OBSTRUCTIVE JAUNDICE

1. OBSTRUCTIVE JAUNDICE DR.RAMDAS RAI PROF. & UNIT CHIEF YMCH

2. Definition • Epidemiology • Classification • Pathophysiology • Clinical evaluation • Management Outline of Discussion

3. Jaundice is the yellowish pigmentation of the skin, the conjunctival membranes over the sclerae, and other mucous membranes caused by hyperbilirubinemia. • Total serum bilirubin values are normally 0.2-1.2 mg/dL. Jaundice may not be clinically recognizable until levels are at least 3 mg/dL. DEFINITION

4. Jaundice is not a diagnosis. • Surgical jaundice is any jaundice amenable to surgical treatment. Majority are due to extrahepatic biliary obstruction. • Not all obstructive jaundice is surgical jaundice e.g hepatitis and not all surgical jaundice is due to obstruction e.g congenital spherocytosis

5. RACE • The racial predilection depends on the cause of the biliary obstruction. • Gallstones are the most common cause of biliary obstruction. EPEDEMIOLOGY

6. Persons of Hispanic origin and Northern Europeans have a higher risk of gallstones compared to people from Asia and Africa. • Native Americans (particularly Pima Indians)have a lifetime chance of developing gallstones as high as 80%.

7. SEX • Women are much more likely to develop gallstones than men. • This increased risk is likely caused by the effect of estrogen on the liver, causing it to remove more cholesterol from the blood and diverting it into the bile.

8. To better understand these disorders, a brief discussion of the normal structure and function of the biliary tree is needed. • Bile is the exocrine secretion of the liver and is produced continuously by hepatocytes. It contains cholesterol and waste products, such as bilirubin and bile salts, which aid in the digestion of fats. Half the bile produced runs directly from the liver into the duodenum via a system of ducts, ultimately draining into the common bile duct (CBD). The remaining 50% is stored in the gallbladder. PATHOPHYSIOLOGY

9. In response to a meal, this bile is released from the gallbladder via the cystic duct, which joins the hepatic ducts from the liver to form the CBD. The CBD courses through the head of the pancreas for approximately 2 cm before passing through the ampulla of Vater into the duodenum

10. Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder(intrahepatic) or from the gallbladder to the small intestine(extrahepatic). • This can occur at various levels within the biliary system.

11. The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination. • The failure of biliary flow may be due to biliary obstruction by mechanical means or by metabolic factors in the hepatic cells.

12. For the sake of simplicity, the primary focus here will be mechanical causes of biliary obstruction, further separating them into intrahepatic and extrahepatic causes.

14. Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary canalicular membrane. Causes include hepatocellular disease (eg, viral hepatitis, drug-induced hepatitis), drug-induced cholestasis, biliary cirrhosis, and alcoholic liver disease.

15. In hepatocellular disease, interference in the 3 major steps of bilirubin metabolism, ie, uptake, conjugation, and excretion, usually occurs. Excretion is the rate-limiting step and is usually impaired to the greatest extent. As a result, conjugated bilirubin predominates in the serum

16. Extrahepaticobstruction to the flow of bile may occur within the ducts or secondary to external compression. Overall, gallstones are the most common cause of biliary obstruction. Other causes of blockage within the ducts include malignancy, infection, and biliary cirrhosis.

17. External compression of the ducts may occur secondary to inflammation (eg, pancreatitis) and malignancy. Regardless of the cause, the physical obstruction causes a predominantly conjugated hyperbilirubinemia

18. The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction. • The cause of itching (pruritus) associated with biliary obstruction is not clear. Some believe it may be related to the accumulation of bile acids in the skin. Others suggest it may be related to the release of endogenous opioids.

19. Causes of biliary obstruction can be separated into intrahepatic and extrahepatic. • Intrahepatic causes are most commonly hepatitis and cirrhosis, Drugs e.g thiazides, chlorpromazine,augmentin etc • Extrahepaticcauses may be further subdivided into intrinsic, intraluminal and extrinsic CAUSES

22. Stone disease is the most common cause of obstructive jaundice.Larger stones can become lodged in the CBD and cause complete obstruction, with increased intraductal pressure throughout the biliary tree.

