Obstructive Jaundice Dr Oladele Situ Snr Registrar General

Obstructive Jaundice Dr. Oladele Situ Snr. Registrar General Surgery National Hospital Abuja © NITMED TUTORIALS

Outline Introduction and normal values Physiology of production and bile function Aetiology & Classification of Obstructive jaundice Pathology: problems of patient with obstructi Clinical features Investigations Management Complication Conclusion 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 2

Introduction Also known as ‘surgical jaundice’ or ‘Cholestatic jaundice’ Yellowish discolouration of the skin and mucous membranes from obstruction to drainage of bile Normal serum bilirubin: 0. 2 -1. 2 mg/dl Conjugated hyperbilirubinaemia Conjugated bilirubin = 2 -3 mg/dl Unconjugated bilirubin 3 -4 mg/dl 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 3

Physiology of bile production RES Reb blood cell breakdown → Haem + Globin Liver Haem → biliverdin → (‘conjugated bilirubin’) bilirubin → bilirubin diglucoronide Bile Canaliculi Conjugated bilirubin → mesourobilinogen → urobilinogen => stools, urine, reabsorption 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 4

Anatomy of the biliary tree 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 5

Bile Composition Component Water Bile salts Bile pigments Cholesterol Inorganic salts Fatty acids Lecithin Fat Alkaline phosphatase Reproduced 12/5/2020 % composition 97. 0 0. 7 0. 2 0. 06 0. 7 0. 15 0. 1 … Nigerian Internationally Trained Medical from Review of Medical Physiology by W. F. Ganong Graduates Tutorials, 2018 6

Bile salts 10 bile salts: Cholate (40%) & chenodeoxycholate (40%). These are conjugated with glycine and taurine (ratio 3: 1) 20 bile salts: Colon flora act on 10 salts = deoxy cholate 20% (reabsorbed) and lithocholate (excreted in stool) About 50% of the bile produced is stored in the gall bladder 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 7

Classification of causes of Obstructive jaundice Intra-luminal, intra-mural, extra-luminal Intra-hepatic, extrahepatic Benjamin Classification Simply: “T. I. N. C. A. M. B. E. D” 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 8

Aetiology of Obstructive jaundice Intra-luminal Intra-mural Extra-luminal Gall stones stricture Tumour head of pancreas parasites cholangiocarcinom a Peri-ampullary tumour Biliary sludge Gall bladder tumour Lymph nodes polyps Sclerosing cholangitis Chronic pancreatitis Liver cirrhosis 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 9

Common causes of Obstructive jaundice Ca Head of Pancreas 12/5/2020 Gall stone disease Nigerian Internationally Trained Medical Graduates Tutorials, 2018 10

Intra-/Extra-Hepatic causes Intra-Hepatic Extra-ductal Intra-ductal Liver Cirrhosis Sclerosing cholangitis Periampullary tumors Drugs e. g. steroids tumours Pancreatic tumours Space Occupying lesions parasites Lymph nodes Gall stones cholangiocarc inoma Hepatitis 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 11

Benjamin classification Type 1: complete Obstruction Tumour head of pancreas Tumour of biliary tract Impacted CBD stone Ligation of the CBD 12/5/2020 Type 2: intermittent Obstruction CBD stone Periampullary tumour CBD polyps and papilloma CBD parasites Choledochal cysts Nigerian Internationally Trained Medical Graduates Tutorials, 2018 12

Benjamin classification Chronic incomplete CBD strictures CBD stenosis Stenosis of sphincter of Oddi Chronic pancreatitis Cystic fibrosis 12/5/2020 Segmental Obstruction Post traumatic Cholangiocarcinoma Sclerosing cholangitis Intrahepatic stones Nigerian Internationally Trained Medical Graduates Tutorials, 2018 13

Problems of obstructive jaundice Problems with absorptions of fat & fat soluble vitamins A: night blindness D: rickets, osteomalacia E: neuromyelopathy K: bleeding dyscrasias steatorrhea Impaired calcium absorption 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 14

Problems of obstructive jaundice Problems from hepatic congestion Early satiety, hepatosplenomegaly Decrease store of hepatic glycogen and energy generation Impaired protein synthesis Problems with fluid and electrolytes Ascites Dilutional hyponatraemia and hypokalaemia Hepatorenal syndrome 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 15

Clinical presentation History: Intermittent or persistent Painful or painless Urine and stool colour Itching Risk factors for stone disease, CLD, malignancies Previous biliary surgical procedures History of possible complications e. g bleeding! History of care 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 16

Clinical presentation Physical Exam Peripheral stigmata of chronic liver disease Glasgow coma scale Bleeding dyscrasias Thorough abdominal examination Charcot’s triad and Raynauds’s pentad Courvoisier’s law 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 17

Obstructive Jaundice 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 18

General Exam of Chronic Liver Disease 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 19

Signs in Obstructive jaundice Steatorhea 12/5/2020 Cola-coloured urine Nigerian Internationally Trained Medical Graduates Tutorials, 2018 20

Diagnosis and clinical investigations Diagnosis: usually clinically suspected Management is multimodal and multidisciplinary and depends on the cause 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 21

Investigations To conform diagnosis Extent of disease Urinalysis Abdominal USS Clotting profile Abdominal CT/MRI Serum protein AFP & CEA CXR LFT Aid with resuscitation EUCr Blood sugar FBC Similar to extent of disease CA 19 -9 ERCP PTC, oral or I. V cholangiogram serology Stool for ova of parasite Stool for faecal fat test Liver 12/5/2020 biopsy Laparoscopy Nigerian Internationally Trained Medical Graduates Tutorials, 2018 22

ERCP CBD stone 12/5/2020 CBD stenosis Nigerian Internationally Trained Medical Graduates Tutorials, 2018 23

Ultrasound Gall stone on USS 12/5/2020 Dilated CBD Nigerian Internationally Trained Medical Graduates Tutorials, 2018 24

Management: supportive Fluid resuscitation and adequate hydration Glycaemic control Correction of bleeding derangement Antibiotic prophylactics Avoid sedatives Control itching Nutritional rehabilitation Ulcer prophylaxis 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 25

Management: interventional Open surgery: resection, by-pass or transplant Endoscopic intervention Minimal access 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 26

Complications Loss of consciousness Bleeding dyscrasia Renal failure Electrolyte derangement Malignant transformation Sepsis Shock Portal hypertension 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 27

Conclusion Obstructive jaundice is relatively common Steatorrhea, cola-coloured urine & itching Pay attention to their resuscitation particularly bleeding, glycaemic control and fluids Often require intervention for his definitive care which may be endoscopic or open surgery Complications are potentially grievious. 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 28

Thank you Acknowledgements: google images 12/5/2020 Nigerian Internationally Trained Medical Graduates Tutorials, 2018 29