Obstructive Jaundice

OBSTRUCTIVE JAUNDICE&

INTESTINAL OBSTRUCTION

PMS 2

Case Scenario• A 78 years old, Chinese gentleman, a known case of

cholelithiasis in 2010 was admitted to the ward with a history of colicky pain at the right upper quadrant of abdomen for one day, associated with fever, vomiting and increasing malaise .

• On examination, he had jaundice and tender hepatomegaly.

• Lab investigation showed a total bilirubin of 151μmol/l.

• Ultrasonography  showed multiple calculi seen within the gallbladder, largest measuring 1.1 cm. Gallbladder wall is thickened measuring 0.5 cm and there is presence of minimal pericholecystic collection.

Definition• Yellowish discoloration of the skin or

sclera due to increase in circulating bilirubin ( >50 umol/L).

• Three type of jaundice which are :-

• In surgery, we will anticipate mostly in post hepatic jaundice.

Pre hepatic - Hemolytic jaundice eg. Spherocytosis, thalassemia, Gilbert syndrome

Intra hepatic - Hepatocelluar carcinoma, chronic liver failure, cirrhosis

Post hepatic - cholelithiasis, cholangitis, cholecystitis

Investigation

Investigation ( Lab )

Investigation ( Imaging )1) Ultrasonography – check for duct

dilatation, dilated gallbadder, present of gallstone.

2) MRCP – non invasive investigation to give view on anatomy of biliary systems.

3) ERCP – invasive investigation and therapeutic for obstructive jaundice ( definitive )

4) CT scan – non invasive investigation that can identify hepatic, bile duct and pancreatic tumors in jaundiced patients

Liver Function TestsUltrasound scan

Biliary dilatation

Gallstones Gallstones

Ix further to exclude medical

cause

MRCP or ERCP CT scan or MRCP

Biliary stent or surgeryERCP/sphincterotomy or laparoscopic cholecystectomy as indicated

Yes No

NoYes No

Management

General pre-operative measures

• AIM: reducing perioperative morbidity (eg. Infection, massive haemorrhage etc.)

• Oral cholestyramine 2 to 8 gm – subsides pruritis (irritation of skin due to high concentration of bilirubin). Acts by binding bile salts in within the intestines

• Vitamin K1 5 to 10 mg sc once/daily (2 to 3 days) – treat hypoprothrombinemia

• Ca and vitamin D supplements – slow progression of osteoporosis. Used with/without biphosphonate.

• Vitamin A supplement – prevent deficiency, due to lacking of utilization of fat soluble vitamin A, caused by deficiency in bile secretion

• Dietary fat – used to minimize the occurrence of steatorrhea.

• Frequent IV hydration and catheterization of urinary bladder – treating electrolytes imbalance d/t nausea & vomiting & wash out the deposition and high concentration of urobilinogen in the renal tubules

• Mannitol 100 – 200 ml BD IV – forced natriuresis, preventing hepatorenal syndrome

• Antibiotic prophylaxis – 3rd generation cephalosporin, immunosuppressed patients

Specific treatment Choledocholithiasis (CBD)- Cholecystectomy, if present. - Choledochotomy, usually supraduodenal- T tube is used in certain conditions, to

confirm the clearance of the duct by a postoperative cholangiogram. Usually removed after 2 weeks, when an epithelialzed tract has formed to avoid bile leak into the peritoneum

- ERCP +/- sphincterotomy A cholangiogram is done after the ampulla of Vater has been identified and cannulated to confirm anatomy and the presence of stones. An adequate sphincterotomy is undertaken and the duct cleared using a balloon catheterSuccess rate is about 90% with low complications.

Complications include perforation, acute pancreatitis, and bleeding from damage to a branch of the superior pancreatico-duodenal artery

- Laparoscopic exploration of the common bile duct May be done through the cystic duct (if the gall bladder has not been previously removed) or common duct via a choledochotomyRequires considerable laparoscopic expertise and is time consuming, more over it’s expensive due to the need of proper equipments

• Advantages- Faster and better wound healing- Better wound appearance- Can acquire a whole and throughout

view of the body

• Cholangiocarcinoma- Classified into intra-hepatic tumours, (extra-

hepatic) hilar tumours and (extra-hepatic) distal bile duct tumours.

- Surgery is the only curative option for cholangiocarcinoma

- Cholecystectomy, lobar or extended lobar hepatic and bile duct resection, regional lymphadenectomy are commonly being used

• Systemic therapy/palliative care- The majority of patients with

cholangiocarcinoma present at an advanced stage or have associated co-morbidity that preclude surgery

- Biliary endoprosthesis (stent) placement is a useful option for palliation of jaundice

- Photodynamic therapy, radiation and chemotherapy are all available as palliative options

Other causes and treatment

• Biliary strictures – stenting, choledochojejunostomy

• Klatskin tumor – radical resection or palliative stenting

• Carcinoma periampullary or head of pancreas – Whipple’s oepration or triple bypass or ERCP stenting

Post-operative care

• Monitoring prothrombin time, bilirubin, albumin, creatinine, electrolytes

• Fresh frozen plasma @ blood transfusion

• Antibiotics• Care of T tube and drains• Observation for septicaemia,

haemorrhage, pneumonia, pleural effusion, bile leak

Complications

• Complications of obstructive jaundice include sepsis especially cholangitis, biliary cirrhosis, pancreatitis, coagulopathy, renal and liver failure

Intestinal Obstruction

Case Scenario A 72 year old Malay gentleman presents to

Emergency Department with complaint of abdominal pain.

