Presenting complaints KM a 64 y/F peasant from pallisa Presenting complaints Epigastric pain 2/12 Itching 1/12 Yellow discoloration of the eyes 2/52 CASE PRESENTATION

CASE PRESENTATIONS Gradual onset of dull epigastric & right hypochondriac pain radiating to the back, aggravated by eating food relieved by analgesics. Generalized body itching with no rash. Unremitting yellow discoloration of the eyes. Pale stool and dark urine. On and off low grade fevers

CASE PRESENTATION No N&V, Loss of weight, loss of appetite No h/o blood transfusion or contact with anyone with yellow eyes . ROS: UNREMARKABLE PMH: index admission. No DM or HTN. HIV seronegative. PSH. No history of major surgery or trauma. FSH. Married , no h/o smoking or alcohol.

CASE PRESENTATION O/E mildly wasted, afebrile, deep jaundice, scratch marks. No stigmata of liver disease. P/A normal fullness, no collaterals, no tender. Two masses in the right hypochondrium. A firm globular mass 3cm in the widest diameter (gall bladder) liver palpable, liver span 16cm, 3cm BCM. No ascites. PR formed pale yellow stool.

CASE PRESENTATION CVS. PR 89bts/min, BP 140/80. CNS. Fully conscious, oriented. INVESTIGATIONS LFTs Alb 31.3g/l AST 70.6U/L ALT 44.2U/L GGT 162.8U/L Bilirubin total 358.8micromoles/L Bilirubin direct 236.1micromoles/L

CASE PRESENTATION CBC WBC 5600/microliter neu 4000/microliter lym 1060/microliter RBC 3790000/microliter Hb 10.4g/dl HCT 31.2 MCV 82 PLAT 388000

CASE PRESENTATION RFTs normal Bleeding time. 2min 45sec(2-7 ) Clotting time, 5 min. (5-11) Blood group O+

CASE PRESENTATION Abd U/S (Dec 2010): showed dilated biliary tract, grossly dilated gall bladder, no mass in the pancreas. Concl: possible stricture at the ampulla CT scan showed dilated BD & small gall stones but demonstrated no pancreatic mass Abdominal ultrasonography (feb 2011) Liver enlarged, intra and extra biliary ducts, gallbladder grossly distended, CBD and pancreatic duct dilated. Lymphadenopathy around the portal hepatis, hyper-echoic mass around the head of the pancreas. Spleen and kidneys normal, no ascites.

CASE PRESENTATIONS. RX SUPPORTIVE Vit k, rehydration, cephalexin, metro, Paracetamol, cholestyramine. SPECIFIC Pre op ReH2O IV abcs, catheterization, vit k

CASE PRESENTATION Surgery Operation: cholecystojejunostomy and jejunojejunostomy post op care NGT IV fluids IV abc tramadol

ANATOMY OF BILIARY TREE The bile ducts of the liver consist of the: Right and left hepatic ducts, Common hepatic duct (4cm), Gallbladder: concentrates bile; stores bile; selectively absorbs bile salts, keeping the bile acid; excretes cholesterol; and secretes mucus, Cystic duct & Common Bile Duct (8cm).

Anatomy

CASE PRESENTATION DISCUSSION:OBSTRUCTIVE JAUNDICE Definition   Definition Jaundice or icterus is the yellow pigmentation of tissues especially skin or sclera due to deposition of bile pigments associated with increased circulating bilirubin (hyperbilirubinemia)

CASE PRESENTATION Serum bilirubin>3mg/dl (app 54micromol/L). Obstructive jaundice occurs as a result of obstruction of the biliary tree, due to either intrahepatic or extrahepatic obstruction. Extrahepatic obstruction is also called surgical jaundice.

CASE PRESENTATION Etiology Common Choledocholithiasis Carcinoma of the head of pancreas Malignant lymph nodes at the porta hepatis  Uncommon Carcinoma of the Ampulla of Vater Chronic Pancreatitis Liver secondaries, cysts and abscesses  

CASE PRESENTATION Rare Benign strictures : 95% iatrogenic, rarely trauma Recurrent cholangitis Mirrizi's syndrome Primary sclerosing cholangitis Cholangiocarcinoma Biliary atresia (neonates) Infestations 

CASE PRESENTATION Clinical features   Jaundice : Onset- Sudden- Gall-stone obstruction Gradual- Carcinoma Progress- Relentless- Carcinoma, Fluctuating- Stones, Ca Papilla Pain : Present- Gall stone. Usually colicky Ca: Moderate midepigastric, deep seated, radiating to back Absent- Ca Bile duct, Ca Ampulla of Vater, Ca Head Pancreas (Early) Fever & Chills: Cholangitis due to obstruction usually due to calculus Pruritis: All forms of cholestatic jaundice Weight Loss: Progressive loss in Ca Head pancreas Stool: Pale, clay-coloured due to excess fat and absence of stercobilin

