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    Obstructive Jaundice

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    Dronacharya Routh
    This document discusses obstructive jaundice, including its definition as a yellowish discoloration of the skin and eyes due to increased bilirubin levels caused by an obstruction of bile flow. It covers the classification of obstructive jaundice, alterations caused by it, imaging studies used for diagnosis like ultrasound and CT, and surgical and nonsurgical treatment options. The management objectives are to identify those needing relief of obstruction, establish the cause, and plan appropriate intervention to prevent complications.

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    Obstructive Jaundice

    Uploaded by

    Dronacharya Routh
    298 views37 pages
    This document discusses obstructive jaundice, including its definition as a yellowish discoloration of the skin and eyes due to increased bilirubin levels caused by an obstruction of bile flow. It covers the classification of obstructive jaundice, alterations caused by it, imaging studies used for diagnosis like ultrasound and CT, and surgical and nonsurgical treatment options. The management objectives are to identify those needing relief of obstruction, establish the cause, and plan appropriate intervention to prevent complications.

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    This document discusses obstructive jaundice, including its definition as a yellowish discoloration of the skin and eyes due to increased bilirubin levels caused by an obstruction of bile flow. It covers the classification of obstructive jaundice, alterations caused by it, imaging studies used for diagnosis like ultrasound and CT, and surgical and nonsurgical treatment options. The management objectives are to identify those needing relief of obstruction, establish the cause, and plan appropriate intervention to prevent complications.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    298 views37 pages

    Obstructive Jaundice

    Uploaded by

    Dronacharya Routh
    This document discusses obstructive jaundice, including its definition as a yellowish discoloration of the skin and eyes due to increased bilirubin levels caused by an obstruction of bile flow. It covers the classification of obstructive jaundice, alterations caused by it, imaging studies used for diagnosis like ultrasound and CT, and surgical and nonsurgical treatment options. The management objectives are to identify those needing relief of obstruction, establish the cause, and plan appropriate intervention to prevent complications.

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    Obstructive

    Jaundice
    Col Dronacharya Routh
    Assoc Prof
    Dept of Surgery
    AFMC, Pune 40
    Definition
    • Jaundice came from the French word
    “jaune” which means yellow.
    • Yellowish discoloration of sclera, skin
    mucous membranes due to
    increased serum bilirubin level.
    Typically can be detected if serum
    bilirubin level above 3 mg/dl (51.3
    μmol/L.
    • Obstructive jaundice is interruption
    to the drainage of bile in the biliary
    system
    Metabolism of Bile acids

    • Primary bile acids


    – Cholic acid
    – Chenodeoxycholic acid
    • Secondary bile acids
    – Deoxycholic acid
    – Lithocholic acid
    Metabolism of Bile salts
    Metabolism of Bilirubin
    Metabolism of Bilirubin
    Classifications:
    I. Prehepatic
    II. Hepatic
    III. Posthepatic (Obstructive)
    • Intraluminal- Transmural- Extramural

    • Common- Infrequent- Rare

    • Etiology (congenital, inflammatory, traumatic, neoplastic,

    parasitic etc.)
    Classifications:
    Obstructive Jaundice
    Alteration in:
    • Systemic and renal
    hemodynamics
    • Hepatic function ( protein
    synthesis, reticuloendothelial
    function,hepatic metabolism)
    • Hemostatic mechanism
    • Gastointestinal barrier
    • Immune function
    • Wound healing
    Managment
    Objectives:
    • To identify pts who need relief of obstruction

    • To establish cause

    • To plan appropriate intervention


    • To prevent complications, prevent recurrence
    S&S for urgent surgical interventions:

    • Abdominal pain (70%)


    • Jaundice (60%)
    • Tea colored urine/ pale stool
    • Altered mental status (10-20%)
    • Hypotension (30%)
    • Fever, persistent (90%)
    • RUQ tenderness