23. Mirizzisyndrome is the presence of a stone impacted in the cystic duct or the gallbladder neck, causing inflammation and external compression of the common hepatic duct and thus biliary obstruction.

24. Of biliary strictures, 95% are due to surgical trauma and 5% are due to external injury to the abdomen or pancreatitis or erosion of the duct by a gallstone. • A tear in the duct causes bile leakage and predisposes the patient to a localized infection. In turn, this accentuates scar formation and the ultimate development of a fibrous stricture.

25. Of parasitic causes, adult Ascarislumbricoides can migrate from the intestine up through the bile ducts, thereby obstructing the extrahepatic ducts. • Eggs of certain liver flukes (eg, Clonorchissinensis, Fasciola hepatica) can obstruct the smaller bile ducts within the liver, resulting in intraductal cholestasis. This is more common in Asian countries

26. Primary Sclerosing Cholangitis is most common in men aged 20-40 years, and the cause is unknown. • Primary Sclerosing Cholangitis is characterized by diffuse inflammation of the biliary tract, causing fibrosis and stricture of the biliary system. It generally manifests as a progressive obstructive jaundice and is most readily diagnosed based on findings from endoscopic retrograde cholangiopancreatography (ERCP).

27. AIDS-related cholangiopathy manifests as abdominal pain and elevated liver function test , suggesting obstruction. The etiology of this disorder in patients who are HIV-positive is thought to be infectious (cytomegalovirus, Cryptosporidium species, and microsporidia have been implicated). • Direct cholangiography often reveals abnormal findings in the intrahepatic and extrahepatic ducts that may closely resemble Primary Sclerosing Cholangitis.

28. Biliary tuberculosis is extremely rare. • Histopathologicevidence of caseating granulomatous inflammation with bile cytology revealing M tuberculosis is confirmatory. • Polymerase chain reaction is useful to expedite the diagnosis if biliary tuberculosis is being considered

29. Biliary obstruction associated with pancreatitis is observed most commonly in patients with dilated pancreatic ducts due to either inflammation with fibrosis of the pancreas or a pseudocyst. • Notably, intravenous feedings predispose patients to bile stasis and a clinical picture of obstructive jaundice. Consider this in the evaluation of biliary obstruction.

30. Sump syndrome is an uncommon complication of a side-to-side choledochoduodenostomy in which food, stones, or other debris accumulate in the CBD and thereby obstruct normal biliary drainage

31. History • Examination • Investigations • Treatment Clinical Evaluation

32. Patients commonly complain of pale stools, dark urine, yellowish discolourationof the eye, and pruritus. • The following considerations are important: • Patients' age • Jaundice (duration ,onset, progression) HISTORY

33. Associated symptoms:- • the presence of abdominal pain( location and characteristics of the pain) • The presence of systemic symptoms (eg:- fever, weight loss) • Symptoms of gastric stasis (eg:- early satiety, vomiting, belching) • Change in bowel habit: • History of anemia

34. Previous malignancy • Known gallstone disease • Gastrointestinal bleeding • Hepatitis • Previous biliary surgery • Diabetes or diarrhea of recent onset • Also, explore the use of alcohol, drugs, and medications

35. Upon physical examination, the patient may display signs of jaundice (sclera icterus). • When the abdomen is examined, the gallbladder may be palpable (Courvoisier sign). This may be associated with underlying pancreatic malignancy. PHYSICAL EXAMINATION

36. COURVOISIER’S LAW:- “When the gallbladder is palpable & the patient is jaundiced , the obstruction of bile duct causing the jaundice is unlikely to be a stone because previous inflammation will have made the gallbladder thick & nondistensible”

37. Also, look for signs of weight loss, adenopathies, and occult blood in the stool, suggesting a neoplastic lesion. • Note the presence or absence of ascites and collateral circulation associated with cirrhosis. • A high fever and chills suggest a coexisting cholangitis.