REFERRED PAIN

CASE PRESENTATION Urine: Dark due to excess bilirubin   Hemorrhage: Failure of absorption of Vit. K with impaired coagulation Supraclavicular node: Virchow’s node indicates malignancy Abdominal Scar: Previous surgery may suggest operative injury to bile duct Gall Bladder: May be palpable with Ca Head of pancreas Non palpable with gall-stone obstruction (Courvoisier’s Law) Hepatomegaly: Hard, nodular in metastases and hepatoma Abdominal Mass: Suggests malignancy and may be associated with ascites Diabetes: Sometimes precedes jaundice

CASE PRESENTATION Investigation of obstructive jaundice 1. LFTs Conjugated hyperbilirubinemia > 50% of total bilirubin Increase in ALP / GGT >> Enzymes AST / ALT Prolonged PT and PTT Urinalysis Bilirubin in urine; urobilinogen absent in total obstruction   3. Stool: Pale, clay colored, absence of stercobilin, ?O/B +ve 4. Ultrasound Scan Initial and most useful investigation Demonstrates dilated ducts (Normal CBD <8 mm diameter) Sensitivity 70 - 95% and specificity 80 - 100% 5. CT and MRI Scan Sensitivity and specificity similar to good quality ultrasound Useful in obese or excessive bowel gas Better at imaging lower end of common bile duct Stages and assesses operability of tumors

CASE PRESENTATION 6. Radionuclide scanning 99 technetium iminodiacetic acid (HIDA) Taken up by hepatocytes and actively excreted into bile Allows imaging of biliary tree Failure to fill gallbladder = acute cholecytitis Delay or absence of flow into duodenum = biliary obstruction 7. (ERCP) Visualization of papilla, biliary and pancreatic ducts Allows biopsy or brush cytology Stone extraction or stenting Complications include hemorrhage, pancreatitis ,sepsis 8. Percutaneous transhepatic cholangiogram (PTC) 90% successful in patients with dilated ducts Performed with 22G Skinny/Chiba Needle Contraindicated with coagulopathy (>PT) , ascitis, sepsis  

CASE PRESENTATION 7. Endoscopic retrograde cholangiogram (ERCP) Visualization of papilla, biliary and pancreatic ducts Allows biopsy or brush cytology Stone extraction or stenting Complications include hemorrhage, pancreatitis ,sepsis 8. Percutaneous transhepatic cholangiogram (PTC) 90% successful in patients with dilated ducts Performed with 22G Skinny/Chiba Needle Contraindicated with coagulopathy (>PT) , ascites, sepsis  

CASE PRESENTATION Consequences of obstructive jaundice Ascending cholangitis Charcot's triad is classical clinical picture Intermittent pain, jaundice and fever Cholangitis can lead to hepatic abscesses Need parenteral antibiotics and biliary decompression Operative mortality in elderly of up to 20% Clotting disorders (Prolonged PT) Vitamin K required for gamma-carboxylation of Factors II, VII, IX, X Vitamin K is fat soluble and not absorbed. Needs to be given parenterally (Vit K 10 mg IM/IV x 3days) Urgent correction will need Fresh Frozen Plasma (FFP) Also endotoxin activation of complement system

CASE PRESENTATION Hepato-renal syndrome (oliguria with >creatinine) Poorly understood Renal failure postoperative Due to gram negative endotoxemia from gut Preoperative lactulose and TBI may improve outcome Drug Metabolism Half life of some drugs prolonged. e.g. opioids Impaired wound healing

CASE PRESENTATION Perioperative management of obstructive jaundice Preoperative biliary decompression improves postoperative morbidity Broad spectrum antibiotic prophylaxis: Cephalosporin/Aminoglycoside Parenteral vitamin K +/- fresh frozen plasma (FFP) Pre operative IV fluids and volume expansion Urinary catheter >50ml/hr Careful post operative fluid balance to correct depleted ECF Consider 250 ml 10% mannitol. No proven benefit. Total bowel irrigation (TBI) NaCl or preferably GolyTELY (PEG)

CASE PRESENTATION Common Bile Duct Stones Accurate prediction of common bile duct stones can be difficult If elevated bilirubin, ALP & CBD > 12 mm risk of CBD stones is 90% If normal bilirubin, ALP & CBD diameter risk of CBD stones 0.2%   A. ERCP and endoscopic sphincterotomy is investigation of choice 1. Stones extracted at endoscopy (ERCP) with balloon or Dormia basket 2. 90% successful 3. Complication rate 8% Alternatives include: Open cholecystectomy & exploration of CBD + T- tube drainage Choledochoduodenostomy- markedly dialated CBD, impacted stone Laparoscopic exploration of CBD

CASE PRESENTATION Carcinoma of Head of Pancreas Curative: Resectional surgery only possible in 20% of patients Pancreaticoduodenectomy (Whipple’s procedure) Traditional surgery Overall mortality in experienced hands is 5% Common complication is pancreatic fistula in 5-20% Pylorus-preserving pancreaticoduodenectomy (Modified Whipple’s) Total pancreatectomy No advantage over Whipple’s but higher mortality and brittle diabetes

CASE PRESENTATION . Palliative: Cholecystojejunostomy Choledochojejunostomy Duodenal obstruction managed by gastrojejunostomy Resectional palliation Endoscopic prosthesis/ stent Percutaneous transhepatic drainage Adjuvant radiation and chemotherapy