Supervised by Dr. Jamal Hamdi Surgical Jaundice Supervised by Dr. Jamal Hamdi

Definition Of Jaundice yellow pigmentation of skin, mucous membrane or sclera Jaundice clinically detected when serum bilirubin level ( 2.5 mg/dl) Normal serum bilirubin (0.2-1.0 mg/dl ) caused by an excess of bile pigments in plasma It is a symptom not a disease

Bilirubin Metabolism Bilirubin is produced from the breakdown of haemoglobin in the reticuloendothelial system. 95% of the circulating bilirubin is unconjugated and bound to albumin .

Bilirubin Metabolism RES Hepatic metabolism occurs in 3 phases: - Uptake - Conjugation - excretion RES

Pathophysiology Of Hyperbilirubinemia Over production by RES Failure of hepatocellular uptake Failure of conjugation or excretion Obstruction of biliary excretion into intestine

Classification Of Jaundice Prehepatic: RBC disorders ( Hereditary spherocytosis , SCA) Auto-immune ( Mismatched blood transfusion ) Infective ( Sepsis , Malaria ) Hepatic : Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome ) Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc ) Posthepatic (obstructed) surgical

Etiology Of Obstructive Jaundice Common: Common bile duct stone. Cancer head of pancreas

Etiology Of Obstructive Jaundice Less Common: Ampullary carcinoma Pancreatitis. Mirrizi syndromes. Sclorosing cholangitis. Cholangiocarcinoma

Approach To Jaundice Patient ( PreHepatic , Hepatic , PostHepatic ) History Careful History is of very important value to guide the D\D toward the cause & the type of jaundice ( PreHepatic , Hepatic , PostHepatic )

Approach To Jaundice Patient History Onset Gradual ? cirrhosis pancreatitis cancer Sudden ? CBD stone Hepatitis

Approach To Jaundice Patient History Pattern Progressive? Pancreatic carcinoma Cholangiocarcinoma fluctuating ? CBD stone Ampullary carcinoma Hemolytic episodes

Approach To Jaundice Patient History Pain Painful? CBD stone Pancreatic diseases painless? Malignancy

Approach To Jaundice Patient Other symptoms of obstructive jaundice History Other symptoms of obstructive jaundice Pruritis Fatty dyspepsia Steatorrhea Dark urine , pale stool Bleeding disorder

Approach To Jaundice Patient History RUQ pain , fever Symptoms of anemia Hx of SCD G6PD deficiency ? Food related ? Symptoms of malignancy ( weight loss & anorexia )

Approach To Jaundice Patient History Past Medical Blood transfusion Hx of drugs Past Hx of surgery Family Hx of jaundice & hemolytic disorders Alcohol Occupation & travel Past Surgical Hx Family Hx

Approach To Jaundice Patient Stigmata of Chronic Liver Disease Physical Examination General Appearance Stigmata of Chronic Liver Disease General Examination Cachexia Muscle Wasting Yellow Discoloration Palmar erythema clubbing . flapping tremor. duputrine’s contracture . Spider nevi gynecomastia caput medosa testicular atrophy Jaundice Scratch marks Pallor Vital Signs

Approach To Jaundice Patient Physical Examination Abdominal Discolration , scars ( collen’s , Grey Tuner ) RUQ pain Murphy sign Palpaple Gallbladder ( Courvoisier’s law ) Abdominal masses ( malignancy ) Hepatomegaly , splenomegaly , ascitis PR : color of stool . Abdominal Examination

Obstructive Jaundice Invistigation Laboratory Exam Imaging Invasive

Obstructive Jaundice Invistigation Laboratory Exam Blood LFT: Serum bilirubin (Direct / Indirect) , Albumin , ALT , AST , ALP, LDH , CBC , Electrolyte , Amylase Urine Urine analysis Stool The investigations will differentiate hepatocellular and obstructive jaundice In most of the cases

Invistigation Obstruction Hepatitis Cirrhosis Bilirubin Alk phos   Alk phos  / ALT/AST / gGT PT (INR) 

Operative cholangiogram Obstructive Jaundice Invistigation Imaging Non-invasive AXR US CT MRI/MRCP Invasive ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy

Obstructive Jaundice Invistigation Imaging Non-invasive 1- The presence of gall stones 2- the thickened wall of the gallbladder in acute or chronic inflammation 3- The Diameter of CBD more than 7mm is suggestive of presence of stones Ultrasounde Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation.

Obstructive Jaundice Invistigation Imaging Ultrasounde Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation.

