Transcript Jaundice - kau.edu.sa

Jaundice
Dr. Ahmed Kensarah
Introduction
Surgical obstructive jaundice (jaundice due to intra- or
extra-hepatic organic obstruction to biliary outflow) can
present problems in diagnosis and management. This
is so because, there is a hard core of jaundiced
patients in whom it is very difficult to distinguish
between organic obstruction and medical causes of
jaundice, particularly intrahepatic cholestasis. Even
serial liver function tests are often inconclusive in
differentiating However, it is mandatory to determine
pre-operatively the existence, the nature and the site
of obstruction in the surgical cases because an ill
chosen therapeutic approach can be dangerous.
Material and Methods
Twenty-six consecutive cases of obstructive jaundice
were diagnosed and treated in one full-time surgical
unit over a period of 3 years from 1976 to 1979. Of
these, 14 cases had malignancy and 12 cases
belonged to the non-malignant group. A11 the patients
were above 40 years of age and the male: female ratio
was 1.9:1.
The patients were subjected to a detailed clinical
examination particularly with reference to the
enlargement of liver, spleen and gall bladder. They
also had urine examination, hemogram and, serum
chemistry including liver function tests.
Material and Methods (cont.)
Australia antigen examination was done in 15
cases. Citrate clearance test' was done in 12
patients. All the patients had plain X-ray of
abdomen and upper GI Barium series. Oral
cholecystography was done in 7 patients
whose serum bilirubin was less than 3 mg%,-.
Percutaneous transhepatic cholangiography
(PTC) was done in 9 patients. Liver scan using
99mTc phytate was done in 13 cases.
Selective hepatic angiography was done preoperatively in 2 patients.
Material and Methods (cont.)
The patients were prepared for surgery with
injectable Vitamin K to correct the
prothrombin time; they were given fresh
blood transfusions if the prothrombin time
did not improve. In order to avert possible
post-operative renal failure, all patients
were treated with correction of
dehydration, intravenous Mannitol and
intravenous Frusemide pre-operatively.
Material and Methods (cont.)
PTCD-Percutaneous Transhepatic Cholangiography
with drainage.
The patients were treated with various surgical
procedures as shown in [Table 1]. Some of the
patients had more than one surgical procedures
mentioned in the table. Curative surgery was
attempted in benign conditions and in early
malignancies. In the advanced malignancies;
surgery was mainly palliative.
Whenever bile could be obtained either during
P.T.C. or during laparotomy (20 cases), it was
subjected to bacteriological examination.
Material and Methods (cont.)
Intra-operative cholangiography was done in
3 cases and it showed the sites of
obstruction. Tube cholangiography was
done post-operatively in 11 cases either
through the cholecystostomy tube or
through a splint kept in the biliary tree.
Results (cont.)
The patient with hepatoma of the liver and one patient
with carcinoma of the gall bladder infiltrating into the
liver had hard enlarged liver. There were 6 cases
who illustrated an exception to Courvoisiers law.Of
these, 4 were patients with cholelithiasis and a
palpable gall bladder; of these, 2 had an associated
malignancy of the biliary tract. The remaining 2
exceptions were patients with malignant obstruction
of the lower end of the common bile duct (CBD), in
whom the gall bladder was not palpable; in one of
them, this was due to an associated carcinoma of
the right hepatic duct involving the cystic duct.
Results (cont.)
Nineteen out of the 26 patients had serum albumin
level of less than 3 gms per cent. The average
total serum bilirubin was 10.4 mg%, the highest
being 35.5 mg%; and the lowest being 1.6 mg%.
The SGPT' was elevated (more than 40 Reitman
and Frankel units/ml) in 11 patients; it was more
than 1G0 Reitman and Frankel Units /ml in 10
patients. The alkaline phosphatase was elevated
(more than 30 K.A. units) in 19 patients; it was
normal in 7 patients. The prothrombin time was
elevated (more than 16, seconds) in all patients.
Citrate clearance was abnormal in all the patients.
Results (cont.)
Plain X-ray abdomen showed enlarged liver shadows in 8
patients and radio opaque gall stones in 5 patients.
Barium meal examination of the G.I. tract showed
chronic gastritis with duodenal ulcer in 1 case of gall
stones, indentation of duodenum by enlarged common
bile duct in 3 patients, `inverted three' (8) appearance in
periampullary malignancy (1 case), widening of duodenal
C in 2 cases of carcinoma of head of pancreas and
displacement of the stomach by enlarged liver in 1 case
of hepatoma of the liver.
Oral cholecystography showed filling defects suggestive
of stones in 2 patients and failure of visualisation of the
gall bladder in 4 patients; it was normal in 1 patient
whose serum bilirubin was 1.6 mg%.
Results (cont.)
