treatment of benign conditions causing surgical jaundice
DESCRIPTION
Aetiology and Management of Benign Conditions Causing Surgical Jaundice ; It includes Biliary atresia , Choledochal cyst , Sclerosing Cholangitis , Gall stones , Biliary stricturesTRANSCRIPT
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BENIGN CONDITIONSAMARAN.M
FINAL YEAR MBBS , S2PROF.P.RAGUMANI UNIT
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JAUNDICE JANEU ( FRENCH ) ; ICTERUS ( LATIN ) DEFINITION “REGAL” DISEASE
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BENIGN CONDITIONS
CONGENITAL : BILIARY ATRESIA ; CHOLEDOCHAL CYST.INFLAMMATORY : SCLEROSING CHOLANGITIS.OBSTRUCTIVE : GALLSTONES ; BILIARY STRICTURES.
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BILIARY ATRESIA
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BILIARY ATRESIA
DEFINITION INCIDENCE 1 :
10,000 ASSOCIATED WITH
CONGENITAL ANAMOLIES
TYPES
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TYPES OF BILIARY ATRESIA
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PATHOGENESIS
CAUSES INFECTIONS : CMV, HPV,
REOVIRUS,
ROTAVIRUS.
AUTOIMMUNE
ABNORMAL DEVELOPMENT
TOXINS
VASCULAR DEFECTS
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TREATMENT
HEPATICO-PORTO-
JEJUNOSTOMY PRESENTLY KASAI
PORTO-ENTEROSTOMY
8 WEEKS OF AGE
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CHOLEDOCHAL CYST
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CHOLEDOCHAL CYST
CYSTIC DIALTATIONS OF BILE DUCT
MORE COMMON IN ASIA
1 :1000 TYPES CAROLI’S DISEASE
( TYPE 5 ) CAUSE IS EXPLAINED
BY BABBIT THEORY
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COMPLICATIONS OF CYSTS
PANCREATITIS MAINLY IN TYPE 3 GALLSTONE AND CBD STONE FORMATION BILIARY CIRRHOSIS MALIGNANCY ( CHOLANGIOCARCINOMA ; COMMON
IN POST.
WALL )
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TREATMENT OF CYSTS
TYPE 1 COMPLETE EXCISION
OF CYST RECONSTRUCTION
BY HEAPTICO-JEJUNOSTOMY
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TREATMENT OF CYSTS
TYPE 2 EXCISION OF
DIVERTICULUM SUTURING THE CBD
WALL
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TREATMENT OF INTRADUODENAL PART
TYPE 3 ENDOSCOPIC
SPHINCTEROTOMY ( FOR
LESIONS < 3cm ) TRANSDUODENAL
APPROACH ( FOR
LESIONS > 3cm )
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TREATMENT OF CYSTS
TYPE 4 EXTRAHEAPTIC PART
IS EXCISED AND RECONSTRUCTION PROCEDURE
INTRAHEPATIC PART ARE RESECTED ONLY WHEN THERE IS STRICTURES OR LIVER ABSCESS
LILY’S OPERATION
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TREATMENT OF CAROLI’S DISEASE
TYPE 5 LEFT LOBAR DUCTS
ARE USUALLY AFFECTED
LOBAR RESECTION IS DONE.
