Transcript Not tumorous (sclerosing, festering cholangitis, strictures

Mechanical jaundice
Main reasons of the mechanical jaundice
Concrement
Diseases of ducts
External
compression
Parasite invasion
Innate (cysts,
atresias)
Choledocholithya
sis
Mirizzi’s
syndrome
Not tumorous
(sclerosing,
festering
cholangitis,
strictures,
cholangiopathies)
Tumors (of
pancreas, liver, gall
bladder, big
duodenal teat,
metastases)
Round worms,
suckers,
Ribbon worms
Choledocholithyasis
Mirizzi’s syndrome
1 type
2 type
Atresia of the
extrahepatic
ducts
Atresia of the
extrahepatic ducts
Posttraumatic strictures of the bile
ducts
Posttraumatic strictures of the bile ducts – it is the strictures of the bile ducts as a
result of their defeat
Classification of the posttraumatic strictures of the bile
ducts
By the level of defeat
High
Low
By the duration of defeat
Limited (to 1 sm)
Spreaded (1-3 sm)
Subtotal (over 3 sm)
Total
By the degree of stricture
Full
Not full
By the clinic currency
With the jaundice
With the cholangitis
With the external bile fistula
With the biliar cirrhosis of liver
Neoplastic lesions of the
biliary tract
Parasitic infestation of biliary
tract
1. Tumors of the head of the pancreas
2. Tumors of the major duodenal papilla
3. Tumors of the porta hepatis
• flukes
• (dvuuska cat, liver)
4. Tumors of the gallbladder
5. Secondary
(metastatic)
•roundworms
• (roundworm, whipworm)
SHOCK-
periholedohialnyh of lymph nodes
• tapeworms
• (tapeworm bovine, pork
tapeworm,
• echinococcus)
Clinical forms of jaundice
Icteric-painful form
Icteric form of pancreaticIcteric-holetsistitnaya form
Yellowness of septic-form
Icteric, painless form
The main clinical symptoms
Yellowing of the skin, sclera
pruritus
discoloration of feces
dark-colored urine
Physical examination of obstructive jaundice
- Yellowing of the skin, sclera, mucous membranes;
- High fever;
- Bright (aholic) excrement;
- Urine "colored beer" or "strong tea";
- Increasing the size of the liver and gallbladder;
- Tenderness in the right upper quadrant;
- Palpable abdominal mass;
- Courvoisier syndrome.
Laboratory data in obstructive jaundice
Hyperbilirubinemia, mainly due to the direct fraction;
The increase in hepatic alkaline phosphatase blood;
High blood levels of bile acids;
hypercholesterolemia;
Absence sterkobilina in the feces urobilinogen in the urine;
The increase of bile pigments in the urine
The pathogenesis of hepatic failure
Increasing the pressure in the bile ducts
biliary hypertension
Violation of the blood and
lymph circulation in the liver
Change of organ
microcirculation
Degenerative changes in hepatocytes
biliary cirrhosis
Inappropriate
secretion of hepatocyte
Stages of the diagnostic search



