Approach to a patient with biliary obstruction.

Approach to a patient with biliary obstruction (Case Presentation):

Approach to a patient with biliary obstruction (Case Presentation) BY Hosam M. Hamza , MSc Assistant Lecturer of GI Surgery & Endsocopy Minia University EGYPT

Physiological background:

Physiological background 2. LIVER 1 3 RBC destruction Indirect bilirubin Conjugation Indirect  Direct Excretion GI Tract ( Direct bilirubin ) BILURUBIN Haemolytic 2.Hepatocellular 3. Cholestatic ( Pre – Hepatic ) ( Hepatic ) ( Post – Hepatic )

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2 kilometers Bile Canaliculi [smallest branches of the biliary tree] ↓ Canals of Hering ↓ Perilobular (Interlobular) bile ducts ↓ Segmental ducts ↓ Sectorial Ducts [Anterior and Posterior] ↓ Right and Left Hepatic Ducts Anatomical background

Common Bile Duct (CBD)(Ductus Choledochus) :

Common Bile Duct (CBD)( Ductus Choledochus) PART of cbd COURSE IMPORTANT RELATIONS Supraduodenal (upper) descends in the free edge of lesser omentum. Anteriorly : Liver. Posteriorly : Portal v. On lt side : Hepatic art. Retroduodenal (middle) runs behind the 1st part of duodenum and slopes down to the right. Anteriorly : 1st part of duodenum. Posteriorly: IVC. On lt side: Portal v & Gastroduodenal art. Infraduodenal (paraduodenal or lower) slopes in a groove between the back of pancreatic head and 2 nd duodenal portion ( or even travels in a tunnel of pancreatic tissue) . Anteriorly: Head of Pancreas. Posteriorly: IVC & Right Renal vein. This classic anatomic description of biliary tract is only present in 58% of the population. Koenraad J.Mortelé and Pablo R.Ros. Anatomic Variants of the Biliary Tree MR Cholangiographic Findings and Clinical Applications . AJR Am.J.Roentgenol. 177, 389-394. 2001.

Clinical background :

Clinical background - Jaundice is from ‘ jaune ’ = yellow. It was once called the " morbus regius " (the regal disease) . - Icterus = Latin word for jaundice

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JAUNDICE It is yellowish discoloration of Skin, sclera, mm & body fluids Due to excess plasma bilirubin Is not a disease but rather a sign that can occur in many different diseases Normal Up to 1.0 mg/dl Physician at 3mg/dl Patient at 6 mg/dl Other differential diagnoses for yellowish skin (pseudo-jaundice) i ncludes Carotenoderma Drugs (Quinacrine) Excessive exposure to phenols Sparing of the sclerae

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Management Of a case Of Obstructive Jaundice * Good HISTORY TAKING drives the rest of management ! * EXAMINATION ! * INVESTIGATIONS ! * Evaluation and management of OJ involve the combined expertise of the gastroenterologists, radiologists, and surgeons !

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HISTORY TAKING age & sex : - complaint : JAUNDICE + pale stool + dark urine PAIN cal. or late cancer fluctuation + melaena periampullary carcinoma

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duration: short + intermittent course  calcular OJ relatively long + progressive  pancreatic head cancer relatively long + flutuant  periampullary carcinoma Cause (past history) : intraheaptic extrahepatic cholestatic viral hepatitis congenital (atresia & choledochal cyst) cholestasis of pregnancy traumatic (e.g. haemobilia), Lymphomas inflammatory drug induced cholestasis : strictures (post-traumatic or post-op.) anabolic steroids. parasites (ascaris & colorichis sineris) oral contraceptives. Calcular Obstructive Jaundice Dubin-Johnson's syndrome. Malignant Obstructive Jaundice Rotor's syndrome.

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PHYSICAL EXAMINATION I- General: TEMP & PULSE low-grade fever, cachexia & bradycardia MOJ Cholangitis high-grade fever & tachycardia Remarkable weight loss Deep jaundice Troisier's sign

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II-Abdominal: Palpable Impalpable GB in 98% of cases of malignant obstructive jaundice in 80% of cases of calcular obstructive jaundice

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History, Exam, Lab US ( or CT) Dilated bile ducts STONES MASS E R C P S U R G E R Y

MASS:

MASS Surgical candidate ? YES EUS resectable irresectable Surgical resection ERCP Stenting sampling Palliative surgery NO

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Palliative Surgery For OJ

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A - Preoperative Evaluation & Management: 1- Improve general condition of the patient. 2- Avoid and Treat complications of cholestasis. 3- Postoperative mortality and morbidity have been suggested to be reduced with the use of preoperative biliary drainage . Despite improvement of LFTs following biliary drainage there is no demonstrable benefits in the morbidity or mortality for patients who underwent surgery. (Saleh MM et al, Gastrointest Endosc. 2002;56:529–34.) [ PubMed ]

(Bilio-digestive bypass):

B - Surgical Procedures removed/diseased intact Techniqually easier. Decreases operative time and intra-operative blood loss. More conducive to laparoscopic approach. recurrent jaundice postoperative cholangitis (Bilio-digestive bypass) GB Choledocojejunostomy Hepaticojejunostomy Choledocoduodenostomy Hepaticoduodenostomy surgeon has the choice bet choledocoj. or cholecystoj.

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A study of 1919 patients with advanced pancreatic cancer demonstrated that patients who underwent cholecystojejunostomy were about 3 times likelier to require additional biliary interventions than those with choledoco- or hepatico-jejunostomy ( Urbach DR, Bell CM et al ,2003 ) .

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THANK U