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OBSTRUCTIVE JAUNDICE

a

Anatomy

Anatomy

Calot's triangle

Physiology

Physiology

Bile salts & enterohepatic circulation

Bile salt pool 2-4g (cycles 6-12 times/day)

hepatic synthesis (0.2-0.6g/day)

stored in gallbladder

(12-32g/day)

(0.2-0.6g/day)

Physiology

Bilirubin

waste product excreted in bile

(not to be confused with bile salts!!)

Obstructive jaundice

Physiology

The gallbladder

  • capacity of 50mL
  • can concentrate bile by a factor of 10

JAUNDICE

Yellow discolouration of skin & sclera

Clinically apparent when serum bilirubin > 50µmol/L (normal <20µmol/L)

Jaundice

Prehepatic Jaundice

haemolytic jaundice

eg:

-hereditary spherocytosis

-post blood transfusion

-haematoma formation (post operative/-accidental trauma)

congenital non-haemolytic hyperbilirubinaemia

eg: Gilbert's syndrome

Hepatic Jaundice

"medical"

viral hepatitis

decompensated liver cirrhosis

drug overdose

etc

Posthepatic jaundice

aka. obstructive/cholestatic jaundice

2 types:

-intrahepatic obstruction

-extrahepatic obstruction

Intrahepatic obstruction

intrahepatic obstruction of bile canaliculi

eg:

-acute/chronic liver disease

-drugs (eg: chlorpromazine)

Extrahepatic obstruction

extrahepatic obstruction

eg:

-gallstones

-cancer of head of pancreas

-cancer of periampullary region/major bile ducts

-extrinsic compression of bile ducts by metastatic tumour/iatrogenic biliary stricture/choledochal cyst

Clinical Presentation

Clinical Presentation

History

History

History:

  • age, sex, occupation, social habits, drug/alcohol intake, injections/infusions
  • pain hx
  • intermittent pain + fluctuating jaundice + dyspepsia = CBD stone
  • weight loss + progressive jaundice = neoplasia
  • dark urine + pale stools + pruritus = obstructive jaundice
  • chronic liver disease stigmata = hepatic jaundice

Examination

Exam

Examination:

  • general demeanor
  • jaundice (serum bilirubin >35µmol/L)
  • hepatomegaly
  • gallbladder distension (gallstones unlikely)

  • signs of chronic liver disease (palmar erythema, spider naevi, gynaecomastia, testicular atrophy)
  • signs of portal hypertension (splenomegaly, ascites, caput medusae)

Investigations

Diagnosis

Bedside Ix

Bedside Ix

Imaging

Imaging

  • Ultrasound Scan (USS)
  • Magnetic Resonance Cholangiopancreatography (MRCP)
  • Endoscopic Retrograde Cholangiopancreatography (ERCP)
  • Percutaneous Transhepatic Cholangiography (PTC)
  • Computed Tomography (CT)
  • Others

USS

  • look for CBD dilatation/gallbladder distension due to obstruction
  • determine level of obstruction following distally from the dilation of intrahepatic biliary radicles
  • look for gallstones (hyperechoic lesions casting an 'acoutic shadow')
  • look for space occupying lesions in liver and pancreas
  • stones in dilated CBD and pancreatic lesions may not be seen clearly due to overlying bowel gas
  • look for regional lymphadenopathy/liver mets/free fluid in cancer

MRCP

  • non-contrast MRI scans for detecting stones (filling defects) amidst biliary secretions (white)
  • contrast MRI scans for staging hepatic/biliary/pancreatic tumours invading biliary tree

ERCP

  • diagnostic & therapeutic
  • outlines biliary system by injecting contrast through a cannula inserted through papilla of Vater by means of a side-viewing endoscope passed into the duodenum
  • indications:

1) endoscopic extaction of CBD stones

2) biopsy of periampullary tumours

3) stent insertion to relieve obstructive jaundice

  • risk of complications:

- acute pancreatitis

- cholangitis (give prophylatic antibiotics in complex interventions)

- haemorrhage

- perforation

PTC

  • restricted to therapeutic indications for proximal biliary lesions or failed ERCP for distal lesions
  • ultrasound-guided needle passed through liver into biliary system
  • catheter passed to drain bile
  • drain/stent passed to cross obstructing lesion
  • risk of complications:

- haemorrhage (check coag before procedure)

- bile leakage

- bacteraemia (prophylactic antibiotics)

- renal dysfunction (hydration before procedure)

  • contraindications: ascites, bleeding disorders, hepatic hydatidosis

CT

  • stage cancer
  • diagnose acute pancreatitis

CT

Other Ix

  • PET-CT is used to stage HPB cancers
  • Isotopic liver scanning (out of fashion)
  • Selective angiography (out of fashion) is used for embolisation of tumours/haemorrhagic complications of HPB diseases

Liver biopsy

Biopsy

  • Indication= unexplained jaundice (obstructing lesion has been excluded on imaging)
  • Ultrasound/CT-guided liver biopsy
  • Check PT, Platelet, HBsAg status & correct clotting before biopsy
  • Absolute contraindication = Ascites

Laparoscopy

/Laparotomy

  • To evaluate liver disease
  • To stage tumour of liver/pancreas/biliary tree to exclude peritoneal/hepatic dissemination
  • Under GA

