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Surgical Jaundice

Surgical Jaundice . Supervised by Dr. Jamal Hamdi. Definition Of Jaundice. yellow pigmentation of skin, mucous membrane or sclera Jaundice clinically detected when serum bilirubin level ( 2.5 mg/dl) Normal serum bilirubin (0.2-1.0 mg/dl ) caused by an excess of bile

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Surgical Jaundice

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  1. Surgical Jaundice Supervised by Dr. Jamal Hamdi

  2. Definition Of Jaundice • yellow pigmentation of skin, mucous membrane or sclera • Jaundice clinically detected when serum • bilirubin level ( 2.5 mg/dl) • Normal serum bilirubin • (0.2-1.0 mg/dl ) • caused by an excess of bile • pigments in plasma • It is a symptom not a disease

  3. Bilirubin Metabolism Bilirubin is produced from the breakdown of haemoglobin in the reticuloendothelial system. 95% of the circulating bilirubin is unconjugated and bound to albumin .

  4. Bilirubin Metabolism Hepatic metabolism occurs in 3 phases: - Uptake - Conjugation - excretion RES

  5. Pathophysiology Of Hyperbilirubinemia • Over production by RES • Failure of hepatocellular uptake • Failure of conjugation or excretion • Obstruction of biliary excretion into intestine

  6. Classification Of Jaundice • Prehepatic: • RBC disorders • ( Hereditary spherocytosis , SCA) • Auto-immune ( Mismatched blood transfusion ) • Infective ( Sepsis , Malaria ) • Hepatic : • Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome ) • Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc ) Posthepatic (obstructed) surgical

  7. Etiology Of Obstructive Jaundice • Common: • Common bile duct stone. • Cancer head of pancreas

  8. Etiology Of Obstructive Jaundice • Less Common: • Ampullary carcinoma • Pancreatitis. • Mirrizi syndromes. • Sclorosingcholangitis. • Cholangiocarcinoma

  9. Approach To Jaundice Patient History Careful History is of very important value to guide the D\D toward the cause & the type of jaundice ( PreHepatic , Hepatic , PostHepatic )

  10. Approach To Jaundice Patient History Onset Gradual ? cirrhosis pancreatitis cancer Sudden ? CBD stone Hepatitis

  11. Approach To Jaundice Patient History Pattern Progressive? Pancreatic carcinoma Cholangiocarcinoma fluctuating ? CBD stone Ampullary carcinoma Hemolytic episodes

  12. Approach To Jaundice Patient History Pain Painful? CBD stone Pancreatic diseases painless? Malignancy

  13. Approach To Jaundice Patient History • Other symptoms of obstructive jaundice • Pruritis • Fatty dyspepsia • Steatorrhea • Dark urine , pale stool • Bleeding disorder

  14. Approach To Jaundice Patient History • RUQ pain , fever • Symptoms of anemia • Hx of SCD • G6PD deficiency ? Food related ? • Symptoms of malignancy • ( weight loss & anorexia )

  15. Approach To Jaundice Patient History Past Medical • Blood transfusion • Hx of drugs • Past Hx of surgery • Family Hx of jaundice & hemolytic disorders • Alcohol • Occupation & travel Past Surgical Hx Family Hx

  16. Approach To Jaundice Patient • Physical Examination General Appearance Stigmata of Chronic Liver Disease General Examination Cachexia Muscle Wasting Yellow Discoloration Palmarerythema clubbing . flapping tremor. duputrine’s contracture . Spider nevi gynecomastia caput medosa testicular atrophy Jaundice Scratch marks Pallor Vital Signs

  17. Approach To Jaundice Patient • Physical Examination Abdominal Discolration , scars ( collen’s , Grey Tuner ) RUQ pain Murphy sign Palpaple Gallbladder ( Courvoisier’s law ) Abdominal masses ( malignancy ) Hepatomegaly, splenomegaly , ascitis PR : color of stool . Abdominal Examination

  18. Obstructive Jaundice • Invistigation • Laboratory Exam • Imaging • Invasive

  19. Obstructive Jaundice • Invistigation • Laboratory Exam • Blood • LFT: Serum bilirubin (Direct / Indirect) , Albumin , ALT , AST , ALP, LDH , • CBC , Electrolyte , Amylase • Urine • Urine analysis • Stool • The investigations will differentiate hepatocellular and obstructive jaundice • In most of the cases

  20. Invistigation

  21. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • AXR • US • CT • MRI/MRCP • Invasive • ERCP • PTC • Operative cholangiogram • T-tube cholangiogram • Angiogram • Biopsy

  22. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • 1- The presence of gall stones 2- the thickened wall of the gallbladder in acute or chronic inflammation 3- The Diameter of CBD more than 7mm is suggestive of presence of stones • Ultrasounde • Is the most useful initial study for evaluation of intra/extrahepaticbiliary dilatation.