    Charcot’s triad, Reynolds’ pentad


    Imaging Studies
    • Ultrasound
    • CECT abdomen
    • MRI, MRCP
    • Cholangiography ERCP, PTC
    • EUS
    • IOUS
    • Digital substraction angiography
    • PET scan
    Ultrasonography
    • 1st choice in obstructive jaundice
    • Non invasive, cheap, bed side
    • Size of bile duct, level of
    obstruction, identify the cause in
    some cases, liver parenchyma
    • Limitation: obese, bowel gas,
    retroduodenal and
    intraduodenal CBD
    CECT Abdomen
    • Very useful for assessment of
    malignancy
    • Intrahepatic biliary dilatations
    • Level of obstruction
    • LN status
    • Metastasis
    • Spiral CT allows : relationship
    vascular and bile duct anatomy
    at the hilum
    MRCP
    • Non invasive
    • Useful when ERCP
    contraindicated
    • No intravenous contrast
    • Purely diagnostic
    • C/I pt with pacemaker,
    cerebral aneurysm
    clips, other metal
    implants
    ERCP
    • Diagnostic and therapeutic
    • Find out obstruction especially in
    the lower part of biliary passage
    • Invasive
    • Cannot reliably distinguish
    between benign and malignant
    features
    • Opportunity to take tissue sample
    • Endoprosthesis
    EUS
    • Diagnostic
    • Find out obstruction especially in
    the lower CBD and pancreas
    • Invasive
    • Can distinguish between benign
    and malignant conditions
    • Can detect early lesions
    • Opportunity to take tissue
    sample for HPE
    PTC
    • Diagnostic and therapeutic
    • Best suited for leisions
    proximal to the bifurcation
    of hepatic duct
    • Invasive
    • Complications similar to
    ERCP
    Laparoscopic cholangiography
    Treatment
    Conservative Rx
    • Fluid and electrolytes

    • Urine output monitoring

    • Correction of coagulation defects

    • Prevention of infection

    • Prevention of hepatorenal syndrome

    • Nutrition
    Conservative Rx
    • Individualized regime for replacement of
    vitamine A, D, E and K as needed.
    • Antihistamine for pruritus
    • Naloxone or nalmefene has improved pruritus
    • Discontinuation of medications that cause or
    exacerbate cholestasis
    Surgical Options
    By Pass Surgeries
    • Roux-en-y hepaticojejunostomy
    • Roux-en-y Choledochojejunostomy
    • Roux-en-y Cholecystojejunostomy
    Choledochoduodenestomy
    Whipple’s operation
    Pylorus Preserving Pancreaticoduedenectomy
    Choledochotomy + T-tube drainage
    Transduodenal sphincterotomy and sphinteroplasty
    Roux-en-Y Hepaticojejunostomy
    Roux-en-Y Choledochojejunostomy
    Cholecystojejunostomy
    Whipple’s Operation
    Pylorus Preserving
    Pancreaticoduedenectomy
    Open Exploration of CBD
    T- tube
    ERCP with Sphincterotomy
    Transcystic CBD Exploration
    Indications for Open CBD Exploration

    • Multiple stones > 5


    • Stones > 1 cm
    • Multiple intrahepatic stones
    • Distal bile duct sticture
    • Failure of ERCP
    • Recurrence of CBD stones after sphinterotomy
    CBD Exploration- Surgical Options:
    • CBD exploration with T-tube decompression
    • Choledochoduodenostomy
    • Transduodenal sphincterotomy and
    sphinteroplasty
    • Roux-en-Y choledochojejunostomy
    Criteria for Irresectability
    • Extra hepatic metastasis
    • Extrahepatic organ invasion
    • Major vascular involvement
    Palliative Procedures

    • Interventional Endoscopy: Endoscopic stenting


    • Radiology: Chemo radiation, Intralumial
    brachitherapy
    • Photo Dynamic Therapy
    • High intensity intraductal ultrasound
    • Palliative surgery: Cholecystojejunostomy,
    choledochojejunostomy, Hepaticojejunostomy
    +/- gastrojejunostomy
    Thank you

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