Surgical Jaundice

KEHINDE Adeleke

Outline of Discussion• Definition• Epidemiology• Classification• Pathophysiology• Clinical evaluation• Management

Definition• Jaundice is the yellowish pigmentation of the skin, the

conjunctival membranes over the sclerae, and other mucous membranes caused by hyperbilirubinemia.

• Total serum bilirubin values are normally 0.2-1.2 mg/dL. Jaundice may not be clinically recognizable until levels are at least 3 mg/dL.

• Jaundice is not a diagnosis.• Surgical jaundice is any jaundice amenable to surgical

treatment. Majority are due to extrahepatic biliary obstruction.

• Not all obstructive jaundice is surgical jaundice e.g hepatitis and not all surgical jaundice is due to obstruction e.g congenital spherocytosis

EpidemiologyRACE• The racial predilection depends on the cause of the

biliary obstruction.• Gallstones are the most common cause of biliary

obstruction. • Persons of Hispanic origin and Northern Europeans

have a higher risk of gallstones compared to people from Asia and Africa.

• Native Americans (particularly Pima Indians)have a lifetime chance of developing gallstones as high as 80%.

SEX• Women are much more likely to develop

gallstones than men. • This increased risk is likely caused by the effect

of estrogen on the liver, causing it to remove more cholesterol from the blood and diverting it into the bile.

Pathophysiology• To better understand these disorders, a brief discussion of the

normal structure and function of the biliary tree is needed.• Bile is the exocrine secretion of the liver and is produced

continuously by hepatocytes. It contains cholesterol and waste products, such as bilirubin and bile salts, which aid in the digestion of fats. Half the bile produced runs directly from the liver into the duodenum via a system of ducts, ultimately draining into the common bile duct (CBD). The remaining 50% is stored in the gallbladder.

• In response to a meal, this bile is released from the gallbladder via the cystic duct, which joins the hepatic ducts from the liver to form the CBD. The CBD courses through the head of the pancreas for approximately 2 cm before passing through the ampulla of Vater into the duodenum

• Biliary obstruction refers to the blockage of any duct that carries bile from the liver to the gallbladder(intrahepatic) or from the gallbladder to the small intestine(extrahepatic).

• This can occur at various levels within the biliary system.

• The major signs and symptoms of biliary obstruction result directly from the failure of bile to reach its proper destination.

• The failure of biliary flow may be due to biliary obstruction by mechanical means or by metabolic factors in the hepatic cells.

• For the sake of simplicity, the primary focus of this presentation is mechanical causes of biliary obstruction, further separating them into intrahepatic and extrahepatic causes.

• The discussion of intracellular/metabolic causes of cholestasis is very complex, the pathogenesis of which is not always clearly defined. Therefore, these causes are mentioned but are not discussed in detail.

• Intrahepatic cholestasis generally occurs at the level of the hepatocyte or biliary canalicular membrane. Causes include hepatocellular disease (eg, viral hepatitis, drug-induced hepatitis), drug-induced cholestasis, biliary cirrhosis, and alcoholic liver disease.

• In hepatocellular disease, interference in the 3 major steps of bilirubin metabolism, ie, uptake, conjugation, and excretion, usually occurs. Excretion is the rate-limiting step and is usually impaired to the greatest extent. As a result, conjugated bilirubin predominates in the serum.

• Extrahepatic obstruction to the flow of bile may occur within the ducts or secondary to external compression. Overall, gallstones are the most common cause of biliary obstruction. Other causes of blockage within the ducts include malignancy, infection, and biliary cirrhosis.

• External compression of the ducts may occur secondary to inflammation (eg, pancreatitis) and malignancy. Regardless of the cause, the physical obstruction causes a predominantly conjugated hyperbilirubinemia

• The lack of bilirubin in the intestinal tract is responsible for the pale stools typically associated with biliary obstruction.