  23. Obstructive Jaundice • Invistigation • Imaging • Ultrasounde • Is the most useful initial study for evaluation of intra/extrahepaticbiliary dilatation.

  24. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Determine the specific causes and level of obstruction • CT scan can only image calcified stones CT Scan

  25. Obstructive Jaundice • Invistigation • Imaging CT Scan

  26. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Routine investigation-base-line & may • show specked calcification in the region of • pancreas. X-Ray

  27. Obstructive Jaundice • Invistigation • Imaging • Non-invasive • Magnatic resonance cholangiopancreatography (MRCP) • Sensitive noninvasive method of detecting biliary and pancreatic duct stones stricture or dilatations within the biliary system MRCP

  28. Obstructive Jaundice • Invistigation • Imaging • Invasive • Useful for lesion distal to the bifurcation of the hepatic ducts (diagnostic ) • ERCP has a (therapeutic) application because obstruction can potentially be relieved by the removal of stones , sphcterotomy and placement of stent and drains ERCP

  29. Obstructive Jaundice • Invistigation • Imaging ERCP

  30. Obstructive Jaundice • Invistigation • Imaging ERCP

  31. Obstructive Jaundice • Invistigation • Imaging • Invasive • Percutaneoustranshepaticcholangiogram (PTC ) • Useful for lesions proximal to common hepatic duct PTC

  32. Obstructive Jaundice • Treatment According To The Cause

  33. Obstructive Jaundice • Treatment Goal of Treatment • Relief of Obstruction • Prevent Complication • Prevent Recurrence

  34. Obstructive Jaundice • Treatment • Defined as stones in the CBD • intermittent obstruction of CBD • Predisposes to Cholangitis & Acute Pancreatitis • Elevated sr. bilirubin & Alk. Phos. • Evaluation By : U\S , ERCP , CT Jaundice caused by Gallstones

  35. Obstructive Jaundice • Treatment • Evaluation By : ERCP • Primary diagnostic and therapeutic modality • Sphincterotomy and stone extraction • Placement of stent if stone extraction unsuccessful • Mortality rate 1.5% • ERCP Jaundice caused by Gallstones

  36. Obstructive Jaundice • Treatment • Open CBD Exploration • Indications • Presence of multiple stones (more than 5) Stones > 1 cm • Multiple intra hepatic stones • Distal bile duct strictures • Failure of ERCP • Recurrence of CBD stones after sphincterotomy Jaundice caused by Gallstones

  37. Obstructive Jaundice • Treatment • CBD Exploration – Surgical Options • Common bile duct exploration with T-tube decompression • Choledochoduodenostomy • Transduodenalsphincterotomy and sphincterplasty • Roux-en-Y Choledochojejunostomy Jaundice caused by Gallstones

  38. Obstructive Jaundice • Treatment • At the time of diagnosis, 52% of all patients have distant disease • 26% have regional spread. •  The relative 1-year survival is only 24% • the overall 5-year survival rate for this disease is less than 5%.  Carcinoma Head Of Pancreas

  39. Obstructive Jaundice • Treatment Resectable Non Resectable Carcinoma Head Of Pancreas Surgical treatment Non surgical treatment (metal stents)

  40. Obstructive Jaundice • Treatment • resectability. ? • Resectable, unresectable ? •  experience and technical skill of the surgeon And overall health of the patient •  Typically, extrapancreatic disease precludes curative resection, and surgical treatment may be palliative at best.  Carcinoma Head Of Pancreas

  41. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas

  42. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor

  43. Obstructive Jaundice • Treatment • Non surgical treatment • Inoperable Patient :- • - Endoscopic expandable metallic stent • Bypassed By Hepatojejunostomy • ( Roux-en-Y) Carcinoma Head Of Pancreas

  44. Obstructive Jaundice • Treatment • surgical treatment • Operable Patient :- • Whipple’s Operation • Pancreaticoduodenectomy • Curative ? Carcinoma Head Of Pancreas

  45. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Is It Curative ??

  46. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  47. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  48. Obstructive Jaundice • Treatment Carcinoma Head Of Pancreas Whipple’s Operation

  49. Obstructive Jaundice • Treatment • Traumatic stricture:- • by passed • Malignant stricture: - • resection with reconstruction by hepaticojejunostomy . • Sclerosingcholongitis: • Surgical excision • Per cuteneous dilation Bile Duct Stricture

  50. Obstructive Jaundice • Complications Of Obstructive Jaundice • Ascending cholangitis • Clotting disorders • Hepato-renal syndrome • Drug Metabolism • Impaired wound healing Be Aware Of life threatening Complications

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