Laparoscopy/ Laparotomy

Investigation Summary

Investigation Summary

Management of the Jaundice patient

Management

  • IV Vitamin K (bleeding risk, so correct prolonged prothrombin time within 36hr)
  • VTE prophylaxis (also thrombogenic)
  • nutritional supplementation & pancreatic enzyme replacement Tx (malnourished & steatorrhoea in chronic obstructive jaundice)
  • hydration (renal vasoconstriction/peripheral vasodilation/hypovolaemia/septicaemia)
  • treat suspected SEPSIS
  • early biliary decompression
  • antibiotic prophylaxis & biliary drainage (jaundiced patients have increased risk of cholangitis & subsequent septicaemia due to bacterial translocation/ iatrogenic)

Gallstones

  • majority of individuals with gallstones are asymptomatic and remain so (<20% gallstones develop symptoms/complications within 10yrs)
  • presence of gallstones is not in itself an indication for cholecystectomy
  • cholecystectomy if stones likely to cause complications (multiple stones/acute pancreatitis/gallbladder ca)
  • ERCP only in high suspicion of choledocholithiasis

(Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Internal Clinical Guidelines Team (UK). London: NICE (UK); 2014 Oct. Available from http://ncbi.nlm.nih.gov/pubmedhealth/PMH0070643/)

Gallstones

Symptomatic gallstones / chronic cholecystitis

Symptomatic gallstones

elective day case laparoscopic cholecystectomy

(to relieve symptoms and avoid complications)

alternatives rarely used: stone dissolution, extracorporeal lithotripsy

Acute cholecystitis

Acute cholecystitis

analgesia

IV fluids

broad spectrum antibiotics (eg: cephalosporin)

early cholecystectomy

(Takada et al. TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2013;20:1-7)

ultrasound-guided percutaneous cholecystostomy + elective cholecystectomy (2 months later) if unfit for surgery/delayed presentation/surrounding inflammation in severe disease/gallbladder empyema

Choledocholithiasis

Choledocholithiasis

offer treatment regardless of presence of symptoms

bile duct clearance (surgically or by ERCP before/during surgery) + laparoscopic cholecystectomy

5-10% of patients undergoing cholecystectomy have ductal stones, many of which are unsuspected

cholangitis and Charcot's triad (pain+jaundice+fever/rigor) frequently develop with ductal stones (treat with resuscitation+antibiotics+biliary decompression by ERCP)

perform sphincterotomy/ biliary stenting if failed ERCP duct clearance (reattempt with elective ERCP/surgical duct clearance)

Cholecystectomy complications

Cholecystectomy complications

Intraoperative:

  • bleeding
  • bile duct injury

Post operative:

  • general complications
  • haemorrhage
  • infection
  • bile leakage
  • retained stones
  • bile duct stricture
  • postcholecystectomy syndrome

Neoplasia

Neoplasia

Depending on resectability assessed on CT/MRI to exclude liver mets, nodal involvement, vascular invasion

Offer surgery if localised tumour and patient fit for radical resection:

  • Whipple operation for tumours involving lower CBD
  • Whipple operation + hepatic resection + Roux-en-Y reconstruction for tumours involving upper biliary tract

Operative mortality=10%

Palliative management:

  • stent (endoscopically or percutaneous transhepatically)
  • often require repeated stenting due to occlusion

Summary

Summary

Offer liver function tests and ultrasound to people with suspected gallstone disease, and to people with abdominal or gastrointestinal symptoms that have been unresponsive to previous management. (Recommendation 1)

Consider magnetic resonance cholangiopancreatography (MRCP) if ultrasound has not detected common bile duct stones but the:

bile duct is dilated and/or

liver function test results are abnormal. (Recommendation 2)

Consider endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made. (Recommendation 3)

Refer people for further investigations if conditions other than gallstone disease are suspected. (Recommendation 4)

Reassure people with asymptomatic gallbladder stones found in a normal gallbladder and normal biliary tree that they do not need treatment unless they develop symptoms. (Recommendation 5)

Offer laparoscopic cholecystectomy to people diagnosed with symptomatic gallbladder stones. (Recommendation 6)

Offer day-case laparoscopic cholecystectomy for people having it as an elective planned procedure, unless their circumstances or clinical condition make an inpatient stay necessary. (Recommendation 7)

Offer early laparoscopic cholecystectomy (to be carried out within 1 week of diagnosis) to people with acute cholecystitis. (Recommendation 14)

Offer percutaneous cholecystostomy to manage gallbladder empyema when:

surgery is contraindicated at presentation and

conservative management is unsuccessful. (Recommendation 8)

Reconsider laparoscopic cholecystectomy for people who have had percutaneous cholecystostomy once they are well enough for surgery. (Recommendation 9)

Offer bile duct clearance and laparoscopic cholecystectomy to people with symptomatic or asymptomatic common bile duct stones. (Recommendation 10)

Clear the bile duct:

surgically at the time of laparoscopic cholecystectomy or

with endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy. (Recommendation 11)

If the bile duct cannot be cleared with ERCP, use biliary stenting to achieve biliary drainage only as a temporary measure until definitive endoscopic or surgical clearance. (Recommendation 12)

Use the lowest-cost option suitable for the clinical situation when choosing between day-case and inpatient procedures for elective ERCP. (Recommendation 13)

Advise people to avoid food and drink that triggers their symptoms until they have their gallbladder or gallstones removed. (Recommendation 15)

Advise people that they should not need to avoid food and drink that triggered their symptoms after they have their gallbladder or gallstones removed. (Recommendation 16)

Advise people to seek further advice from their GP if eating or drinking triggers existing symptoms or causes new symptoms to develop after they have recovered from having their gallbladder or gallstones removed. (Recommendation 17)

(Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Internal Clinical Guidelines Team (UK). London: NICE (UK); 2014 Oct. Available from http://ncbi.nlm.nih.gov/pubmedhealth/PMH0070643/)

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