Six day history of increasing abdominal pain in LLQ, colicky in nature.

Pain is dull and constant with nausea and vomiting No bowel movements or flatus for the past six days. Increasing abdominal distention with lack of

appetite. Over the past several days he has tried laxatives and

enemas. Did not relieve his constipation.

Definition

• Impedance to the normal passage of bowel content through the small bowel or large bowel.

Classification of Intestinal Obstruction Dynamic

• Peristalsis is working against a mechanical obstruction.

• The obstruction may be: 1. Intraluminal (Ex. impacted

faeces, foreign bodies, bezoar, gallstones)

2. Intramural (Ex. malignant or inflammatory strictures)

3. Extramural (Ex. intraperitoneal bands and adhesions, hernias, volvulus or intussusception.)

Adynamic• Peristalsis is absent (eg.

Paralytic ileus) • May be present in a

non-propulsive form (eg. Pseudo-obstruction)

Clinical Features

Small bowel Large bowel

Colicky pain

Vomiting - bile – proximal obstruction - feculent – distal obstruction

Constipation

Abdominal distension

Signs of dehydration

Constipation/diarrhea

Abdominal distension

Colicky pain

Vomiting

Hematochezia/tenesmus

Signs of dehydration

Investigation

Investigation ( lab )

• Full blood count – Hb level, • Renal profile – Creatinine level for

hydration status, hypokalemia• Tumor marker ( if suspected )

Investigation ( imaging )

1) Abdominal x-ray – Dilated bowels, stack of coins appearance, string of beads, mass/calcification.

2) Barium enema – large bowel3) Barium meal – small bowel4) Colonoscopy/sigmoidscopy

Management

• Admit the patient with high suspicious of IO– Acute abd pain + vomiting +

constipation + abd distension

• Supportive management– Nasogastric decompression• Ryles or Salem tube• On free drainage with 4 hourly aspiration or

on continous or intermittent suction• To decompress area proximal to obstruction

n also reduce risk of aspiration during induction of anaesthesia

– Analgesics• IV Tramal

– IV fluids• To correct the electrolyte imbalance and also

rehydrate if patient is dehydrated • Main electrolyte imbalance in IO is sodium n water loss• Use Hartmann’s solution or normal saline • Electrolyte imbalance is one of the causes of paralytic

illeus

– IV antibiotics • Is not mandatory except for surgical resection of small

or large bowel• May use broad spectrum because of high risk of

bacterial outgrowth (e.g. 3rd generation cephalosporin, ceftriaxone)

Surgical Treatment

• Principles– Manage segment at the site of obstruction– Manage distended proximal bowel– Manage underlying causes of obstruction

• Indications for early surgery– Obstructed or strangulated external hernia– Internal intestinal strangulation– Acute obstruction

Small Bowel ObstructionCauses of obstruction Surgical Procedure

Foreign bodies .e.g hair or gallstones Laparotomy: Removal of foreign bodies

Adhesions IV rehydration n nasogastric decompression, if failed go forLaparotomy: Lyse the adhesions

Hernia Laparotomy: Removal of the gangrenous part and herniorraphy

Disseminated Intraperitoneal Ca that obstruct small bowel

Bypass the obstruction through laparomoty of endoscopy, to relieve symptoms

Large BowelCauses of obstruction Surgical Procedure

Diverticulitis Laparotomy: Diverticulectomy

Colon Ca Laparotomy: Single stage resection n anastomosis

Cecal Valvulus Surgical resection and anostomosis/Cecotomy to recorrect the cecal position

Sigmoid valvulus Decompression by rectal tube followed by resection of valvulus as it has high recurrence rate

Fecal impaction Removal of feces by digit (if it is in rectum)Laparotomy if it is complete obstruction

Adynamic Obstruction

Paralytic Ileus Principles of Management

› Primary cause must be removed (infection, uremia, hypokalemia)

› GI distension must be relieved by decompression› Maintain fluid n electrolyte balance› If resistant, use neostigmine (cholinergic

stimulation)› If prolong n life threatening, use laparotomy to

decompress n fine hidden causes

Pseudo-obstruction Small intestine pseudo-obstruction

› Treat underlying causes› Use metoclopramide n erythromycin

Colonic PO › Colonic decompression or flatus tube

Acute messenteric ischemia› Early phase

Embolectomy via ileocolic artery Revascularization of Sup. Messenteric Art.

› Late phase Surgical resection of affected bowel