L13: Obstructive Jaundice Flashcards
(115 cards)
1
Q
Def of Obstructive Jaundice
A
Jaundice that occurs due to obstruction to the outflow of bile.
2
Q
Another Name of Obstructive Jaundice
A
It is also called Surgical Jaundice, Since these cases are managed by surgical intervention.
3
Q
Indications of surgery in Jaundice
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Obstructive Jaundice & Some Hemolytic Jaundice require spleenectomy
4
Q
Causes of Obstructive Jaundice
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4
Q
Lumen Causes of Obstructive Jaundice
A
5
Q
Wall Causes of Obstructive Jaundice
A
6
Q
External Causes of Obstructive Jaundice
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7
Q
Benjamin Classification of Biliary Obstruction
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8
Q
Type 1 (Complete Obstruction)
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9
Q
Type 2 (Intermittent Obstruction)
A
10
Q
Type 3 (Chronic Complete Obstruction)
A
11
Q
Type 4 (Segmental Obstruction)
A
12
Q
CP of Obstructive Jaundice
A
13
Q
From the clinical point of view, 90% of cases of obstructive jaundice are due to either
A
- Stones.
- Periampullary carcinoma or carcinoma of the head of the pancreas.
13
Q
Charcot’s Triad & Reynold Pentad in Obstructive Jaundice
A
14
Q
Courvoisier Law
A
15
Q
Exceptions to Courvoisier’s Law
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16
Q
Clinical Features of Gall Bladder Mass
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17
Q
DDx of OJ
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Differentiate between stone in the CBD & Periampullary Carcinoma/Cancer head of pancreas (See Pancreatic Neoplasms Lecture Page 7).
18
Q
Lab INVx in Obstructive Jaundice
A
- LFTs
- Others
19
Q
LFTs in Obstructive Jaundice
A
20
Q
Why prothrombin time is prolonged in obstructive jaundice?
A
21
Q
How to Correct prothrombin time in obstructive jaundice?
A
Parenteral administration of vitamin K (deep intramuscular) For 5-7 days will correct prothrombin time in patients with OJ.
22
Q
Urine Urobilinogen in OJ
A
Negative
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HB% in OJ
Decrease in malignancy
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TC & DC in OJ
Increase in Infections
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Other Labs in OJ
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Imaging in OJ
- Abdominal US
- Triphasic CT
- MRCP
- EUS
- ERCP
- Angiography
- FDG PET Scan
- Laparoscopy
- PTC
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Significance of US in OJ
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Indications of US in OJ
The initial test should be an abdominal ultrasound
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Advantages of US in OJ
The most useful, noninvasive, reliable & quick investigation For obstructive jaundice
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Role of US in Evaluation of OJ
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Dilated Biliary Radicals by US in OJ
- Both intrahepatic and extrahepatic can be demonstrated.
- It’s First clue in obstructive jaundice
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Stones by US in OJ
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What is US sensitive to in OJ? and what is it not sensitive to?
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Pancreatic Lesions by US in OJ
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Liver Lesions by US in OJ
US can detect muitiple secondaries in the liver, thus,
favoring the diagnosis of malignancy.
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LNs By US in OJ
Endosonogram can detect lymph nodes also.
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Indications of **Triphasic CT** in OJ
- For Painless jaundice, since the suspicion for malignancy is high, the next study of choice is a “triple-phase” abdominal CT scan as ultrasound cannot rule out pancreatic lesions.
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Phases of **Triphasic CT**
Triple phase CT captures images during three phases of contrast:
1. Arterial phase
2. Early venous phase
3. Late venous phase.
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Clinical Findings by **Triphasic CT** in OJ
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What Indicates Operability in **Triphasic CT** in OJ?
- Obliteration of fat plane between the mass and superior mesenteric vessels which decides the operability.
- It can also detect coeliac nodes, presence of which is a contraindication for radical resections.
41
Limitations of **Triphasic CT** in OJ
CTscan cannot differentiate head mass of carcinoma FROM chronic pancreatitis (PET scen may differentiate).
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Precaution of **Triphasic CT** in OJ
Take precautions Against contrast induced nephropathy.
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Indications of **MRCP** in OJ
It is the investigation of choice in cases of obstructive jaundice or of high strictures and cholangiocarcinomas.
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Advantages of **MRCP** in OJ
- It is non-invasive.
- Delineates the bile ducts very well so that a biliary bypass can also be planned.
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Disadvantages of **MRCP** in OJ
Biopsy is not possible with MRI.
- While Brush cytology is possible while doing ERCP
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Findings in **MRCP** in OJ
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Advantages of **EUS** in OJ
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Significance of **EUS** in OJ
EUS is a useful adjunct that is utilized in some centers
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If CT/EUS does show a pancreatic mass suspicious for malignancy, FNA/biopsy is ......... if patientis a surgical candidate
not necessary
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Indications of **ERCP** in OJ
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Routine ERCP is not indicated in patient with obstructive jaundice due to carcinoma head pancreas or periampullary carcinoma
..
