JAUNDICE

It is yellowish discoloration of Skin, mucous membranes, scleraDue to excess plasma bilirubin

Is not a disease but rather a sign that can

occur in many different diseases

Normal range

5-17 m mol/l

Clinically obvious    50 mmol/l (2.5mg/dl)

The differential diagnosis for yellowing of the skin is

limited. Inaddition to jaundice, it includes CarotenodermaThe use of the drug Quinacrine Excessive exposure to phenols

in carotenoderma the pigmentis concentrated on the palms, soles, forehead, and nasolabialfolds. Carotenoderma can be distinguished from jaundice by the sparing of the sclerae

E V Pathway for RBC E V Pathway for RBC ScavangingScavanging

Liver, Spleen & Bone marrow

Hemoglobin

Globin

Amino acids

Amino acid pool

Heme Bilirubin

Fe2+

Excreted

Phagocytosis & Lysis

Through Liver

33www.drsarma.inwww.drsarma.in

Bilirubin Production & Bilirubin Production & Metabolism:Metabolism:Fo

rmatio

n o

f Biliru

bin

Main

ly in

RES (S

ple

en

)

Conju

gatio

n o

f biliru

bin

in H

epato

cyte

About 70 to 80% of the 250 to 300

mg of bilirubinproduced each day is derived

from the breakdown ofhemoglobin in senescent red

blood cellsThe remainder

comes fromprematurely destroyed

erythroid cells in bone marrow and

from theturnover of

hemoproteins such as

myoglobin and cytochromes

foundin tissues

throughout the body.

Excretion

Etiology Of Jaundice:Etiology Of Jaundice:

Incre

ase

of

pro

ductio

n

Imp

aire

d o

f C

leara

nce

Direct Hyperbilirubiemia

Medical Causes

1-Alcoholic hepatitis2-Drugs-Intravenously administered tetracycline, chlorpromazineHydrochloride, oral contraceptives,methyl testosterone, halothane, azathioprine3-Lymphomas4-Primary biliary cirrhosis5-Cholestasis of pregnancy (3rd trimester)6-Benign, recurrent intrahepatic cholestasise7-Post-operative jaundice (anoxia, transfusions, etc.)8-Sclerosing cholangitis9-Pericholangitis

Surgical Causes

Medical Causes

Very common (25 to 35 percent)Choledocholithiasis

Carcinoma of head of pancreasCommon (5 to 10 percent)

Carcinoma of common ductStricture of common duct

Ampullary carcinomaUncommon (I to 5 percent)

Chronic pancreatitisSclerosing cholangitis

LymphomaMetastatic carcinoma

Primary liver cell carcinomaRare (less than I percent)

Post-bulbar ulcerHepatic artery aneurysm

Choledochal cystBiliary atresia

Duodenal diverticulumhemobilia

Anatomy of biliary systemAnatomy of biliary system

Gallstones are also associated with certain medical conditions including:

1-Diabetes 2-Liver disease 3-Crohn's disease 4-Blood disorders like sickle-cell anaemia 5-Stomach surgery - gallstones are more common if you have had surgery to remove part of your stomach

Gall bladder Stone

Risk Fa

ctors

Gall bladder StoneThe majority of cases

(approximately 80%)are asymptomatic (silent) gall

stones , discovered accidentally by abdominal

sonar .

Oth

er sy

mpto

ms a

re re

late

d to

site

of m

ovem

en

t of sto

ne

A gall stone may impact in the neck of gall

bladder or in the

cystic duct giving biliary pain or

cholecystitis

Biliary pain usually occurs in the

epigastrium and right

hypochondrium

Obstruction of common bile duct leading to pain &

jaundicePancreatitis.

Gall stones increase risk of carcinoma of the gall bladder

Obstruction of common bile duct leading to pain

& jaundiceMay Complicate to

Charcot’s Triad:1-Pain2-Jaundice3-Fever

Reynold’s Pentad:1-Pain 2-Jaundice3-Fever4-Altered Mental State5-Shock

Abdominal Ex:1-Gall Bladder: in 80%Not Distended

When gall bladder be distended??Murphy’s sign +ve

2-Liver:Enlarged?????

Treatment of Treatment of Choledocholithiasis:Choledocholithiasis:Preoperative Preparation:

Correct Clotting DysfunctionGuard vs LCFGuard vs RF

Definitive Treatment:Remove Source of Obstruction (stone) Remove Source of Stone (Gall bladder)

Reynold’s PentadObstructive Jaundice Charcot’s TriadChronic

cholecystitis

Treatment

ttt Of

Shock

3 rd

Genera

tion

Cephalo

sporin

ERCP

Chole

cyste

ctom

y

Carcinoma of head of pancreas

Symptoms Signs

CachecxiaCriteria of obstructive jaundicePain which is common, characterized by starting as vague

( Lower abdomen or back)Usually worsen in supine position & relived by lining forward It may be caused by:

A) Tumor invasion of splanchnic plexuses & retroperitoneum

B) Obstruction of pancreatic ductDigestive symptoms

JaundicePalpable liverPalpable gall bladderTendernessAscitesAbdominal mass In advanced cases:Nodular liverEnlarged supraclavicular

lymph node Periumblical adenopathy

Courvoisier’s sign = painless, palpable/distended gallbladder on

exam (think of CA)

Diagnosis & management of pancreatic cancer:

It depends on results of

Spiral CT 1 )Resectable: ask yourself if operative candidate or not

a)YES :Explore for resectionb) NO: =NONOPERATIVE: Palliation, Biliary stent & Chemo/Radiotherapy

2 )Unresectable: is it only Biliary or associated with duodenal obstruction a)only Biliary:Endobiliary stentb)Both: Operative palliation(Biliary bypass)GastrojejunostomyCeliac plexus block

Whipple operation:Whipple operation:

http://upload.wikimedia.org/wikipedia/commons/e/e4/Gallstones.jpg

Diagnostic: MRCP and ERCPMagnetic resonance cholangiopancreatography (MRCP)– Advantage

• Detects choledocholithiasis, neoplasms, strictures, biliary dilations

• Sensitivity of 81-100%, specificity of 92-100% of choledocholithiasis

• Minimally invasive- avoid invasive procedure in 50% of patients

– Disadvantage: • cannot sample bile, test cytology, remove stone• Contraindications: pacemaker, implants, prosthetic valves

– Indications• If cholangitis not severe, and risk of ERCP high, MRCP

useful• If Charcot’s triad present, therapeutic ERCP with drainage

should not be delayed.

Endoscopic retrograde cholangiopancreatography (ERCP)-Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction-Advantage

•Therapeutic option when CBD stone identified•Stone retrieval and sphincterotomy

-Disadvantage•Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding•Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

MRCPMRCP

• purely diagnostic . purely diagnostic . • rapid, accurate and rapid, accurate and

non-invasive non-invasive • SafeSafe : : no contrast material no contrast material

administrationadministration no radiation. no radiation. • alternative to alternative to

diagnostic ERCP. diagnostic ERCP. • MRCP avoids the MRCP avoids the

complications of ERCP complications of ERCP

• Case 1: Normal MRCP. Note good Case 1: Normal MRCP. Note good delineation of normal caliber pancreatic delineation of normal caliber pancreatic and bile ducts. Fluid in stomach and and bile ducts. Fluid in stomach and duodenum also demonstrated.duodenum also demonstrated.

• Case 2: MRCP. Large common hepatic Case 2: MRCP. Large common hepatic duct stone (asterisk) within dilated duct stone (asterisk) within dilated bile ducts. Note multiple gallstonesbile ducts. Note multiple gallstones

Surgical treatment

• Endoscopic biliary drainage– Endoscopic sphincterotomy with stone extraction and

stent insertion

• CBD stones removed in 90-95% of cases

• Therapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression

• Surgery– Emergency surgery replaced by non-operative biliary drainage– Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal– Elective surgery: low M & M compared with emergency survey– If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

ERCPERCP

•   

ERCP(theraputic)ERCP(theraputic)

Choledocholithiasis

• Choledocholithiasis develops in 10-20% of patients with gallbladder disease

• At least 3-10% of patients undergoing cholecystectomy will have CBD stones– Pre-op– Intra-op– Post-op

Pre-op diagnosis & management

– Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP

• High risk (>50%) of choledocholithiasis: – clinical jaundice, cholangitis,– CBD dilation or choledocholithiasis on ultrasound– Tbili > 3 mg/dL correlates to 50-70% of CBD stone

• Moderate risk (10-50%): – h/o pancreatitis, jaundice correlates to CBD stone in

15%– elevated preop bili and AP, – multiple small gallstones on U/S

• Low risk (<5%): – large gallstones on U/S– no h/o jaundice or pancreatitis, – normal LFTs-Treatment:

•ERCP•Surgery

Intra-op diagnosis and management

• Diagnosis: intraoperative cholangiography (IOC)– Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and

common hepatic duct diameter, presence or absence of filling defects.

– Detect CBD stones– Potentially identify bile duct abnormalities, including iatrogenic

injuries– Sensitivity 98%, specificity 94%– Morbidity and mortality low

• Treatment -Open CBD exploration

Most surgeons prefer less invasive techniques -Laparoscopic CBD exploration

•via choledochotomy: CBD dilatation > 6mm•via cystic duct (66-82.5%)•CBD clearance rate 97%•Morbidity rate 9.5%•Stones impacted at Sphincter of Oddi most difficult to extract

-Intraoperative ERCP

Early years: Open CBD exploration & Introduction of endoscopic

sphincterotomy• 1889, 1st CBD exploration by Ludwig

Courvoisier, a Swiss surgeon – Kocherization of duodenum and short

longitudinal choledochotomy– Stones removed with palpation, irrigation

with flexible catheters, forceps, – Completion with T-tube drainage– For many years, this was the standard

treatment for cholecystocholedocholithiasis

• 1970s, endoscopic sphincterotomy (ES)

-Gained wide acceptance as good, less invasive, effective alternative -In patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choice

PTC PTC RadiologyRadiology

• Diagnostic Diagnostic and theraputicand theraputic• Performed with 22G Performed with 22G Chiba Needle Chiba Needle

• Complication:Complication: --Bacteremia Bacteremia --HaemorrhageHaemorrhage --Contrast reactionContrast reaction --PneumothoraxPneumothorax --IntrahepaticIntrahepatic arterioportal fistulaarterioportal fistula --Bile leakageBile leakage

PTCPTC

Percutaneous access to Percutaneous access to the biliary tree, through the the biliary tree, through the CBD, if possible, and into CBD, if possible, and into the duodenum. the duodenum. Downsides:Downsides:• External drainageExternal drainage• Procedural risks:Procedural risks:

– CoagulopathyCoagulopathy– ascitesascites