PTC showed obstruction at the lower end of the
CBD in 5 cases, 2 due to stones, 2 due to
malignancy and one due to inflammatory
stricture. PTC also helped to diagnose
choledochal cyst in 2 cases (which showed
dilated CBD) and it showed dilated intrahepatic
ducts filled with stones in 2 cases.
Results (cont.)
Selective hepatic angiography showed an avascular area in
the patient with intrahepatic choledochal cyst and in the
patient with hepatoma, it outlined the vascular tumor.
Hepatic scanning showed mild to moderate
hepatomegaly in 12 cases. Two patients showed cold
areas in the liver and another 2 in the region of the gall
bladder invaginating into the liver substance suggesting
a gall bladder mass. Sparse and scattered uptake by the
liver suggestive of mild to moderate affection of liver
function was seen in 9 cases.
Bacteriological examination of bile showed
Staphylococcus (coagulase positive) in 3 cases, E. coli
in 4, Klebsiella in 3, Proteus in 3, Pseudomonas in 1 and
Salmonella typhi in 1. In 2 cases, more than one
organism was present. The bile was sterile in 6 patients.
Results (cont.)
The surgical procedures performed are outlined in
[Table 1]. Percutaneous Transhepatic
Cholangiography with drainage (PTCD) using a
polyethylene PTCD set (commercially available)
was done in 3 patients. This served as a palliative
procedure to drain the bile. However, the
maintainance of this tube was difficult.
Cholecystostomy was done in 5 patients. This was
done under local anaesthesia whenever the
patient's general condition and clotting was poor.
In 2 patients it was done as the only (palliative)
procedure.
Results (cont.)
The commonest procedure performed (15 cases)
was a cholecystectomy, with exploration of the
common bile duct together with removal of
stones or dilatation of stricture. This was
followed by sphincteroplasty and internal
splintage with a sterile plastic tube. The
duodenum had to be opened in most cases. The
splintage tube would then be brought out
through a high choledochotomy or sometimes
through the liver to come out externally from the
anterior abdominal wall.
Results (cont.)
The other end of the tube would lie in the duodenum across
the obstruction and the sphincter, with a few side holes
in that part which lay in the CBD. The lengths of the
tubes and the sites of the holes were carefully measured
as it was possible to change the tube if necessary in the
postoperative period when the tract was established.
This procedure was done in all cases of cholelithiasis
with obstruction to CBD and also in many cases of
malignant and inflammatory strictures of CBD.
The histopathological confirmation of the cause of
obstructive jaundice could be established in most cases
on exploration. Eleven patients developed complications
during the post-operative period: biliary peritonitis in 2,
wound infection in 6, G.I. bleeding in 2 and right
subphrenic abscess in one.
Discussion
Obstructive lesions of the biliary system are difficult
problems for the surgeon. Majority of the patients are old
and poor surgical risks.
Clinical symptoms are fairly typical although jaundice
itself makes the patient seek surgical aid. Charcot's triad
of intermittent fever, pain and jaundice is characteristic of
ascending cholangitis and indicates biliary obstruction.
Hepatomegaly is present in most cases of obstructive
jaundice and is due to congestion and stretching out of
intrahepatic biliary spaces. Long-standing biliary
obstruction can also cause portal hypertension. This was
seen in 2 of our patients who had palpable spleen. A
palpable gall bladder usually indicates obstruction of the
distal CBD, due to other causes than stone (Courvoisier's
law). However, exceptions to Courvoisier's law are
common,as seen in 6 patients in our series.
Discussion (cont.)
It is necessary to follow a standard system of investigations
in order to arrive at a correct diagnosis of obstructive
jaundice and also to assess fitness for surgery. An
increased WBC count and ESR indicates severity of
biliary sepsis. Bile salts and pigments in urine and absent
urobilinogen also favour the diagnosis of obstructive
jaundice. Serum albumin and prothrombin time are good
indicators of liver function derangement. Serum bilirubin
levels indicate severity of jaundice and high direct
bilirubin rules out hemolytic jaundice. Mild elevation of
SGPT levels are also seen in obstructive jaundice
consistent with liver dysfunction. An elevated alkaline
phosphatase (above 30 K.A. units) is ,always present in
obstructive jaundice.
Discussion (cont.)
Plain X-ray of the abdomen may fail to show gall
stones (4 out of 9 were radiolucent in our series).
Barium series of the upper G.I. tract are very
informative especially in peri-ampullary carcinoma
(E appearance) and carcinoma of head of
pancreas (widening of duodenal C). Oral
cholecystography and intravenous
cholangiography are of limited usefulness in
obstructive jaundice.Hypotonic duodenography
and endoscopic retrograde
cholangiopancreaticography (ERCP) can also be
of immense diagnostic value. These were not done
in our series.
Discussion (cont.)