38. Abdominal pain may be misleading; some patients with CBD calculi have painless jaundice, whereas some patients with hepatitis have distressing pain in the right upper quadrant. Malignancy is more commonly associated with the absence of pain and tenderness during the physical examination. • Xanthomata are associated with Primary Biliary Cirrhosis . • Excoriations suggest prolonged cholestasis or high-grade biliary obstruction

39. Basic • Complete blood count : • Urine analysis : bilirubin present, urobilinogen absent • Stool for ocult blood: Ca ampula • Stool for ova and parasites • Clotting profile: PT deranged • Hepatitis serology: HbsAg, HCV • LFT: LABORATORY TESTS pptk

41. Plain radiographs are of limited utility to help detect abnormalities in the biliary system • Ultrasonography (USG):USG is the procedure of choice for the initial evaluation of cholestasis and for helping differentiate extrahepatic from intrahepatic causes of jaundice. Extrahepatic obstruction is suggested by the presence of dilated bile ducts, but the presence of normal bile ducts does not exclude obstruction that may be new or intermittent. IMAGING

42. Traditional Computed Tomography (CT) scan is usually considered more accurate than USG for helping determine the specific cause and level of obstruction. • Percutaneous transhepaticcholangiogram: done espesciallyif the intrahepatic duct is dilated, outline the biliary tree, locates stones and is therapeutic for stent placement and stone retrieval.

43. ERCP is an outpatient procedure that combines endoscopic and radiologic modalities to visualize both the biliary and pancreatic duct systems. • Endoscopic ultrasound (EUS) combines endoscopy and USG to provide remarkably detailed images of the pancreas and biliary tree. It uses higher-frequency ultrasonic waves compared to traditional USG (3.5 MHz vs 20 MHz) and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA)

44. Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive way to visualize the hepatobiliary tree. • MRCP provides a sensitive noninvasive method of detecting biliary and pancreatic duct stones, strictures, or dilatations within the biliary system. It is also sensitive for helping detect cancer.

45. Medical care:Treatment of the underlying cause is the objective of the medical treatment of biliary obstruction. Do not subject patients to surgery until the diagnosis is clear. • In cases of cholelithiasis in which either the patient refuses surgery or surgical intervention is not appropriate give Treatment

46. Ursodeoxycholic acid (10 mg/kg/d) works to reduce biliary secretion of cholesterol. In turn, this decreases the cholesterol saturation of bile. • Extracorporeal shock-wave lithotripsy may be used as an adjunct to oral dissolution therapy. By increasing the surface-to-volume ratio of the stones, it both enhances dissolution of stones and makes clearing the smaller fragments easier. • Contraindications include complications of gallstone disease (eg, cholecystitis, choledocholelithiasis, biliary pancreatitis), pregnancy, and coagulopathy or anticoagulant medications (ie, because of the risk of hematoma formation).

47. Bile acid–binding resins, cholestyramine (4 g) or colestipol (5 g), dissolved in water or juice 3 times a day may be useful in the symptomatic treatment of pruritus associated with biliary obstruction. • VIT ADEK SUPPLEMENTS • Antihistamines may be used for the symptomatic treatment of pruritus, particularly as a sedative at night.

48. Discontinuation of medications that may be causing or exacerbating cholestasis and/or biliary obstruction often leads to full recovery. Similarly, appropriate treatment of infections (eg, viral, bacterial, parasitic) is indicated.

49. The following are problems of a jaundiced patient and all must be taken care of before surgery • Infection due to biliary stasis • Uncontrolled bleeding due to vit k deficiency • Liver glycogen depletion • Dehydration • Hepatorenal syndrome SURGERY..Preop care

50. Fluid resuscitation using dextrose alternate with Saline. Encourage oral rehydration as well • Give broad spectrum antibiotics at induction of anaesthesia to cover for Gram+,Gram- and anaerobes • Bowel preparation • Inj.VitK10mg IM daily until PT INR normalises( start 5 days preoperatively) • Monitor urine output • You may consider giving mannitol preoperative ,intraopand post op for diuresis to prevent hepatorenal syndrome Therefore;