Obstructive jaundice

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By: pradhan_sridhar (37 month(s) ago)

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OBSTRUCTIVE JAUNDICE : 

Dr. Srinivas Asst. professor Dept. of Surgery OBSTRUCTIVE JAUNDICE

Obstructive jaundice : 

Definition : Is a condition characterized by Yellow discoloration of the skin , sclera & mucous membrane as a result of an elevated Sr. Bilirubin conc. due to an obstructive cause. Obstructive jaundice

Classification of obstructive jaundice : 

Type I : complete obstruction Tumors : Ca. head of Pancreas Ligation of the CBD Cholangio carcinoma Parenchymal Liver diseases Classification of obstructive jaundice

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Type II : Intermittent obstruction Choledocholithiasis Periampullary tumor Duodenal diverticula Choledochal Cyst Papillomas of the bile duct Intra biliary parasites Hemobilia

TYPE III : Chronic incomplete obstruction : 

Strictures of the CBD Congenital Traumatic Sclerosing cholangitis Post radiotherapy Stenosed biliary enteric anastamosis Cystic fibrosis Chronic pancreatitis Stenosis of the Sphincter of Oddi TYPE III : Chronic incomplete obstruction ERCP showing distal common bile duct stricture with proximal dilation

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TYPE IV : Segmental Obstruction Traumatic Hepatodocholithiasis Sclerosing cholangitis Cholangio carcinoma

PATHOPHYSIOLOGY OF OBSTRUCTION : 

Alterations in – Systemic and renal hemodynamics – Hepatic function – Hemostatic mechanism – Gastrointestinal barrier – Immune function – Wound healing • Protein synthesis, • Reticulo-endothelial function • Hepatic metabolism PATHOPHYSIOLOGY OF OBSTRUCTION

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Coagulation system Prolonged bile duct obstruction leads to significant defects in clotting factors Before surgery these defects should be corrected by Fresh frozen plasma and Vitamin K Even if there is no measurable coagulation dysfunction Vitamin K should be given to all patients with obstructive jaundice

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ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile

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ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile X

Abnormal LFTs : 

Abnormal LFTs

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• Fever, persistent (90%) Abdominal pain (70%) • Jaundice (60%) • Tea-colored urine/pale stools • Altered mental status (10-20%) • Hypotension (30%) • RUQ tenderness What are reliable signs & symptoms (more than 90% certainty) that a patient with obstructive jaundice need urgent intervention ?

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

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Are the ducts dilated What is the level of obstruction What is the cause What is the best therapeutic approach The role of Radiology

JAUNDICE : 

JAUNDICE

Investigations : 

Non-invasive AXR US CT HIDA Scintigram MRI/MRCP Invasive ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy Investigations

Obstructive Jaundice : 

CBD stones (Choledocholithiasis) vs. tumor Clinical features favoring CBD stones: Age < 45 Biliary colic Fever Transient spike in AST or amylase Clinical features favoring cancer: Painless jaundice Weight loss Palpable gallbladder Bilirubin > 10 Obstructive Jaundice

Unconjugated vs. Conjugated : 

Unconjugated  production exceeds ability of liver to conjugate Ex. Hemolytic anemia's, hemoglobinopathies, in-born errors of metab., transfusion rxn. Conjugated Can produce but not excrete Intra- or extra hepatic obstruction Metabolic defect Unconjugated vs. Conjugated

Choledocholithiasis : 

Defined as stones in the CBD Patho physiology : intermittent obstruction of CBD Often asymptomatic Symptoms are indistinguishable from other causes of Biliary pain Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos. Choledocholithiasis

Evaluation : 

ERCP Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5% Evaluation

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 Open CBD Exploration

CBD Exploration - SurgicalOptions : 

Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy CBD Exploration - SurgicalOptions

CHOLEDOCHAL CYSTS : 

Congenital anomalies of the biliary tract that manifest as cystic dilatation of the extra hepatic and intra hepatic bile ducts Females are most commonly affected ETIOLOGY : Congenital weakness of the bile duct wall Congenital obstruction of the bile ducts Reo virus association is seen in 78% of patients 40% of anomalies are seen at the junction of pancreatic and common bile ducts CHOLEDOCHAL CYSTS

CLASSIFICATION OF CHOLEDOCHAL CYST : 

Proposed by Todani & colleagues TYPE I : accounts for 80 – 90 % of cases exhibit segmental or diffuse fusiform dilatation of the CBD. TYPE II : consists of a true Choledochal diverticulum TYPE III : consists of dilatation of the intra duodenal portion of the CBD. TYPE IV : multiple intra hepatic & extra hepatic cysts TYPE V or CAROLIS disease : consists of single or multiple dilatation of the intra hepatic ductal system CLASSIFICATION OF CHOLEDOCHAL CYST

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Clinical features : Disease often appears during first months of life 80% of pts. have cholestatic jaundice & acholic stools Vomiting , irritability & failure to thrive may occur Spontaneous perforation of a Choledochal cysts may occur Progressive hepatic injury due to biliary obstruction DIAGNOSIS : BEST established by USG Abdomen In Older children PTC or ERCP may help define the anatomy of the cyst.

