1. 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

2. 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

3. 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.

4. 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.

5. 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

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

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

8. 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.

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

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

11. 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).

12. Anatomy

13. 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)

14. 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.

15. 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

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

17. 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

18. REFERRED PAIN

19. 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

20. 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 % and specificity %
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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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

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