3. OBSTRUCTIVE JAUNDICE-Definition
● Biliary obstruction commonly refers to blockage of the bile duct system
leading to impaired bile flow from the liver into the intestinal tract.
● Biliary obstruction is generally referred to as blockage of the extrahepatic
biliary system.
● Biliary obstruction can occur anywhere along this path and can lead to
serious complications such as hepatic dysfunction, renal failure, nutritional
deficiencies, bleeding problems, and infections.
4.
5. CAUSES OF OBSTRUCTIVE JAUNDICE
● Gall stone
● Worms
● Daughter hydatid
cyst
● Biliary
stricture(Benign/Malig
nant)
● Sclerosing cholangitis
● Choledochal cyst
● Invasion from
surrounding structures
Eg. GB Cancer
● Enlarged lymph
node
● Peri Hilar liver mets
● Chronic pancreatitis
● Pseudo cyst of
pancreas
Intra
luminal
Intramural
Extra
mural
8. APPROACH TO EXAMINATION IN A PT WITH
OBSTRUCTIVE JAUNDICE
P/A examination
on inspection
Signs of liver
failures/portal
hypertension
Enlarged
Virchows node
Icterus
Pulse
Clubbing
Organomegaly/
ascites
Umbilical nodule
P/R examination
Gall bladder
12. Case scenarios
Periampullary
carcinoma
● Intermittent
Jaundice
● Itching
● Clay coloured
stools(Malena
+clay
stools=Silvery
stools)
● No fever/pain
● GB-Palpable
Head of pancreas
cancer
● Progressive
jaundice
● Itching
● Weight loss
● Epigastric pain
radiating to
back
● GB-palpable
Hilar
cholangiocarcino
ma
● Progressive
jaundice
● Severe itching
● Rt
hypochondrial
pain
● Weight Loss
● GB- Not
palpable
Stone disease
● Charcots
traid
● Short term
history
● Jaundice
<7 mg/do
● Itching -mild
13. CHOLEDOCHOLITHIASIS
.
Retained stones are secondary stones found in bile duct within 2 years of
cholecystectomy and occur in 1% to 2% of patients
Primary CBD stone
● brown pigment
stones(precipitated
bile pigments and
cholesterol)
Secondary stones
● From
Gallbladder
17. PTC
● PTC can also be used to treat choledocholithiasis in case of unsuccessful
ERCP, or anatomical difficulty for ERCP such as the patients’ post-Roux-en-Y
procedures.
● PTC is as effective as ERCP in patients with dilated biliary system with similar
complication rate, but less effective in a nondilated biliary tree patient.
18. Treatment of choledocholithiasis
ERCP
● Sphinterotomy with
stone removal f/b
stenting
CBD Exploration by open / lap
Primary
stone;
Drainage
procedure
(CDD/CDJ)
Secondary
stones:
Cholecystectomy
+stone removal
20. C/F
● Jaundice is the most consistent symptom,
● right upper quadrant pain
● rarely a palpable mass.
● nonspecific problems such as weight loss, nausea, and vomiting.
21.
22. Management
Type 1&4b
Type 3
Type 2
Type 4a
Type 5
Complete surgical excision, cholecystectomy, and
Roux-en-Y hepaticojejunostomy.
Excision
transduodenal excision or sphincteroplasty
Liver transplantation
Liver transplantation
24. MANAGEMENT
Distal cholangiocarcinoma: Whipples procedure
Hilar cholangiocarcinoma:
Type 1&2 :Common bile duct
resection+cholecystectomy
With 5- to 10-mm margin of resection.
Type II lesions may also require partial
hepatic resection, which commonly
includes resection of the caudate lobe.
Types III and IV lesions may involve complex
resection and reconstruction of the portal vein,
hepatic artery, or both.
A substantial improvement in long-term survival has
correlated with the increasing use of hepatic
resection to achieve negative margins.
28. Investigations
● LFT
● Nutritional assessment: Albumin/prealbumin
● CA 19-9 is most sensitive for pancreatic adenocarcinoma(predictive and
prognostic marker)
● Multidetector CT is the imaging study of choice for the evalu- ation of lesions
arising in the pancreas.
● suspected periampullary disease, a three-phase (noncontrast, arterial, and portal
venous) CT scan with 3-mm slices and coronal and three-dimensional reconstruc-
tion should be routine.
● ERCP is frequently used in the assessment of the jaundiced patient because of its
ability to perform a biopsy and to palliate jaundice, if necessary.
● The use of ERCP for biliary decompression is bound to increase, given the
increased use of neoadjuvant chemotherapy approach.
