Download - Surgical Jaundice
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Objectives:-
•Definition .
•Bilirubin Pathophysiology
•Classefication of jaundice
•Causes
•Approach a jaundice pt
•Management
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Definition:-
-Jaundice ( hyperbilirubinemia ) is a yellowish discoloration of the skin & sclera due to accumulation of the pigment bilirubin in the blood & tissue.
-Bilirubin level has to exceeds 35-40 Mmol/L before jaundice is clinically apparent.
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Classefication:-
1.Prehepatic jaundice (hemolytic jaundice = acholuric jaundice)
2.Hepatic jaundice ( disturbed conjugation or uptake) .
3.Post-hepatic jaundice (disturbed excretion )= surgical/ obstructive.
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Causes:-1- prehepatic Jaundice:- (hemolytic/acholuric)
•Hereditary spherosytosis
•Hereditary non-spherosytosis anemias
•Sickle cell anemia
•Thalasemia
•Acquired hemolytic anemia
•Incompatible blood transfusion
•Sever sepsis
•Drugs(chloropromazine,paracetamol,methyldopa,repeated exposure to halothane)
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2) Hepatic Jaundice:-
•Viral hepatitis
•Hepatotoxins
•Cirrhosis
•Familial neonatal hyperbilirubinemia
•Gilbert’s familial hyperbilirubinemia
•Criglar-Najjar’s familial jaundice
•Dubin-jhonson syndrom
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3)Post-hepatic Jaundice:-
-Intrahepatic(without mechanical obstruction):
•Cirrhosis.
•Viral (chronic active hepatitis).
•Certain drugs (methyltestosteron).
•Primary biliary cirrhosis.
•Parentral or enteric feeding with synthetic nutrition.
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-Extrahepatic(surgical-obstructive):
•Intraductal>>> gall stones , foreign body (broken T-tube , parasites (hydatid , liver flukes).
•Wall>>> congenital atresia , traumatic stricture , sclerosing cholangitis , tumor of bile duct .
•Extraductal>>> pancreatic head cancer , ampullary cancer , pancreatitis , L.N metastasis .
•N.B>>>>>> commonest in surgical jaundice are gall stones & pancreatic carcinoma
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1) History:-
•Personal data>>> age, sex, occupation .
•HPI>>> yellow discoloration of skin and sclera , abdominal pain (details) , fever , nausea , vomiting , chills , dark urine , pale stool ,itching , diarrhea , steatorrhea , contact with viral hepatitis patients.
•Hx of blood transfusion.
•PMHx , PSHx , Medications
•FHx of anemia , splenectomy or gall stones
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2) Examination:-•General condition of patient & color.
•Vitals.
•Hand(clubbing , palmar errythema , duputeryn contractures , flapping tremors>>liver stigmata)
•Face & neck >>jaundice , pallor ,L.N
•Chest>>spider nevi , gynecomastia
•Genetalia>>>testicular atrophy
•Lower limbs >>> edema
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-Abdominal Ex:-
•Inspection>>>scars , distended veins , diverted umbilicus , pigmentations
•Palpation>>> tenderness, masses , liver , spleen & gallbladder (murphy’s) .
•Percussion>>> ascitis
•Auscultation>> venous hums
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3) Investigations:-A) LAB:-
• CBC>> Hb , WBC , PLT.
• Chemistry>> electrolytes, albumin,haptoglobin LFT(transaminases.ALP.GGT.5-Nucleotidase) , Bilirubin , Amylase ,BUN.
• Coagulation profile , pt , ptt
• Urine & Stool.
• Serology >> hepatitis , tumor markers , kazoni test
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B) Imaging:-
1.x-ray: - galls tones 10%
- gas in biliary tree
2. U/S (1st line):
-intra/extra hepatic ducts
- gall bladder
-CBD
-pancrease
-liver parynchyma
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3. CT: better reolution than U/S in:
.demonstrating pancreatic lesions
.obese pt
.intrahepatic lesions(tumor,abcess,cyst)
.pt with excess bowel gas shadow
4.
ERCP/MRCP(if intrahepatic ducts are not dilated)
PTC(if intrahepatic ducts are dilated)
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4.PTC:
•If dilated intrahepatic ducts on ct
•ideal for demonstrating anatomy above extrahepatic obstruction
•Contraindications:-
-coagulopathy,prolonged pt & ptt , plt below 40,000
-peri/intra hepatic sepsis
-ascitis
-disease of right lower lung or pleura
•Complications:-
-bile peritonitis -bilothorax -pneumothorax
-sepsis -hemobilia -bleeding
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5.ERCP/MRCP:-
•If no dilated intrahepatic ducts on ct
•Visualize >>>upper GIT , ampullary region , biliary & pancreatic ducts
•Complications:-
-traumatic pancreatitis
-biliary sepsis
6.HIDA(unreliable if bilirubin more than 20 mg/dl).
7.Liver Bx
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4) Management:-
-It includes:-
•Establishing the cause of jaundice
•Assesment of patient general condition
•Staging patient with tumor
•Appropriate treatment which maybe surgical, endoscopic , radiological
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**Preoperative management:--includes:-
1-correction of metabolic abnormalities
2-improvement of general condition
3-institution of general measures designed to minimize the incidence of complications assosciated with prolonged or sever cholestasis (infection , renal failure , Liver failure , fluid & electrolytes abnormalities )
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•Drugs & anasthetics agents metabolism & conjugation
•Hypokalemia
•Viral screen
•Prophylactic Antibiotics
•Coagulation disorder (prolonged PT)>>I.M phytomenadione 10-20 mg
•Renal failure>>adequate hydration & preoperative induction of natriuresis / diuresis
•(I.V 5% dextrose/12-24 h prior to surgurey – followed by osmotic diuretic (mannitol) or loop diuretic (furosemide) I.V at time of induction
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•Pt undergoing surgurey>>>catheterization & measure urine output hourly
•Liver failure in pt with preexisting chronic hepatocelullar disease or with complete large duct obstruction
-if jaundice sever> 150Mmol/L or pt with signs of impending liver failure >>period of decompression before surgurey is indicated
-other prophylactic measures against encephalopathy includes correction of hypokalemia , restricted use of sedatives , hypnotics & potent analgesics & prompt ttt of infections.
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Treatment of some conditions
•Gall stone with a CBD stone
•Pancreatic carcinoma
•Cholangitis
•Bile duct stricture
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1)Gall stone with a CBD stone:-
-ERCP for CBD stone , 1-2 days after proceed for choecystectomy
2)Benign traumatic stricture:-
Damaged area should be bypasses & choledojejunostomy is done (Roux-en-Y).
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3)pancreatic cancer:-
a)Resectional surgurey>>whipple’s operation
b)Palliative surgurey>>aim to relieve
..biliary obstruction& duodenal obstruction endoscopic or radiologic stenting(biliary bypass & gastrojejunostomy)
.. Painceliac plexus block , splanchnicectomy
c) Palliative therapy
d) Chemotherapy / radiotherapy .
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4)Cholangitis:-
-resuscitation >> I.V fluids , blood culture ,systemic AB
-endoscopic decompression (sphincterotomy& calculi extraction) / temporary stenting for drainage
-surgical exploration with ductal clearance and T-tube insertion
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