Surgical jaundice

• Jaundice
• Jaundice is caused by an increase in the level of circulating bilirubin and
becomes obvious in the skin and sclera when levels exceed 50 μmol/L .
It may result from excessive destruction of red cells (haemolytic
jaundice), from failure to remove bilirubin from the bloodstream
(hepatocellular jaundice), or from obstruction to the flow of bile from
the liver (cholestatic or obstructive jaundice) . Congenital
nonhaemolytic hyperbilirubinaemia (Gilbert’s syndrome) is a relatively
rare cause of jaundice due to defective bilirubin transport; the
jaundice is usually mild and transient, and the prognosis is excellent.
• To the surgeon, the most important type of haemolytic jaundice is that caused
by hereditary spherocytosis, in which splenectomy may be necessary.
Hepatocellular jaundice is usually a medical rather than a surgical condition.
• Extrahepatic obstruction most commonly results from cancer of the head of
the pancreas.
• Extrinsic compression can result from neoplastic lesions such as metastatic
nodal disease, inflammatory pseudopseudocysts or chronic pancreatitis.
• luminal causes include parasitic infection.
• Examples of lesions of the wall include primary neoplastic lesions such as
cholangio or ampullary carcinoma, inflammatory lesions such as primary
sclerosing cholangitis or congenital lesions such as choledochal cysts.
• Courvoisier’s law-In the presence of jaundice if a mass (the gall bladder )is
palpable in the right upper quadrant ,the cause is unlikely to be due to gall
stone.
• Classification of jaundice
• prehepatic
• hepatic
• post heapatic
• Normal bilirubin-<17 mmol/l and it usually has to reach at least 3 times this
before the sclera is discoloured,i.e>50 mmol/l
•
 Liver function tests
prehepatic hepatic Post hepatic
Major causes Haemolysis Hepatitis Gall stones → CBD stones
Heriditary,e.g gilbert synd Decompensated chronic Carcinoma of the
liver disease pancreas
Drugs Lymph nodes
compression on CBD
Biliubin type Unconjugated conjugated conjugated
ALT +/++ ++/+++ +/++
ALP(Alkaline -/+ +/++ ++/+++
Phosphatase)
 Investigation
• Full blood count
• Renal function
• Liver function tests
• Clotting
• Radiological investigations
Ultrasound will show
presence of underlying liver disease
degree of dilatation of the common bile duct(>8mm is abnormal)
Presence of a gall stones
Presence of lymphadenopathy
Pancreatic mass
• CT scan
• Endoscopic Retrograde Cholangiopancreatography(ERCP)
• Magnetic Resonance CholangioPancreatogrphy(MRCP)
 Treatment
• Mirizzi syndrome-the cystic duct is densely adhered to common bile
duct and a stone ulcerating through neck of GB into the common bile
duct.
Computed tomography scan demonstrating a
gallstone within the gallbladder (arrow).
Endoscopic retrograde cholangiography demonstrating multiple stones
(arrows) within the biliary tree. These calculi were removed
from the dilated bile duct by balloon extraction following sphincterotomy
Endoscopic retrograde cholangiopancreatography:
normal cholangiogram.
Endoscopic retrograde cholangiopancreatography:
partial occlusion of the bile duct by a malignant stricture
Magnetic resonance cholangiopancreatography:
projectional images demonstrating stones and hilar obstruction
Transhepatic cholangiogram showing a
stricture of the common hepatic duct
• Percutaneous transhepatic cholangiography (PTC)
PARASITIC INFESTATION OF THE BILIARY TRACT

• Biliary ascariasis
• The roundworm Ascaris lumbricoides may enter the biliary tree
through the ampulla of Vater and cause biliary pain.
• Complications include strictures, suppurative cholangitis, liver
abscesses and empyema of the gallbladder.
• In the uncomplicated case, antispasmodics can be given to relax the
sphincter of Oddi and the worms will return to the small intestine to
be dealt with by anthelminthic drugs.
• Operation may be necessary to remove the worms or deal with
complications.
