Mechanical jaundice

ETIOLOGY OF THE MECHANICAL JAUNDICE MJ (obturative, obstructive, subhepatic) is the pathologic state, conducting with the jaundice of the skin, skleras, mucous shells as a result of increasing of bilerubin in blood, developing because of different pathologic processes, induct the obturation of the bile ducts

Main reasons of the mechanical jaundice Concrement Diseases of ducts External compression Parasite invasion Innate (cysts, atresias) Choledocholithyasis Tumors (of pancreas, liver, gall bladder, big duodenal teat, metastases) Not tumorous (sclerosing, festering cholangitis, strictures, cholangiopathies) Round worms, suckers, Ribbon worms Mirizzi’s syndrome

Choledocholithyasis Choledocholithyasis – is the localization of the concrements in extra- and intrahepatic bile ducts, appears more frequently as a result of migration of the concrements from the gall bladder at the calculous cholecystitis

Mirizzi’s syndrome 1 type– the concrement, wedging to the neck of gall bladder, Hartman’s pocket or bladder’s duct, compresses the common bile duct from the outside 2 type- development of the bedsore with the formation of the cholecystocholedochial fistula

Atresia of the extrahepatic ducts Atresy of the extrahepatic ducts – is characterized with the full defeat of the bile’s evacuation as a result of full obliteration of the extrahepatic ducts

Cysts of the bile ducts Cysts of the bile ducts – is the extension of the intra- and extrahepatic bile ducts

Posttraumatic strictures of the bile ducts Posttraumatic strictures of the bile ducts – it is the strictures of the bile ducts as a result of their defeat Classification of the posttraumatic strictures of the bile ducts By the level of defeat High Low By the degree of stricture Full Not full By the duration of defeat Limited (to 1 sm) Spreaded (1-3 sm) Subtotal (over 3 sm) Total By the clinic currency With the jaundice With the cholangitis With the external bile fistula With the biliar cirrhosis of liver

Primary sclerosing cholangitis Primary sclerosing cholangitis – idiopathic disease, characterised with the diffuse inflammation and fibrosis of the bile ducts 1. PSC, not connected with other additional diseases 2. PSC, developing on the background of inflammatory diseases of intestines (ulcer colitis, Crone’s disease) 3. PSC, connected with the system fibrous changes (retroperitoneal fibrosis, Veber-Crengen’s disease, Ridel’s thyreoditis, mediastinal fibrosis) 4. PSC, connected with other autoimmune diseases (lupus, RA, diabetes 1 type, Shegren’s disease) 5. At some cases the development of the PSC connect with the development of immune deficit, as innate, so obtained (AIDS and other)

Secondary sclerosing cholangitis Secondary sclerosing cholangitis unites the group of cholangitis with the directly stated etiologic factor The reasons of the secondary sclerosing cholangitis 1. Choledocholithyasis 2. Postoperative scare strictures 3. Fungous infection 4. Parasite invasion 5. Pancreatitis 6. Intraductal and intraarterial introducing of some medicines 7. Ischemia as a result of trauma of the vessels 8. Cholangiocarcinoma or limphoma

Recidivate festering cholangitis – develops after passed cholangitis as a result of not adequate sanation of the bile ducts Clinic picture Pain in the right under-rib, high temperature with the shiverings, slow progressive jaundice Incitants of the RFC Gram negative, conditionally pathogeneous flora, less – anaerobe infection

Tumorous defeats of the bile ducts 1. Tumors of the pancreas’s head 2. Tumors of the big duodenal teat 3. Tumors of the liver’s gates 4. Tumors of the gall bladder 5. Secondary (metastatic) defeat of the perycholedochial lymph nodes

External compression of the bile ducts Tumorous defeat of the hepatobiliar zone Tumors of the pancreas’s head, tumors of the big duodenal teat, tumors of the liver’s gates, gall bladder, secondary (metastatic) defeat of the perycholedochial lymph nodes Inflammatory diseases Pancreatitis, cysts of the pancreas, papillitis, diverticulitis, perycholedochial lymphadenitis, postbulbar ulcer of the duodenum, parapapillar or perypapillar divrticulitis Diseases of the vessels Aneurisms of the hepatic artery, abdominal aorta, cavernous transformation of the portal vein

Parasite invasion of the bile ducts Round worms (ascarides, hair-head) Suckers (two-moustaches of cats, hepatic) Ribbon worms (bull cepen, pig cepen, echinococc)

The main clinic symptoms at the mechanical jaundice Jaundice of the skin, scleras; Skin scratching; Discoloration of the excrements; Darkening of urine.  

