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Clinical Practice GuidelinesJaundice

Department of Surgery

What is an operational concept of jaundice?

A yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.

Beers M, Berkow R. The Merck Manual of Diagnosis and Therapy, Seventeenth Edition.Sec 4, Chapter 38.

hypercarotenemia or just carotenemia.

A yellow-to-orange color may be imparted to the skin by consuming too much beta carotene, the orange pigment seen in carrots. In this condition, the whites of the eyes remain white, while people with true jaundice often have a yellowish tinge to the eyes.

MedlinePlus Medical Encyclopedia.

Etiology

Jaundice

PREHEPATIC HEPATIC POSTHEPATIC

Etiology

Jaundice


Etiology

Jaundice


Increased quantity of bilirubin

Etiology

Jaundice


Increased quantity of bilirubin

Decreased transport to liver

Etiology

Jaundice


Etiology

Jaundice


Defective uptake

Etiology

Jaundice


Defective uptake

Defective conjugation

Etiology

Jaundice


Defective uptake

Defective conjugation

Defective excretion of bilirubin by liver cell

Etiology

Jaundice


Etiology

Jaundice


Defective Transport of bilirubin by the Bilary duct system

Treatment

Jaundice


MEDICAL SURGICAL

What are reliable symptoms and signs (more than 90% certainty) that will indicate that patients with jaundice will need surgical treatment?

– RUQ pain– Jaundice– Tea-colored urine/ pale stools– Fever (+/-)– RUQ tenderness– No hepatomegaly

What are reliable symptoms and signs (more than 90% certainty) that a patient with obstructive jaundice needs urgent intervention?

• Abdominal pain (70%) • Jaundice (60%)• Tea-colored urine/pale stools• Altered mental status (10-20%)• Hypotension (30%)• Fever, persistent (90%)• RUQ tenderness

If a paraclinical diagnostic procedure is needed in a patient with suspected obstructive jaundice, what is the most cost-effective procedure?

• Ultrasound

Goal of Treatment

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

Ascending Cholangitis• Prompt drainage• Control infection

Treatment Options

Not available

*40-60,000 pesos in private hospitals

-complications of anesthesia-bleeding-iatrogenic injury to biliaryducts-trocar and needle insufflation injuries

-able to achieve primary treatment objectiveSR=85-100% CBD Clearance

Laparo-scopicsurgery

available*20-30,000 pesos in private hospitals*free to charity pxsat OM

-complications of anesthesia-bleeding-iatrogenic injury to biliaryducts


Opensurgery

Not available

*12-15,000 pesos at MetropolitanHospital *2-3,000 pesos at PGH

-bleeding-perforation-pancreatitis


ERCPAvailabilityCostRiskBenefitTreatment

Treatment Options

available10000-bleedingSR=90% CBD decompressionMtR=15%

PTBD

available*20-30,000 pesos in private hospitals*free to charity pxsat OM

-complications of anesthesia-bleeding-iatrogenic injury to biliaryducts

-able to achieve primary treatment objectiveSR=90-100% CBDMtR=32-40%

Opensurgery

Not available

*12-15,000 pesos at MetropolitanHospital *2-3,000 pesos at PGH

-bleeding-perforation-pancreatitis

-able to achieve primary treatment objectiveSR=90-98% CBD decompressionMtR=10%

ERCPAvailabilityCostRiskBenefitTreatment

Management of the gallbladder after bile duct clearance

4 RCT’sBoerma D, Rauws EA, Keulemans YC, et al. Wait-and-see policy or

laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial. Lancet 2002;360:761-5.

Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients. Lancet 1996;347:926-9.

Hammarstrom LE, Holmin T, Stridbeck H, Ihse I. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg1995;82:1516-21.

Panis Y, Suc B, Escat J. Surgery versus endoscopic sphincterotomy for choledocholithiasis: results of a prospective randomized study. Gastroenterology 1995;108:A431.

Boerma et al• 120 patients aged 18 to 80 years with proved

symptomatic common bile duct and concomitant gallbladder stones who underwent ES and bile duct clearance.

• Patients were randomized to:– LC within 6 weeks of endoscopic stone clearance– “wait and see” approach.

• Results– mean follow-up period of 30 months

• 47% of patients in the wait and see group had recurrent biliary symptoms compared with 2% in the LC group.

• 37% of the wait and see group needed cholecystectomy.

Targarona et al

• randomized 98 elderly and other high-risk patients with symptoms likely caused by bile duct stones– ES alone – open surgery

• Result– mean follow-up of 17 months,

• biliary symptoms recurred in 20% of the ES group and 6% of the surgery group.

Hammarstrom et al• randomized 83 patients with bile duct stones

– ES and stone removal – open surgery (cholecystectomy and bile duct

exploration) • Result

– after more than 5 years, • 20% of the ES group underwent cholecystectomy because of

recurrent biliary symptoms, • 2% of patients in the surgery group had recurrent symptoms

from bile duct stones.• During the follow-up period, nonbiliary mortality was

significantly more common in the ES group

Panis et al

• randomized 206 patients with commonbile duct stones– endoscopic therapy alone – surgery

• Result– early surgery was required in 19% in the

endoscopic group, – only 2% of the surgical group needed

reoperation.

recommendation

patients with cholangitis should undergo elective Lap Chole after bile duct clearance if they are fit for surgery (unless an open approach is known to be required).

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Clinical Practice Guidelines jaundice - Tripod.comj_deguzman_gsj.tripod.com/Clinical Practice Guidelines jaundice.pdf · obstructive jaundice, what is the most cost-effective procedure?