• The cause of itching (pruritus) associated with biliary obstruction is not clear. Some believe it may be related to the accumulation of bile acids in the skin. Others suggest it may be related to the release of endogenous opioids.

Causes

• Causes of biliary obstruction can be separated into intrahepatic and extrahepatic.

• intrahepatic causes are most commonly hepatitis and cirrhosis, Drugs e.g thiazides, chlorpromazine,augmentin etc

• Extrahepatic causes may be further subdivided into intrinsic, intraluminal and extrinsic

• Stone disease is the most common cause of obstructive jaundice.Larger stones can become lodged in the CBD and cause complete obstruction, with increased intraductal pressure throughout the biliary tree.

• Mirizzi syndrome is the presence of a stone impacted in the cystic duct or the gallbladder neck, causing inflammation and external compression of the common hepatic duct and thus biliary obstruction.

• Of biliary strictures, 95% are due to surgical trauma and 5% are due to external injury to the abdomen or pancreatitis or erosion of the duct by a gallstone.

• A tear in the duct causes bile leakage and predisposes the patient to a localized infection. In turn, this accentuates scar formation and the ultimate development of a fibrous stricture.

• Of parasitic causes, adult Ascaris lumbricoides can migrate from the intestine up through the bile ducts, thereby obstructing the extrahepatic ducts.

• Eggs of certain liver flukes (eg, Clonorchis sinensis, Fasciola hepatica) can obstruct the smaller bile ducts within the liver, resulting in intraductal cholestasis. This is more common in Asian countries

• PSC is most common in men aged 20-40 years, and the cause is unknown.

• PSC is characterized by diffuse inflammation of the biliary tract, causing fibrosis and stricture of the biliary system. It generally manifests as a progressive obstructive jaundice and is most readily diagnosed based on findings from endoscopic retrograde cholangiopancreatography (ERCP).

• AIDS-related cholangiopathy manifests as abdominal pain and elevated liver function test results, suggesting obstruction. The etiology of this disorder in patients who are HIV-positive is thought to be infectious (cytomegalovirus, Cryptosporidium species, and microsporidia have been implicated). Direct cholangiography often reveals abnormal findings in the intrahepatic and extrahepatic ducts that may closely resemble PSC.

• Biliary tuberculosis is extremely rare.• Histopathologic evidence of caseating

granulomatous inflammation with bile cytology revealing M tuberculosis is confirmatory. Polymerase chain reaction is useful to expedite the diagnosis if biliary tuberculosis is being considered

• Biliary obstruction associated with pancreatitis is observed most commonly in patients with dilated pancreatic ducts due to either inflammation with fibrosis of the pancreas or a pseudocyst.

• Notably, intravenous feedings predispose patients to bile stasis and a clinical picture of obstructive jaundice. Consider this in the evaluation of biliary obstruction.

• Sump syndrome is an uncommon complication of a side-to-side choledochoduodenostomy in which food, stones, or other debris accumulate in the CBD and thereby obstruct normal biliary drainage

Clinical Evaluation

• History• Examination• Investigations• Treatment

History• Patients commonly complain of pale stools, dark urine, yellowness of the eye,

and pruritus.• The following considerations are important: • Patients' age • Jaundice (duration ,onset, progresion,Associated symptoms:• the presence of abdominal pain( location and characteristics of the pain)• The presence of systemic symptoms (eg, fever, weight loss)• Symptoms of gastric stasis (eg, early satiety, vomiting, belching)• Change in bpwel habit:• History of anemia• Previous malignancy• Known gallstone disease• Gastrointestinal bleeding• Hepatitis• Previous biliary surgery• Diabetes or diarrhea of recent onset• Also, explore the use of alcohol, drugs, and medications

Physical

• Upon physical examination, the patient may display signs of jaundice (sclera icterus).

• When the abdomen is examined, the gallbladder may be palpable (Courvoisier sign). This may be associated with underlying pancreatic malignancy.

• Also, look for signs of weight loss, adenopathies, and occult blood in the stool, suggesting a neoplastic lesion.