A careful history, physical examination, the use of search
(screening) laboratory tests.
The wording of the preliminary diagnosis (suspected obstructive
jaundice genesis).
Selecting and sequencing using special instrumental methods for
topical diagnosis.
Methods of instrumental diagnostics
1 Noninvasive methods:
ultrasound
Computed tomography
2 Invasive methods:
ERCP
TTChG
Ultrasound examination
Sensitivity - 70-90%, specificity
- 80-85%.
Computed tomography
Sensitivity - 70-90%, specificity 80-85%.
Endoscopic retrograde
cholangiopancreatography
Sensitivity - 90-98%, specificity 90-100%
Percutaneous transhepatic
cholangiography
Sensitivity and 100%
specificity - 90%
Diagnostic algorithm at obstructive
jaundice
J
A
U
N
D
I
C
E
History, physical examination,
routine laboratory tests
Therapeutic measures
(traditional or
minimally invasive
surgery)
Increased alkaline phosphatase
or transaminases
ultrasound
Chance of biliary obstruction
RPHG, TTHG, CT
Differential diagnostic of the jaundices by the clinic
signs
Clinic sign
Type of the jaundice
mechanical
parenchimatous
hemolytuc
Weakness, adynamy
Yes
Yes
Absence
Gall bladder
Increased at the
low obstruction
Not increased
Not increased
Pulse
Bradicardy
Bradicardy
Normal or
tachycardia
Liver
Increased
Increased
Not very increased
Селезенка
Not increased
Sometimes
increased
Often increased
Повышенная
кровоточивость
Yes
Yes
Yes
Algorithm for the management of patients with obstructive jaundice
Stage I
Drainage
Dosage decompression
Elimination of multiple organ failure
Stage II
Restoration of normal passage of bile into the intestine
Endoscopic retrograde intervention
Percutaneous transhepatic endobiliary intervention
Lack of effect
open surgery
Indications for endoscopic retrograde endobiliary
interventions
• Extension of the common bile duct by ultrasound than 8 mm
• Identifying the causes of breast and localization of the pathological process
in the biliary tract
• Hyperbilirubinemia with poor visualization of the extrahepatic bile passages
by ultrasound
Indications for endoscopic
papillosphincterotomy
• choledocholithiasis
• stenosing papillitis
• Stenosis of the terminal part of the common bile duct and
major duodenal papilla of up to 1.5 cm
• Jaundice with liver failure in the I and II
Contraindications
CAD – AMI; Stroke; AHI; ABI
Drug treatment
In the stage of compensation
•
•
•
•
Improvement of bioenergetic processes in the liver (rr glucose with insulin, vitamin C and
kokarboksilaza)
Correction of acid-base balance (with acidosis aq sodium hydrogen carbonate, with alkalosis
aq hydrochloric to-you)
Correction of electrolyte abnormalities is preferably carried out with the help of diet and fruit
juices.
In the presence of hepatic cytolysis, prescribe medications that have membranostabi-lysing
action (legalon, essentiale, geptral).
Under subcompensation
•
•
•
•
Detoxification therapy (gemodez, neokompensan)
Correction of electrolyte disorders
Correction of protein malnutrition (albumin, plasma, etc..)
Correction of coagulation disorders (menadione, aminocaproic to-one Dicynone, platelets)
In decompensated stage
• Treatment in an intensive care unit and intensive care
• Inclusion in the complex of the above activities or lymph hemosorption systematic cleansing the
gastrointestinal tract (gastric lavage, siphon enema)
• Appointment of large doses of corticosteroids (prednisone, hydrocortisone)
• Suppress the activity of proteolytic enzymes (trasilol, contrycal, gordox)
Operation to establish a permanent passage of bile
1. EPST
2. Removing gallstones with a probe Dormia
3. Removing gallstones with flexible forceps
4. Removing gallstones with a probe Fogarty
5. Dilatation technique in secondary terminal part of the common
bile duct strictures
6. Removal of stones double latex balloon
7. Mechanical lithotripsy and aspiration method
8. Loop-trap extraction of stones
Endoscopic retrograde
sphincterotomy
ERPChG before
EPST
ERPChG after EPST
Removing the gallstones with a probe Dormia
Removing gallstones with
flexible forceps
Removing gallstones with a
probe Fogarty
Dilatation of the terminal part
of the common bile duct
stricture at
Removal of stones
double latex balloon
Mechanical lithotripsy and
aspiration method
Loop-trap extraction
of stones
Indications to TTChG

Inability to perform endoscopic retrograde vmeschatelstv-tion,
their inefficiency, the presence of anti-testimony to them.

Tumors гепатикопанкреатодуоденальной zone, creating a
block of biliary tract.
Contraindications to TTChG






The presence of space-occupying lesions in the projection of the
proposed puncture
Reduction of PTI to 50% or lower
Decrease in platelet count to 100 thousand. Below and
Colon interposition between the abdominal wall and the liver
Suppurative diseases of soft tissues in the area of ​the proposed
puncture
Allergic reactions to iodine in history
Percutaneous transhepatic cholangiography
Open surgery in the treatment of obstructive jaundice
Internal transduodenalnym
choledochoduodenostomy
Transduodenalnym
papillosphincterotomy and
papillosfinkteroplastika
choledochoduodenostomy
HDA by Yurash
HDA on Flerkenu
HDA by Finsterer
Operations performed when the common bile duct
strictures
Plastic bile duct by GeynekeMikelichu
Resection of the common bile duct
with the anastomosis "end to end"
Terminolateralny
gepatikoenteroanastomoz
with V-shaped
mezhkishechnye fistula after
Roux
Terminolateralny
gepatikoenteroanastomoz with
intestinal anastomosis "side to
side"
New in the diagnosis and treatment of obstructive jaundice
• Adenometionin in complex therapy of liver failure in patients with
obstructive jaundice
• Molecular adsorbent recirculating system in the treatment of obstructive
jaundice (MARS)
• Application erythrocyte farmakotsitov in treatment of acute liver failure in
obstructive jaundice
• Controlled laser therapy in complex treatment of patients with
cholelithiasis complicated by cholangitis and obstructive jaundice
• Application sporobacterin for the prevention and treatment of cholangitis
in patients with obstructive jaundice
• Peritoneal detoxification in the treatment of obstructive jaundice
• The drug Hepa-Merz in treatment of hepatic failure with jaundice