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

pigments in plasma• It is a symptom not a

disease

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 .

Bilirubin Metabolism

RES

Hepatic metabolism occurs in 3 phases:

- Uptake - Conjugation - excretion

Pathophysiology Of Hyperbilirubinemia

•Over production by RES

•Failure of hepatocellular uptake

•Failure of conjugation or excretion

•Obstruction of biliary excretion into intestine

Classification Of Jaundice

Posthepatic(obstructed)

surgical

Hepatic :

•Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome )

•Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc )

Prehepatic:•RBC disorders• ( Hereditary spherocytosis , SCA) •Auto-immune ( Mismatched blood transfusion ) •Infective ( Sepsis , Malaria )

Etiology Of Obstructive Jaundice

Common:

• Common bile duct stone.

• Cancer head of pancreas

Etiology Of Obstructive Jaundice

Less Common:

•Ampullary carcinoma

• Pancreatitis.

•Mirrizi syndromes.

•Sclorosing cholangitis.

•Cholangiocarcinoma

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 )

Approach To Jaundice Patient

History

Onset

Sudden ?

CBD stone

Hepatitis

Gradual ?

cirrhosis pancreatitis

cancer

Approach To Jaundice Patient

History

Pattern

fluctuating ? CBD stone

Ampullary carcinoma Hemolytic episodes

Progressive? Pancreatic carcinoma

Cholangiocarcinoma

Approach To Jaundice Patient

History

Pain

painless?

Malignancy

Painful? CBD stone

Pancreatic diseases

Approach To Jaundice Patient

History

Pruritis

Fatty dyspepsia

Steatorrhea

Dark urine , pale stool

Bleeding disorder

Other symptoms of obstructive jaundice

Approach To Jaundice Patient

History

RUQ pain , fever

Symptoms of anemia

Hx of SCD

G6PD deficiency ? Food related ?

Symptoms of malignancy

( weight loss & anorexia )

Approach To Jaundice Patient

History

Blood transfusion

Hx of drugs

Past Hx of surgery

Family Hx of jaundice & hemolytic disorders

Alcohol

Occupation & travel

Past Medical

Family Hx

Past Surgical Hx

Approach To Jaundice Patient

Physical Examination

General Appearance

Cachexia

Muscle Wasting

Yellow Discoloration

Stigmata of Chronic Liver

Disease

Palmar erythema clubbing .

flapping tremor. duputrine’s

contracture . Spider nevi

gynecomastia caput medosa

testicular atrophy

General Examination

Jaundice

Scratch marks

Pallor

Vital Signs

Approach To Jaundice Patient

Physical ExaminationAbdominal 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

Obstructive Jaundice

Invistigation

InvasiveImagingLaboratory

Exam

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

Obstruction Hepatitis CirrhosisBilirubin

Alk phos / /

ALT/AST/ /

gGT /

PT (INR)

Invistigation

Obstructive Jaundice

Invistigation

ImagingNon-invasive

AXR

US

CT

MRI/MRCP

Invasive

ERCP

PTC

Operative cholangiogram

T-tube cholangiogram

Angiogram

Biopsy

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

Is the most useful initial study for

evaluation of intra/extrahepatic biliary dilatation.

Ultrasounde

Obstructive Jaundice

Invistigation

Imaging

Is the most useful initial study for

evaluation of intra/extrahepatic biliary dilatation.

Ultrasounde

Obstructive Jaundice

Invistigation

Imaging

Non-invasive

Determine the specific causes and level of obstruction

CT scan can only image calcified stones

CT Scan

Obstructive Jaundice

Invistigation

Imaging

CT Scan

Obstructive Jaundice

Invistigation

Imaging

Non-invasive

Routine investigation-base-line & may

show specked calcification in the region of

pancreas.

X-Ray

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

Obstructive Jaundice

Invistigation

ImagingInvasive

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

Obstructive Jaundice

Invistigation

Imaging

ERCP

Obstructive Jaundice

Invistigation

Imaging

ERCP

Obstructive Jaundice

Invistigation

ImagingInvasive

Percutaneous transhepatic cholangiogram (PTC )

Useful for lesions proximal to common hepatic duct

PTC

Obstructive Jaundice

Treatment

According To The Cause

Obstructive Jaundice

Treatment

• Relief of Obstruction

• Prevent Complication

• Prevent Recurrence

Goal of Treatment

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

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

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

Obstructive Jaundice

Treatment

CBD Exploration – Surgical Options

•Common bile duct exploration with T-tube decompression

• Choledochoduodenostomy

• Transduodenal sphincterotomy and sphincterplasty

•Roux-en-Y Choledocho jejunostomy

Jaundice caused by Gallstones

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

Obstructive Jaundice

Treatment

Surgical treatment

Carcinoma Head Of Pancreas

Non surgical treatment

(metal stents)

Non Resectabl

e

Resectable

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

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Non-resectable pancreatic head

tumor

Obstructive Jaundice

Treatment

Non surgical treatment

Inoperable Patient :-

- Endoscopic expandable metallic stent

- Bypassed By Hepatojejunostomy

( Roux-en-Y)

 

Carcinoma Head Of Pancreas

Obstructive Jaundice

Treatment

surgical treatment

Operable Patient :-

Whipple’s Operation

Pancreaticoduodenectomy

Curative ?

 

Carcinoma Head Of Pancreas

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Is It Curative ??

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Whipple’s Operation

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Whipple’s Operation

Obstructive Jaundice

Treatment

Carcinoma Head Of Pancreas

Whipple’s Operation

Traumatic stricture:-

by passed

Malignant stricture: -

resection with reconstruction by hepatico jejunostomy .

Sclerosing cholongitis:

Surgical excision

Per cuteneous dilation

Obstructive Jaundice

Treatment

Bile Duct Stricture

•Ascending cholangitis

•Clotting disorders

•Hepato-renal syndrome

•Drug Metabolism

•Impaired wound healing

Obstructive Jaundice

Complications Of Obstructive

Jaundice

Be Aware Of life threatening Complications

References

•Bailey & Love short practice of surgery

•Clinical Surgery By : A.Cuschieri

•Lecture Note : General Surgery 11th Edition

•http://www.radiologyassistant.nl/en/43848b63def9d

•http://emedicine.medscape.com/

Done By

•Abbas A. Damanhori

•Abdulmajeed Fairaq

•Abdulrahman R. Nazer

•Hassan Abu Rokbah