• Note the presence or absence of ascites and collateral circulation associated with cirrhosis.

• A high fever and chills suggest a coexisting cholangitis.• Abdominal pain may be misleading; some patients with CBD calculi have

painless jaundice, whereas some patients with hepatitis have distressing pain in the right upper quadrant. Malignancy is more commonly associated with the absence of pain and tenderness during the physical examination.

• Xanthomata are associated with primary biliary cirrhosis (PBC).• Excoriations suggest prolonged cholestasis or high-grade biliary obstruction

Lab studies

Basic• FBC+ Blood film: aneamia, infection,Hgbpathy• Serum E/U/Cr• Urinalysis : bilirubin present, urobilinogen absent• Stool for ocult blood: ca ampula• Stool mcs for ova and parasites• Clotting profile: PT deranged• Hepatitis serology: HbsAg, HCV• LFT: see next slide

pptk

Imaging• Plain radiographs are of limited utility to help

detect abnormalities in the biliary system• Ultrasonography (USS):USS is the procedure of

choice for the initial evaluation of cholestasis and for helping differentiate extrahepatic from intrahepatic causes of jaundice. Extrahepatic obstruction is suggested by the presence of dilated bile ducts, but the presence of normal bile ducts does not exclude obstruction that may be new or intermittent.

• Traditional computed tomography (CT) scan is usually considered more accurate than US for helping determine the specific cause and level of obstruction.

• Percutaneous transhepatic cholangiogram: done esp if the intrahepatic duct is dilated, outline the biliary tree, locates stones and is therapeutic for stent placement and stone retrieval.

• ERCP is an outpatient procedure that combines endoscopic and radiologic modalities to visualize both the biliary and pancreatic duct systems.

• Endoscopic ultrasound (EUS) combines endoscopy and US to provide remarkably detailed images of the pancreas and biliary tree. It uses higher-frequency ultrasonic waves compared to traditional US (3.5 MHz vs 20 MHz) and allows diagnostic tissue sampling via EUS-guided fine-needle aspiration (EUS-FNA)

• Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive way to visualize the hepatobiliary tree.

• MRCP provides a sensitive noninvasive method of detecting biliary and pancreatic duct stones, strictures, or dilatations within the biliary system. It is also sensitive for helping detect cancer.

Treatment

• Medical care:Treatment of the underlying cause is the objective of the medical treatment of biliary obstruction. Do not subject patients to surgery until the diagnosis is clear.

• In cases of cholelithiasis in which either the patient refuses surgery or surgical intervention is not appropriate give

• Ursodeoxycholic acid (10 mg/kg/d) works to reduce biliary secretion of cholesterol. In turn, this decreases the cholesterol saturation of bile.

• Extracorporeal shock-wave lithotripsy may be used as an adjunct to oral dissolution therapy. By increasing the surface-to-volume ratio of the stones, it both enhances dissolution of stones and makes clearing the smaller fragments easier.

• Contraindications include complications of gallstone disease (eg, cholecystitis, choledocholelithiasis, biliary pancreatitis), pregnancy, and coagulopathy or anticoagulant medications (ie, because of the risk of hematoma formation).

• Bile acid–binding resins, cholestyramine (4 g) or colestipol (5 g), dissolved in water or juice 3 times a day may be useful in the symptomatic treatment of pruritus associated with biliary obstruction.

• VIT ADEK SUPPLEMENTS• Antihistamines may be used for the symptomatic

treatment of pruritus, particularly as a sedative at night.

• Discontinuation of medications that may be causing or exacerbating cholestasis and/or biliary obstruction often leads to full recovery. Similarly, appropriate treatment of infections (eg, viral, bacterial, parasitic) is indicated.