PTC is an extremely useful investigation in the diagnosis of
the nature and site of block in obstructive jaundice. An
acceptably low complication rate has been reported in
several recent series and with the new Chiba needle
technique, the procedure has been widely accepted in
the past few years. PTC is usually done just prior to
exploration of the patient as several complications
following PTC have been described. In our series only
one patient developed biliary peritonitis following PTC.
Other complications were not seen. Per-operative
cholangiograms (3 cases in our series) are reliable in 951
of cases and may be used on the table if the site of
obstruction is not clear, to confirm that all stones have
been removed and pre-operative PTC was not done.
Discussion (cont.)
Hepatic angiograms are useful in vascular
tumors and space occupying lesions in the
liver.99mTc Phytate liver scan is a useful noninvasive procedure which can outline cold
areas in the liver and can give an idea of liver
function. Rose Bengal liver scan (not done in
our series) can indicate the site of obstruction.
Discussion (cont.)
Ultrasound scanning of the abdomen (not done in our
series) is another useful non-invasive investigation in
the diagnosis of obstructive jaundice. This method
utilises physical and mechanical means of producing
an image by reflected ultrasonic pulses created by
stimulation of a piezoelectric transducer. The images
are recorded' as dots of varying brightness (B mode
studies or Beta scanning). Gall bladder dilatation in
obstructive jaundice is easily demonstrable by B
mode scanning and gall stones can also be
recognised by the presence of strong internal echoes
within the normally echo-free bile.
Discussion (cont.)
Bacteriological examination of bile should be
done in every case as sepsis is common in an
obstructed biliary tree. Large number of
pathogenic bacteria can be isolated from the
bile in 50% of the cases requiring surgery on
the biliary tract. Patients with biliary sepsis may
develop clinical septicaemia before or after
operation. This was seen in 5 patients in our
series.
Discussion (cont.)
The commonest surgical procedure practised in our series
and the procedure we advocate is a cholecystectomy
with common bile duct exploration, dilatation,
sphincteroplasty and internal splintage, with a tube by
Rodney Smith's technique.We prefer to leave the splint in
position for a minimum period of one year. Advantages of
biliary splintage include obtaining bile for repeated
cultures, regular washes of the biliary tree,
cholangiograms, prevention of recurrence of obstruction,
dilatation and for non3perative treatment of
residual/recurrent stones. The longer the tube remains in
situ, the better are the results.[
Discussion (cont.)
Cholecystostomy is claimed to be a useful
procedure for biliary drainage in moribund
patients with severely impaired liver function.
However, in our experience it has proved to
be an unsuitable procedure for long term
decompression as the oedematous cystic
duct prevents adequate drainage.
Discussion (cont.)
Choledochal cysts can be treated in several ways.We
have treated one case of fusiform Choledochal cyst
of CBD successfully by choledochoduodenostomy
with a splint across the anastomosis which was
removed after one year. Biliary enteric anastomosis
(gall bladder or CBD with duodenum or jejunum) are
frequently employed for bypassing lower CBD
obstruction.However, an internal anastomosis has
the disadvantage of getting blocked, leaking into the
peritoneal cavity and a high incidence of ascending
cholangitis.
Discussion (cont.)
Most of the malignancies presented late when
inoperable in our series, hence radical surgery
was not done (except in 2 cases). Major
resection of the nature of Whipples' operation
(pancreatico-duodenectomy has been
described with good results in early cases. We
had one case each of Whipple's operation and
hemihepatectomy. Both succumbed in the
postoperative period.
Discussion (cont.)
The high incidence of complications, increased
mortality and morbidity could be explained by
advanced age, poor cardiac/
pulmonary/hepatic,/renal function and
associated biliary sepsis. Tolerance to major
surgical procedures is poor. Surgery of
obstructive jaundice therefore continues to be a
challenge.
Contents
Introduction
Symptoms
Causes
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Introduction
Condition where blockage of the flow of bile
from the liver causes overspill of bile
products into the blood and incomplete
bile excretion from the body. More detailed
information about the symptoms, causes,
and treatments of Obstructive Jaundice is
available below.
What are the causes of Jaundice?
Some of the possible causes of Obstructive
Jaundice include:
Gallstones - most common cause
Pancreatic cancer
Hepatitis
Drugs/medications
Interstitial liver diseases
What are the symptoms of Obstructive
Jaundice ?
Some of the symptoms of Obstructive
Jaundice include:
Dark coloured urine
Pale stools
Yellow colouration of skin and eyes
Itchy skin
Fever
What treatments are available for
Obstructive Jaundice ?
Surgical removal of obstruction - generally
keyhole (laparascopic) surgery or ERCP
Cease drugs suspected to be causing liver
inflammation - e.g. steroids, sulfonylureas
Antibiotics
Liver transplantation