TREATMENT : 

Surgical excision of the cyst with Reconstruction of the extra hepatic biliary tree Biliary drainage is accomplished by Choledocho – jejunostomy with a Roux – en – Y anastamosis Long term follow up is necessary because of complications like cholangitis , lithiasis , anastomotic stricture TREATMENT

Cholangiocarcinoma : 

90% are extra-hepatic 60’s and 70’s Highest incidence in Japan, Israel, and Native Americans Increased 3 fold in the last 30yrs in the USA M/F=3/2 Cholangiocarcinoma

CholangiocarcinomaEtiology : 

CholangiocarcinomaEtiology

CholangiocarcinomaExtra-hepatic: Distribution : 

Right or left hepatic duct = 10% Bifurcation = 20% Proximal CBD = 30% Distal CBD = 30% CholangiocarcinomaExtra-hepatic: Distribution

CholangiocarcinomaDiagnosis and Initial Workup : 

Jaundice Wt loss, anorexia, abdominal pain, fever US then CT (CTA?) Followed by ERCP, PTC or MRCP CEA and CA 19-9 can be elevated CholangiocarcinomaDiagnosis and Initial Workup

CholangiocarcinomaIntra-hepatic Disease : 

Suspicious mass on CT. Quadruple phase CT with 0.5 cm cuts through the liver and portal hepatitis. Consider CTA reconstruction. Treatment If adenoncarcinoma: look for primary with a chest CT and upper/lower endoscopy. Colon, pancreas, and stomach are common primary sites. CholangiocarcinomaIntra-hepatic Disease

CholangiocarcinomaIntra-hepatic Disease-Surgery/Ablation : 

Extent of surgical therapy is determined by the location, hepatic function, and underlying cirrhosis. Anatomic resections have lowest recurrence rates. However non anatomic resection increases potential surgical candidates and improves survival Hepatic devascularization prior to resection is preferred Ablative therapy gives good local control. CholangiocarcinomaIntra-hepatic Disease-Surgery/Ablation

MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation : 

MRCP of Extra-hepatic Cholangiocarcinoma at the Bifurcation Klatskin tumor

ERCP: Distal CBD Cancer : 

ERCP: Distal CBD Cancer

Ca of CBD Bifurcation : 

Ca of CBD Bifurcation

Periampullary Carcinoma and The Whipple : 

Periampullary Carcinoma and The Whipple

Endoscopic View : 

Endoscopic View

Pathology : 

Adeno carcinoma accounts for 95% Arises from 4 different tissues of origin Head of pancreas Distal Bile duct Ampullary of Vater Periampullary duodenum Pathology

Pathology : 

Prognosis for each of these are different. Five year survival for pancreas: 18% Five year for ampulla: 36% Five year for distal bile duct: 34% Five year for duodenum: 33% Determination of tissue origin is important for prognosis, extent of resection. Pathology

Pathology : 

Determination of tissue origin from FNA, endoscopic biopsy. Also from thin section CT scan, ERCP Determination of k-Ras also helps (95% of pancreatic cancer). Pathology

Spread : 

Loco regional spread results from lymphatic invasion and direct tumor spread to adjacent soft tissue. Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group. Duodenal has intermediate spread. Pancreas metastasizes 88% to multiple sites. Spread

Treatment : 

Standard Whipple pancreaticoduodenectomy thought to provide adequate tumor clearance in the case of non-pancreatic ampullary tumor, because tumor spread is localized. Biopsy proven paraduodenal LN is thought by most to preclude curative resection Treatment

Surgery and Chemotherapy : 

Low risk patients had 5 year local control and survival of 100% and 80% respectively. High risk patients had 5 year local control and survival of 50% and 38%, respectively. Based on these findings, some have proposed a course of preoperative chemoradiation to improve local disease control in these high risk patients. Surgery and Chemotherapy

Whipple Procedure : 

Five basic techniques are used to resect pancreatic cancers Standard pancreaticoduodenectomy Pylorus preserving pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson) Whipple Procedure

Kocherizing the Duodenum : 

Kocherizing the Duodenum

SMA Involved? : 

SMA Involved?

SMV Identification : 

SMV Identification

Dividing the Neck : 

Dividing the Neck

The End Result : 

The End Result

Adjuvant Therapy : 

Autopsy series show that 85% of patients will experience recurrence in operative field. 70% have metastases to liver. So need to address local control (radiation) and distant disease (chemotherapy). Most commonly used is 5 FU and this only has a 15-28% response on its own, but it’s a radio sensitizer, so it improves response to chemo. Adjuvant Therapy

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Thank you