• Worms can be extracted via the ampulla of Vater by ERCP.
Clonorchiasis (Asiatic cholangiohepatis)
• It is a type of liver fluke. Infection occurs due to ingestion of infected
fish or snails harbouring the fluke as intermediate host. Man is the
definitive host. The adult worm matures in the intrahepatic biliary
radicals causing duct thickening, dilatation and periductal fibrosis.
• Dead worms or eggs form a nidus for formation of stones anywhere in
the biliary tree.
• Suppurative cholangitis develops and pigment stones form in the
intrahepatic and extrahepatic biliary tree.
• The fluke, up to 25 mm long and 5 mm wide, inhabits the bile ducts,
including the intrahepatic ducts.
• Fibrous thickening of the duct walls occurs. Many cases are
asymptomatic. Complications include biliary pain, stones, cholangitis,
cirrhosis and bile duct carcinoma.
• Choledochotomy and T-tube drainage and, in some cases,
choledochoduodenostomy are required. Because a process of
recurrent stone formation.
• The clinical features are those of obstructive jaundice, pain and
fever, and liver abscesses may form. Stool examination can show the
presence of eggs or worms. Ultrasonography shows thick walled and
dilated ducts. ERCP can show the presence of worms as filling defects.
Cholangitis is treated with antibiotics, and stones in the duct can be
removed by percutaneous, endoscopic and operative means.
Praziquantel or albendazole remain the drugs of choice for medical
management of the worm. Ductal obstruction may be treated by
choledochoduodenostomy or hepaticojejunostomy in addition to
cholecystectomy.
Primary sclerosing cholangitis
• In this condition, both intrahepatic and extrahepatic bile ducts may
become indurated and irregularly thickened. There is a marked
chronic inflammatory cell infiltrate and fibrous narrowing of the
biliary tree. Its aetiology is unknown, but it may have an
immunological basis since most patients have evidence of
autoantibodies.Over three-quarters of patients also suffer from
ulcerative colitis.
• Choledochal cysts
• Cystic transformation of the biliary tree choledochal cyst) is rare. It
• is more common in females and in Mongolian races. Five types have
been described. The most common type (1) results in a fusiform
dilatation of the common bile duct.
Endoscopic retrograde cholangiopancreatography
demonstrating the common type of choledochal cyst involving the
common bile duct
• Malignant tumours of the biliary tract
• Malignant tumours of the gallbladder and extrahepatic biliary tree are
uncommon.
• Unfortunately, owing to advanced stage at presentation, surgical
resection, which offers the best survival, is only possible for a minority
of patients. Thus, for most patients treatment is generally palliative in
nature and survival is limited.
Clinical features
• Early symptoms of cholangiocarcinoma are often non-specific, with
abdominal pain, early satiety, anorexia and weight loss.
• Symptoms associated with biliary obstruction (puritus and jaundice) may be
present in a minority of patients.
• clinical signs of jaundice, cachexia is often noticeable and a palpable
gallbladder present if the obstruction is in the distal common bile duct
(Courvoisier’s sign).
• Investigations
• Biochemical investigations will confirm the presence of obstructive jaundice
(elevated bilirubin, alkaline phosphatase and γ-glutamyltransferase). The
tumour-marker CA 19-9 may also be elevated. Imaging studies such as
ultrasound, MDR-CT and MRI/MRCP are essential for diagnosis and staging.
• Depending on the site of disease, surgery may involve either a standard or
extended hepatic resection with en bloc lymphadenectomy and reconstruction of
the biliary tree.
• Distal common duct tumours may require pancreaticoduodenectomy
(Whipple procedure). Local resection should be avoided.
• In selected patients, liver transplantation has been recommended
• for those with locally unresectable disease without evidence of distant metastases.
• The majority of patients who present with unresectable disease are candidates for
palliative therapy.
• Biliary obstruction can be relieved by either endoscopic (ERCP) or percutaneous
(PTC) methods.
• Surgical bypass rarely has a role apart from in patients who present with a distal
bile duct lesion and are found to have unresectable disease at operation.