Clinic forms of the mechanical jaundice Jaundice-painful form Jaundice-pancreatic form Jaundice-cholecystitis form Jaundice-septic form Jaundice-not painful form

Physical data at the mechanical jaundice Jaundice of the skin, scleras, mucous shells; High temperature; Light (acholic) excrement; Urine with a color of beer or strong tea; Increased sizes of liver and gall bladder; Pain in the right under-rib;  Formation in the abdominal cavity at the palpation; Curvuaz’e’s syndrome.

Laboratory data at the mechanical jaundice Hyperbilerubinemia because of direct fraction; Increased level of the hepatic fraction of alkaline phosphatas of blood; High level of bile acids; Hypercholesterinemia; Absence of the stercobilin in the excrement, urobilinogen in the urine; Increased content of the bile pigments in urine.

Hepatic insufficiency It is the complex of symptoms, characterized with the defeat of one or many functions of the liver as a result of acute or chronic defeat of its parenchima, at which there is no correspondence between requirements of the organism and possibilities of the liver in satisfaction of these requirements.

Clinic stages of the hepatic insufficiency I stage of the hepatic insufficiency II stage of the hepatic insufficiency III stage of the hepatic insufficiency

Clinic picture at the I stage of the heepatic insufficiency The state is satisfactory, asthenovegetative, dyspeptic, painful syndromes. Cholestatic syndrome. Jaundice of the scleras, skin, increasing of the liver; hypoalbuminemia. Cytolitic syndrome. Subicterous scleras, the liver is increased, compact concentration, its border is sharp, sometimes the spleen is increased; Субиктеричность склер, печень умеренно увеличена, плотной консистенции, край её заострен, иногда увеличена селезенка; hypoalbuminemia with dysproteinemia.

Biochemical factors of blood at the first stage of hepatic insufficiency Bilirubin Alkaline phosphatase AST ALT Cholestatic syndrome Cytolitic syndrome

Clinic picture at the II stage of hepatic insufficiency the state is middle: asthenovegetative, dyspeptic syndromes, insomnia, sleepiness in a day, apathy, fever.. Cholestatic syndrome. Jaundice of the scleras, skin with the grey tone, scratching, pain in joints and bones, balloned abdomen, hemorrhages, significant increasing of the liver; its surface is smooth, compact, the border is rounded or sharp, hypoalbuminemia. Cytolitic syndrome. Icterous scleras, skin, vessel’s stars on the skin, the liver is significantly increased, compact concentration, not smooth surface, spleenomegaly with the hyperspleenism; ascitis, varicous extended veins of the esophagus, different hemorrhages, nasal, gastral, uterus bleedings; hypoalbuminemia with dysproteinemia.

Biochemical factors of blood at the first stage of hepatic insufficiency Bilirubin Alkaline phosphatase AST ALT Cholestatic syndrome Cytolitic syndrome

Clinic picture at the III stage of the heepatic insufficiency The state is hard or very hard, jaundice of the skin, fever, sometimes the “hepatic” smell from the mouth, hemorrhagic diathesis, significant increasing of liver or its reduction. А – deceleration of the thinking, defeat of sleeping, disorientation, depression or euphoria, sometimes appearance of the tremor of hands. Hypoalbuminemia with dysproteinemia. B – defeat of the consciousness, enxiety with the delirium, sleepiness, disorientation, significant tremor of hands (pre-coma). C – absence of the consciousness, rigid muscles of the head, pathologic reflexes (coma).

Biochemical factors of blood at the third stage of hepatic insufficiency Bilirubin AST ALT

Stages of the diagnostic careful gathering of the anamnesis, physician examination, using of the screening laboratory researches. wording of the preliminary diagnosis (suspicion to the obstructive genesis of the jaundice). choose and indication of the sequence of using of the special instrumental methods of the research for topic diagnostic.