SURGERY..Preop care• The following are problems of a jaundiced ptx

and all must be taken care of before surgery• Infection due to biliary stasis• Uncontrolled bleeding due to vit k def• Liver glycogen depletion• Dehydration• Hepatorenal syndrome

Therefore;• Fluid resuscitation using dextrose alternate with

Saline. Encourage oral rehydration as well• Give broad spectrum antibiotics at induction of

anaesthesia to cover for G+,G- and anaerobes• Bowel prep• IM VitK 10mg daily until PT/PPTK normlises( start

5days preop)• Monitor UO, catheterize night before surgery• You may consider given mannitol preop,intraop

and post op for diuresis to prevent hepatorenal syndrome

surgery

• the need for surgical intervention depends on the cause of biliary obstruction.

• Cholecystectomy is the recommended treatment in cases of choledocholithiasis .(open or lap)

• Open cholecystectomy is relatively safe, with a mortality rate of 0.1-0.5 %.

• Laparoscopic cholecystectomy remains the treatment of choice for symptomatic gallstones, partially because of the shorter recovery period, decreased postoperative discomfort, and improved cosmetic result.

• Ca head of pancres• Early stage: whipples operation, pancreatoduodenectomy+ pancreticojejunostomy+

gastrojejunostomy+ cholecystojejunostomy

• Late surgey: bypass surgery

• Cholangiocarcinoma: hepatodochojejunostomy• Cancer ampulla of vater: whipples operation• Chronic pancreatitis: subduodenal exploration,

sphincterectomy, insertion of stent• Liver transplantation may be considered in

appropriate patients.

Prevention• In patients with risk factors for developing any

of the conditions that lead to biliary obstruction, awareness of the signs and symptoms can improve chances for early diagnosis and improved outcome.

• Diet: Reduce intake of saturated fats, High intake of fiber has been linked to a lower risk for gallstones.

• Gradual and modest weight reduction may be of value in patients who are at risk.

• Activity:Regular exercise may reduce the risk of gallstones and gallstone complications

• Estrogens cause an increase in the risk for formation of gallstones and may need to be avoided in patients with known gallstones or a strong family history of stone disease.

Complications

• The complications of cholestasis are proportional to the duration and intensity of the jaundice.

• High-grade biliary obstruction begins to cause cell damage after approximately 1 month and, if unrelieved, may lead to secondary biliary cirrhosis.

• Acute cholangitis is another complication associated with obstruction of the biliary tract and is the most common complication of a stricture, most often at the level of the CBD. Bile normally is sterile. In the presence of obstruction to flow, stasis favors colonization and multiplication of bacteria within the bile. Concomitant increased intraductal pressure can lead to the reflux of biliary contents and bacteremia, which can cause septic shock and death.

• Biliary colic that recurs at any point after a cholecystectomy should prompt evaluation for possible choledocholithiasis.

• Failure of bile salts to reach the intestine results in fat malabsorption with steatorrhea. In addition, the fat-soluble vitamins A, D, E, and K are not absorbed, resulting in vitamin deficiencies.

• Disordered hemostasis with an abnormally prolonged PT may further complicate the course of these patients.

• Cholestyramine and colestipol, used to treat pruritus, bind to bile salts and can exacerbate these vitamin deficiencies.

• Persistent cholestasis from any cause may be associated with deposits of cholesterol in the skin (cutaneous xanthomatosis) and, occasionally, in bones and peripheral nerves.

Conclusion• There are certain signs and symptoms common to all jaundiced patients

(yellow skin, itching). • Specific items from the history and physical examination along with

blood work can help the clinician classify jaundice into obstructive and nonobstructive jaundice.

• Surgical or other mechanical intervention almost exclusively is restricted to cases of obstructive (posthepatic) jaundice.

• Imaging evaluation of the gallbladder and biliary system plays an important role in the evaluation of obstructive jaundice by locating the site and disclosing the nature of the obstruction.

• Ultrasound imaging usually is the first step for suspectedbiliary stone disease. • The physician’s level of suspicion about benign versus malignant causes

of obstructive jaundice will lead to different radiologic tests and interventions.

• Treatment is tailored to the cause of obstruction.

Thank you