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Interpretation of **ERCP** in OJ
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Complications of **ERCP** in OJ
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Uses of ERCP in **ERCP** in OJ
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Uses of ERCP in **ERCP** in OJ
- Stones
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Uses of ERCP in **ERCP** in OJ
- Cholangitis with OJ
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Uses of ERCP in **ERCP** in OJ
- Biliary Strictures
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Uses of ERCP in **ERCP** in OJ
- Chronic Pancreatitis
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Role of Preoperative Biliary Stenting
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Indications of Preoperative Biliary Stenting
1. Cases require palliation of jaundice in advance cases.
2. When neoadjuvant chemotherapy is indicated before surgical treatment is considered.
60
Angiography is not routinely required in OJ, Why?
As good quality contrast CT scan may show any invasion of vessels by pancreatic growth.
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Findings of Angiography in OJ
1. Angiographic appearance of occlusion of celiac, superior mesenteric vessels or portal vein suggests non-resectability.
2. Distortion of the vessels is commonly seen.
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What is **FDG PET Scan**?
Fludeoxyglucose-18 (FDG) Positron Emission Tomography (PET)
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Indications of **FDG PET Scan**
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Advantages of **FDG PET Scan**
FDG PET scan combined with CT scan is able to differentiate between benign & malignant pancreatic lesion
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Disadvantages of **FDG PET Scan**
Inflammatory lesion in pancreas may show false positive results.
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Role of Laparoscopy in OJ
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Indications of Laparoscopy in OJ
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Experienced laparoscopists are also trying biliary and gastric bypass laparoscopically.
..
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Role of Percutaneous Transhepatic Cholangiography (PTC) in OJ
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Indications of Percutaneous Transhepatic Cholangiography (PTC) in OJ
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More inuestigations to assess the patient for fitness for GA
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Preoperative Preparation in OJ
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Preoperative Preparation in OJ
- Anemia
The patient isusually anemic
- If Hb level < 10 gm%: correction of anemia by preoperative blood transfusion.
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Preoperative Preparation in OJ
- Hepatocellular Dysfunction
-
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Preoperative Preparation in OJ
- Chronic Dysfunction
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Preoperative Preparation in OJ
- Impaired renal Function
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Preoperative Preparation in OJ
- Prolonged PT
may be corrected with an injection of vitamin K for 5-7 days before the operation.
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Preoperative Preparation in OJ
- Infection
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Preoperative Preparation in OJ
- Malnourishment
Enteral or parenteral nutrition may be given preoperatively.
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Preoperative Preparation in OJ
- Pulmonary Function
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Algorithm of Managment of OJ
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When to suspect OJ by labs?
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Initial Radiological Study in OJ? and why is it used?
USG Abdomen
- for Cause & Level of Block
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Look for any mass lesion in head of pancreas or evidence of chronic Pancreatitis by ....
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Lesion in periampullary region is detected by ....
UGI Endoscopy
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How to Conrirm Lesion in periampullary region?
Bx + CT
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History of CBD Stones
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Types Of CBD Stones (In terms of Site)
- Primary & Secondary
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Site of **Primary Stones**
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Nature of **Primary Stones**
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Causes of Primary Stones
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Nature of **Secondary Stones**
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Site of **Secondary Stones**
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Aim in **Calcular Obstructive jaundice**
1. To relieve biliary obstruction by removal of stones from CBD.
2. To remove the gall bladder (if present), that is usually the source of CBD calculi.
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Managment options in Calcular Obstructive jaundice
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Management Of CBD Stones With Cholangitis
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Management Of CBD Stones Without Choiangitis
- If the GB Contains Calculi
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Management Of CBD Stones Without Choiangitis
- If the Gallbladder Contains NO Calculi
1. ERCP extraction.
2. ESWL (Extracorporeal shock wave lithotripsy).
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Management Of CBD Stones Without Choiangitis
- In case of retained stone
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Management of Malignant Obstructive Jaundice
- Benign Strictures (Low CBD Obstruction)
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Management of Malignant Obstructive Jaundice
- Benign Strictures (High CBD Obstruction)
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Management of Malignant Obstructive Jaundice
- Periampullary Carcinoma
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Surgical Treatment of periampullary carcinoma
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Nonsurgical Treatment of periampullary carcinoma
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Which Has better Prognosis, Periampullary Carcinoma & Carcinoma head of pancreas?
Periampullary Carcinoma
103
Management of Malignant Obstructive Jaundice
- Sclerosing Cholangitis
1. Steroids in large doses.
2. Cholestyramine.
3. Stenting.
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Management of Malignant Obstructive Jaundice
- Cholangiocarcinoma
1. Stenting for relief of jaundice
2. Chemotherapy: Not much helpful Klatskin tumor.
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What is **Klatskin tumor**?
It is cholangiocarcinoma at the confluence of the hepatic ducts.
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TTT of Klatskin tumor
- Treatment is similar to cholangiocarcinoma.
107
Management of Malignant Obstructive Jaundice
- Carcinoma Gallbladder
108
Post-Operative Managment of OJ
109
Done
Finally