Anamnesis Presence of the GSD in the anamnesis Attacks of the pain Fever, shivering Operations on the bile ducts in the anamnesis Firm skin scratching Loss of the weight Elder age

Methods of the instrumental diagnostic 1. Not invasive methods: US computer tomography 2. Invasive methods : ERPChG TTHG

Ultra sonic research

Computer tomography

Endoscopic retrograd pancreatocholagiography

Transcutaneus transhepatic cholangiography

Types of jaundice Hemolytic Parenchimatous Mechanical

Hemolytic jaundice Hemolytic jaundice is conditioned by the increased defeat of the erytocytes or their not developed predecessors. As a result of this the increased formation of the bilerubin begins, that the liver cannot evacuate it fully.

Parenchimatous jaundice is conditioned by the defeat of the hepatocytes and bile capillaries, with the increasing of the not direct bilerubin in blood.

Mechanical jaundice Mechanical jaundice develops at the obstacle to the passage of bile from the bile ducts to the duodenum

Differential diagnostic of the jaundice by the clinic signs Type of the jaundice mechanical parenchimatous hemolytuc Color of skin Green-yellow with the bronze tone Red-yellow with the orange tone Lemon-yellow Skin scretching Very expressed Expressed Absence Color of excrement decolorized, grey-white At the top of the disease decolorized Intensive colorized Color of urine Dark Ordinary Appetite Defeated at the long lasting jaundice Reduced or absence Not defeated Dyspeptic phenomena Yes Pain in the abdomen May be No or not strong No

Differential diagnostic of the jaundices by the clinic signs Type of the jaundice mechanical parenchimatous hemolytuc Weakness, adynamy Yes Absence Gall bladder Increased at the low obstruction Not increased Pulse Bradicardy Normal or tachycardia Liver Increased Not very increased Селезенка Sometimes increased Often increased Повышенная кровоточивость

When the mechanical character of jaundice is defined it is necessary to carry out the differential diagnostic between the benignus and malignus jaundice to the right choose of the treatment tactic

Differential diagnostic of the mechanical jaundices by the clinic signs Benignus jaundice Malignus jaundice External look of the patient The patients are thick The patients are cachectic anamnesis Calculous cholecystitis in the anamnesis, the pain connects with the feeding. No particularities Complaints Pain in the right under-rib Repulsion to the feeding, general weakness, loss of weight. Gall bladder Gall bladder may be not palpated Positive Curvuas’e’s symptom

Need of two-stage treatment On the background of the hepatic and renal insufficiency, long lasting at the state of jaundice inducts such changes in the organs and systems that the reconstruction of the normal passage of bile by the one-stage operative way may cause the progressing of the hepatic insufficiency

Liquidation of the polyorgan insufficiency I stage Drainage Dosed decompression Liquidation of the polyorgan insufficiency

Reconstruction of the normal passage of the bile into the intestine II stage Reconstruction of the normal passage of the bile into the intestine Endoscopic retrograd interventions Transcutaneus transhepatic endobiliar interventions Absence of the effect Open operations

Indications to the endoscopic retrograd interventions extension of the choledoch by the US data over 8 mm discovery of the reasons of the MJ and localization of the pathologic process in the bile ducts hyperbilerubinemia with the bad visualization of the extrahepatic bile ducts by the US data

Contraindications to the endoscopic retrograd endobiliar interventions Acute infarct acute breaches of the blood circulation hard not corrective manifestations of the heart-vassels and breathing insufficiency

Endoscopic retrograd pancreatocholangiography Nasobiliar drainage Types of the endoscopic retrograd endobiliar interventions Endoscopic retrograd pancreatocholangiography Nasobiliar drainage

Indications to the endoscopic papillosphincterotomy choledocholithyasis stenosing papillitis stenosis of the terminal department of the choledoch and big duodenal teat with the duration to 1,5 sm mechanical jaundice with the hepatic insufficiency of I and II degree

Types of the papillosphincterotomy Boarded papillosphincterotomy Subtotal or total papillosphincterotomy Papillotomy