BILOBAR INVOLVEMENT : TRANSPLANTATION
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SCLEROSING CHOLANGITIS
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SCLEROSING CHOLANGITIS INFLAMMATION AND SUBSEQUENT OBSTRUCTION OF BILE
DUCTS AT BOTH INTRAHEPATIC & EXTRAHEPATIC LEVELS
+ DILATATION OF PRESERVED SEGMENTS
HIGH RISK FOR CHOLANGIOCARCINOMA TYPES
1. PRIMARY ( NO CAUSE IS FOUND )
2. SECONDARY TO OTHER DISEASES
(CHEMOTHERAPY 5-FU)
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PATHOGENESIS OF PSCAUTOIMMUNE ; HLA-B8/DR3
T CELL MEDIATED INFLAMMATION ; FIBROSIS & STRICTURES
PROGRESSIVE DESTRUCTION OF SMALL & MEDIUM SIZED DUCTS WITHIN LIVER & LARGE DUCTS OUTSIDE LIVER
OBSTRUCTION TO BILE FLOW (CHOLESTASIS)
CHRONIC INFLAMMATION
CHRONIC INFLAMMATION MAY PROGRESS TO :
CHOLANGIOCARCINOMA
CIRRHOSIS OF LIVER
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MANAGEMENT
IMMUNOSUPPRESSION
•METHOTREXATE•AZATHIOPRINE•CYCLOSPORINE•TACROLIOMUS
GALLSTONE SOLUBILIZER
•URSODIOL ( suppresses hepatic synthesis of cholesterol )
LIPID LOWERING AGENT
•CHOLESTYRAMINE ( forms a non absorbable complex with bile acids and inhibits the reuptake )
STEROIDS IN LARGE DOSES VITAMIN SUPPLEMENTS
STENTING LIVER TRANSPLANTATION is the
only proven long term treatment
GENERAL
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GALLSTONE
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GALLSTONE CHOLELITHIASIS INVOLVES THE PRESENCE OF GALLSTONES IN
THE GALLBLADDER ;
CHOLEDOCHOLITHIASIS IS THE PRESENCE OD GALLSTONES IN COMMON
BILIARY DUCT
FAT, FERTILE , FORTY, FLATULENT, FEMALE
TYPES CHOLESTEROL STONES
PIGMENT STONES
MIXED ( COMMONEST 90 % )
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CHOLESTEROL STONE PATHOGENESIS OBESITY PREGNANCY DRUGS HEREDITARY
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PIGMENT STONES
INSOLUBLE Ca SALTS OF UNCONJ. BILIRUBIN
INORGANIC Ca SALTS
PIGMENT STONES
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PIGMENT STONES PATHOGENESIS
PREDISPOSING FACTORS
CHRONIC HEMOLYTIC SYNDROMES
BILIARY INFECTION GI DISORDERS
PREDISPOSING FACTORS
ELEVATED LEVELS OF UNCONJUGATED BILIRUBIN
PIGMENT STONES
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MANAGEMENT • CHENODEOXYCHOLIC ACID &
URSODEOXYCHOLIC ACID ( INHIBITS ABSORPTION OF CHOLESTEROL FROM
GUT)
DISSOLUTION
THERAPY
• OPEN CHOLECYSTECTOMY• CHOLEDOCHOTOMY• OPEN
CHOLEDOCHODUODENOSTOMY• OPEN CHOLEDOCHOJEJUNOSTOMY
OPEN PROCEDU
RES
• LAPROSCOPIC CHOLECYSTECTOMY
LAPROSCOPIC
PROCEDURES
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OPEN CHOLECYSTECTOMY
PREOPERATIVE PREPARATION :
DEHYDARTION CORRECTION (IV DEXTROSE 5%)
IV ANTIBIOTICS
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PNEUMOPERITONEUM WITH CO2 GAS AT SUBUMBILICAL PORT
GRASPING THE GALL BLADDER & CALOT’S TRAINGLE VISUALISATION
PLACING CLIPS AROUND CYSTIC DUCT & ATRERY TO CUT
GALL BLADDER IS DISSECTED OFF THE LIVER
BLEEDING CHECK & WASH & REMOVE THE GAS
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BILIARY STRICTURE
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BILIARY STRICTURE CAUSES
POST OP. ( MOST COMMON )
INFLAMMATORY CBD STONES
PARASITES
PSC
MALIGNANT TRAUMATIC
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BISMUTH CLASSIFICATION
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MANAGEMENT ERCP CHOLEDOCHOJEJUNOSTOMY CHOLEDOCHODUODENOSTOMY ROUX EN Y HEPATICOJEJUNOSTOMY ( IDEAL )
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TAKE HOME MESSAGES
CONGENITAL MALFORMATION OF BILIARY TREE MAY BE EITHER ILEANA OR NAMITHA
SCLEROSING CHOLANGITIS IS AUTOIMMUNE INFLAMMATION + DESTRUCTION = OBSTRUCTION
MIXED TYPE IS THE COMMONEST STONE LAPROSCOPIC > OPEN PROCEDURE T TUBE PALCEMENT (CHOLANGIOGRAM
DONE TWICE )
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DON’T AFRAID OF BEING DIFFERENT! HUMAN BEING IS ALWAYS AFRAID OF “BEING DIFFERENT” ; NOT BECAUSE THEY ARE DIFFERENT, ITS BECAUSE HUMANS ARE “WEAKER THAN” DIFFERENT !
THANK YOU