphincterotomy& calculi extraction) / temporary stenting for drainage -surgical exploration with ductal clearance and T-tube insertion

  27. THANQ

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