Technic of the nasobiliar drainage

ERPChG after EPST ERPChG before EPST

Types of the REBI Extraction of the stones with the help of flexible irons Extraction of the stones with the help of Dormia’s probe Extraction of the stones with the help of Fogarty’s probe dilatation at the strictures of the TDCh Deleting of the stones by the double latex balloon Deleting of the stones by the Fogarty-Dormia’s catheter Loop-trap for extraction of the stones

Complications after the retrograd interventions 1. fever, sepsis, bacteriemia 2. acute pancreatitis 3. ascending festering cholangitis and abscesses of the liver 4. hard painful reaction with the picture of acute abdomen 5. perforation of the wall of the common bile duct, peritonitis, subhepatic abscesses 6. shock state as a result of acute defeat of the passage of bile and defeat of the wall of the common bile duct 7. false ways in the tissues, appears at the introducing of different instruments

Indications to the TTChG Impossibility of the performing of the endoscopic retrograd interventions, their inefficiency, presence of the contraindications to them. Tumors of the hepaticoduodenal zone, creating the block of the bile ducts.

Contrandications to the TTChG - presence of the volume formations in the projection of the possible puncture -  reducing of the PTI to 50% and lower -  reducing of the number of trombocytes to 100 thousands and lower -  interposition of the intestine between the abdominal wall and liver - festering diseases of the soft tissues in the zone of possible puncture -  allergic reactions to the iodine preperates in the anamnesis

Types of drainage of the bile ducts - External - External-internal - Internal

External drainage

External-internal drainage

Internal drainage

Complications of the TTEBI Bleeding Haemobilia Cholangitis Bilerhea into the abdominal cavity Dislocation of the catheter Pneumothorax

The way of dosed decompressio to 5-6 hours decompression on 35-40 mm hyd. pole.

Method of the double drainage of the bile ducts

Extractor of the stones type Dormia

Dilatation catheter of Gruntcig

Indication to the second stage of the treatment of mechanical jaundice – reconstruction of the constant passage of bile into the intestine Reducing of the bilerubin lower than 40 mcmol/l, transaminases lower than 1,5 mmol/l, normalization of the factors of the urea, creatinin, electrolytes, coagulogramme, level of common peptid not lower than 50 g/l, normalization of the biliar pressure, reducing of the microbe contamination to 103 CFU/ml, improvement and stabilization of the general state of the patients

Operations, performing at the impassibility of the disatal department of the choledoch 1) Internal transduodenal choledochoduodenostomy. 2) transduodenal sphincterotomy and sphincteroplastic 3) choledochoduodenostomy by Yurash, Finsterer, Flerken 4) Pancreatoduodenal resection

Internal transduodenal choledochoduodenostomy

Transduodenal papillosphincterotomy and papillosphinteroplastic

Choledochoduodenostomy ChDA by Yurash ChDA by Flerken ChDA by Finsterer

Pancreatoduodenal resection

Defects of the choledochoduodenostomy 1) ChDA unloads only bile system and doesn’t induct the decompression at the system of pancreatic ducts. 2) ChDA promotes the development of the bends and deformations of the duodenum after the operation. 3) At the ChDA the distal department of the choledoch forms blind bag. 4) Risk of the development of the ascending cholangitis

Operations, performing at the impassibility common bile duct and supraduodenal part of the choledoch 1) Choledochotony with the “deaf stitich” or different types of the drainage of the choledoch 2) Plastic of the stricture or its resection with the anastomosis of the duct “end-by-end” 3) Bileodigestive anastomosis

Operations, performing at the strictures of the choledoch Plastic of the choledoch by Geyneke-Mikulich Resection with the anastomosis “end-by-end”

Terminolateral hepaticoenteroanastomosis Terminolateral hepaticojejunoanastomosis with the Y-form interintestinal mouth by Ru Terminolateral hepaticojejunoanastomosis with the Y-form interintestinal anastomosis “side-by-side”

Ways of the drainage of the bile ducts Drainage of the choledoch by Vishnevskiy Drainage of the choledoch by Ker Drainage of the choledoch by Certe Drainage of the choledoch by Holsted