Obstructive Jaundice Invistigation Imaging Non-invasive Determine the specific causes and level of obstruction CT scan can only image calcified stones CT Scan

Obstructive Jaundice Invistigation Imaging CT Scan High-resolution, helical CT scan in a patient with obstructive jaundice. The scan demonstrates a tumor (large arrow) anterior to the portal vein with a stent (white area adjacent to large arrow) in place. Dilated intrahepatic bile ducts (small arrows) are evident in the right lobe of the liver.

Obstructive Jaundice Invistigation Imaging Non-invasive Routine investigation-base-line & may show specked calcification in the region of pancreas. X-Ray

Magnatic resonance cholangiopancreatography (MRCP) Obstructive Jaundice Invistigation Imaging Non-invasive Magnatic resonance cholangiopancreatography (MRCP) Sensitive noninvasive method of detecting biliary and pancreatic duct stones stricture or dilatations within the biliary system MRCP

Obstructive Jaundice Invistigation Imaging Invasive Useful for lesion distal to the bifurcation of the hepatic ducts (diagnostic ) ERCP has a (therapeutic) application because obstruction can potentially be relieved by the removal of stones , sphcterotomy and placement of stent and drains ERCP

Obstructive Jaundice Invistigation Imaging ERCP

Obstructive Jaundice Invistigation Imaging ERCP

Useful for lesions proximal to common hepatic duct Obstructive Jaundice Invistigation Imaging Invasive Percutaneous transhepatic cholangiogram (PTC ) Useful for lesions proximal to common hepatic duct PTC

Obstructive Jaundice Treatment According To The Cause

Obstructive Jaundice Treatment Goal of Treatment • Relief of Obstruction • Prevent Complication • Prevent Recurrence

Jaundice caused by Gallstones Obstructive Jaundice Treatment Defined as stones in the CBD intermittent obstruction of CBD Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos. Evaluation By : U\S , ERCP , CT Jaundice caused by Gallstones

Jaundice caused by Gallstones Obstructive Jaundice Treatment Evaluation By : ERCP Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5% ERCP Jaundice caused by Gallstones

Jaundice caused by Gallstones Obstructive Jaundice Treatment Open CBD Exploration Indications Presence of multiple stones (more than 5) Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones after sphincterotomy Jaundice caused by Gallstones

CBD Exploration – Surgical Options Jaundice caused by Gallstones Obstructive Jaundice Treatment CBD Exploration – Surgical Options Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy Jaundice caused by Gallstones

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment At the time of diagnosis, 52% of all patients have distant disease 26% have regional spread.  The relative 1-year survival is only 24% the overall 5-year survival rate for this disease is less than 5%.  Carcinoma Head Of Pancreas

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Resectable Non Resectable Carcinoma Head Of Pancreas Surgical treatment Non surgical treatment (metal stents)

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment resectability. ?  Resectable, unresectable ?  experience and technical skill of the surgeon And overall health of the patient  Typically, extrapancreatic disease precludes curative resection, and surgical treatment may be palliative at best.    Carcinoma Head Of Pancreas

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Carcinoma Head Of Pancreas

Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor

Non surgical treatment Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Non surgical treatment Inoperable Patient :- - Endoscopic expandable metallic stent Bypassed By Hepatojejunostomy ( Roux-en-Y)   Carcinoma Head Of Pancreas

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment surgical treatment Operable Patient :- Whipple’s Operation Pancreaticoduodenectomy Curative ?   Carcinoma Head Of Pancreas

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Is It Curative ??

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipple’s Operation

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipple’s Operation

Carcinoma Head Of Pancreas Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipple’s Operation

Obstructive Jaundice Treatment Bile Duct Stricture Traumatic stricture:- by passed Malignant stricture: - resection with reconstruction by hepatico jejunostomy . Sclerosing cholongitis: Surgical excision Per cuteneous dilation Bile Duct Stricture

Complications Of Obstructive Jaundice Ascending cholangitis Clotting disorders Hepato-renal syndrome Drug Metabolism Impaired wound healing Be Aware Of life threatening Complications

Bailey & Love short practice of surgery References Bailey & Love short practice of surgery Clinical Surgery By : A.Cuschieri Lecture Note : General Surgery 11th Edition http://www.radiologyassistant.nl/en/43848b63def9d http://emedicine.medscape.com/

Abbas A. Damanhori Abdulmajeed Fairaq Abdulrahman R. Nazer Done By Abbas A. Damanhori Abdulmajeed Fairaq Abdulrahman R. Nazer Hassan Abu Rokbah