word “jaune” which means yellow. • Yellowish discoloration of sclera, skin mucous membranes due to increased serum bilirubin level. Typically can be detected if serum bilirubin level above 3 mg/dl (51.3 μmol/L. • Obstructive jaundice is interruption to the drainage of bile in the biliary system Classifications: I. Prehepatic II. Hepatic III. Posthepatic (Obstructive) • Intraluminal- Transmural- Extramural
etc.) Obstructive Jaundice Alteration in: • Systemic and renal hemodynamics • Hepatic function ( protein synthesis, reticuloendothelial function,hepatic metabolism) • Hemostatic mechanism • Gastointestinal barrier • Immune function • Wound healing Managment
Objectives:
• To identify pts who need relief of obstruction
To establish cause, to plan appropriate intervention, prevent complications, prevent recurrence. S&S for urgent surgical interventions: • Abdominal pain (70%) • Jaundice (60%) • Tea colored urine/ pale stool • Altered mental status (10-20%) • Hypotension (30%) • Fever, persistent (90%) • RUQ tenderness Imaging Studies • Ultrasound • CT scan, Spiral CT scan • MRI, MRCP • Digital substraction angiography • Cholangiography ERCP, PTC • IDUS • PET Ultrasonography • 1st choice in O.J. • Non invasive, cheep, bed side • Size of bile duct, level of obstruction, identify the cause in some cases, liver parenchyma, • Limitation: obese, Exessive bovel gases, retroduodenal and intraduodenal CBD CT scan of Abdomen • Very useful for assessment of malignancy • Intrahepatic biliary dilatations, • Level of obstruction • Spiral CT allows : relationship vascular and bile duct anatomy at the hilum MRCP • Non invasive • Useful when ERCP contraindicated • No intravenous contrast • Purely diagnostic • C/I pt with pacemaker, cerebral aneurism clips, other metal implants ERCP • Diagnostic and therapeutic • Find out obstruction especially in the lower part of biliary passage • Invassive • Cannot reliabily distinguish betweenbenign and malignant features • Opportunity to take tissue sample • Endoprosthesis ERCP • Diagnostic and therapeutic • Find out obstruction especially in the lower part of biliary passage • Invassive • Cannot reliabily distinguish betweenbenign and malignant features • Opportunity to take tissue sample • Endoprosthesis PTC • Diagnostic and therapeutic • Best suited for leisions proximal to the bifurcation of hepatic duct • Invasive • Complications similar to ERCP Endoscopic Ultrasound • Assessment bile duct and proximal pancreatic pathology • Recently IDUS in ERCP Laparoscopic cholangiography Treatment Conservative 1 • Fluid and electrolytes • Urine output monitoring • Correction of coagulation defects • Prevention of infection • Prevention of hepatorenal syndrome • Nutrition Conservative 2 • Bile acid binding resins, Cholestyramine (4g) or cholestipol (5g) disolved in wter or juice × TDS • Individualized regime for replacement of vitamines A, D, E and K as needed. • Antihistamine for pruritus • Naloxone or nalmefene has improved pruritus • Discontinuation of medications that cause or exacerbate cholestasis Surgical Options By Pass Surgeries • Roux-en-y hepaticojejunostomy • Roux-en-y Choledochojejunostomy • Roux-en-y Cholecystojejunostomy Choledochoduodenestomy Whipple’s operation Pylorus Preserving Pancreaticoduedenectomy Choledochotomy + T-tube drainage Transduodenal sphincterotomy and sphinteroplasty Roux-en-Y Hepaticojejunostomy Roux-en-Y Choledochojejunostomy Cholecystojejunostomy Whipple’s Operation Pylorus Preserving Pancreaticoduedenectomy Open Exploration of CBD T- tube ERCP with Sphincterotomy Transcystic CBD Exploration Indications for Open CBD Exploration • Multiple stones > 5 • Stones > 1 cm • Multiple intrahepatic stones • Distal bile duct sticture • Failure of ERCP • Recurrence of CBDS after sphinterotomy CBD Exploration- Surgical Options: • CBD exploration with T-tube decompression • Choledochoduodenostomy • Transduodenal sphincterotomy and sphinteroplasty • Roux-en-Y choledochojejunostomy Criteria for Irresectability • Extra hepatic metastasis • Extrahepatic organ invasion • Peripheral hepatic metastasis remote from primary tumor • Major vascular involvement Palliative Procedures