● EUS may be beneficial for the identification of small tumors that do not appear on
CT scans and for the delineation of more clearly suspicious lesions smaller than 2
cm; it therefore plays an impor- tant complementary role
● detailed assessment of luminal pancreato- biliary anatomy, MRCP should be
considered.
30. WHIPPLES PROCEDURE
Pancreaticoduodenectomy : Removal of head of pancreas,
CBD,GB,Duodenum,Proximal part of jejunum,distal part of stomach.
Reconstruction:
Pancreaticojejunostomy+Hepaticojejunostomy+Gastrojejunostomy
31.
32.
33.
34. SURGERY IN PREHEPATIC JAUNDICE
• Membrane abnormalities: Hereditary spherocytosis and elliptocytosis
• Enzyme defects: Pyruvate kinase deficiency
• Hemoglobinopathy: Thalassemias and sickle cell
• AIHA
35. Hereditary spherocytosis
Splenectomy is effective in reducing the hemolysis associated with HS
Adverse events
● Lifelong risk of severe sepsis from encapsulated organisms,
● Late vascular complications such as pulmonary hypertension and atherosclerosi
● Concomitant cholecystectomy is
performed if gallstones are present.
● Prophylactic cholecystectomy in the
absence of stones is not required.
38. Thalassemia
● Although splenectomy does not influence the basic hematologic disorder, it may eliminate or
reduce the hemolytic process responsible for accelerated destruction of normal donor red
cells within the patient’s circulation, and this reduces transfusion requirements.
● In general, the best results associated with splenectomy have been obtained in older children
and in young adults with large spleens in whom excessive splenic sequestration of red cells
has been demonstrated.
● Occasionally, splenectomy may be indicated because of mass effect symptoms associated
with marked splenomegaly or repeated episodes of abdominal pain due to splenic infarction.
39. Sickle cell disease
The acute splenic sequestration is usually
effectively treated with packed red cell
transfusion.
If there is a propensity for recurrence,
splenectomy may be indicated.
40. Immune Hemolytic Anemia
● Approximately 80% of patients have a partial or complete response to steroids,
but only 20% to 30% are cured.
● In nonresponders or those requiring maintenance steroid dose greater than 10 to
15 mg of prednisone daily, second-line therapy should be considered.
● These options include splenectomy or rituximab, a monoclonal antibody against
CD20 found on the surface of B cells. Splenectomy can lead to good short-term
results, with early response in approximately 70% of patients and cure in 20% to
60%.
42. LIVER TRANSPLANTATION
Indications and patient selection
The indications for liver transplantation fall into four groups:
1 cirrhosis;
2 acute fulminant liver failure;
3 metabolic liver disease;
4 primary hepatic malignancy.
43. Technique of transplantation
supra- and infrahepatic caval anastomoses are performed.
The portal vein anastomoses
hepatic arterial anastomoses &the graft is re-perfused.
Finally, biliary drainage is re-established usually by a duct- to-duct anastomosis
44. PORTAL HYPERTENSION
An elevation in portal pressure is most commonly
found in the presence of liver cirrhosis, although it
may be present in patients with extrahepatic portal
vein occlusion, intrahepatic veno-occlusive disease
or occlusion of the main hepatic veins (Budd–Chiari
syndrome (BCS)).
46. Transjugular intrahepatic portosystemic stent shunts(TIPSS)
● The emergency management of variceal haemorrhage has been revolutionised by
the introduction of transjugular intrahepatic portosystemic stent shunts (TIPSS).
● Over a short period, this has become the main treatment of variceal
haemorrhage that has not responded to drug treatment and endoscopic therapy.
● The shunts are inserted under local anaesthetic, analgesia and sedation, using
fluoroscopic guidance and ultrasonography.
● Via the internal jugular vein and SVC, a guidewire is inserted into a hepatic vein
and through the hepatic parenchyma into a branch of the portal vein.
● The track through the parenchyma is then dilated with a balloon catheter to allow
insertion of a metallic stent, which is expanded once a satisfactory position is
achieved to form a channel between systemic and portal venous systems.
47. SURGICAL SHUNTS
Surgical shunts for variceal haemorrhage
● The increasing availability of liver transplantation and TIPSS has greatly
reduced the indications for surgical shunts.
● It is rarely considered for the acute management of variceal haemorrhage, as
the morbidity and mortality in these circumstances are high.
● The main current indication for a surgical shunt is a patient with CTP grade A
cirrhosis, in whom the initial bleed has been controlled by sclerotherapy.
