Case Presentation Obstructive Jaundice

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Case Presentation Obstructive Jaundice

• Dr. Ravi Madhusudhana
• Professor
• Dr. Manjunath
• Post Graduate
• Dept of Anaesthesiology. SDUMC, Kolar.

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• History- Relevant To Causes Of Jaundice
  Symptoms
• Abdominal Examination To Differentiate Liver/
  Spleen/Kidney For Ascites
• Types Of Jaundice- LFT
• Problems Of Hyperbilirubinemia
• Relevance Of Child-pugh Score

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Jaundice

• Accumulation of Bilirubin (yellow pigment)in the
  skin and other tissues

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Classification of Jaundice

• Hemolytic Jaundice
• Hepatic Jaundice
• Obstructive Jaundice(Cholestasis)
• Congenital Jaundice

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Obstructive Jaundice

• It is due to intra- or extra hepatic obstruction
  of bile ducts
• Intra Hepatic Jaundice
• Hepatitis,
• Primary Biliary Cirrhosis,
• Drugs (contact with DDT, heavy metals, beryllium
  )
• Extra Hepatic Biliary Obstruction
• Stones,
• Stricture,
• Inflammation,
• Tumors, (Ampulla of Vater)

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Case history

• Name kalyan,
• Age -50yrs ,
• sex- male
• occupation - Farmer
• Main complaints
• Pain in abdomen - 15 days
• Yellowish discoloration of urine - 12 days
• Yellowish discoloration of eye - 10 days

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H/O present illness

• pain at rt. Upper abdomen which is sudden in
  onset ,severe and colicky in nature ,increasing
  intensity for 2-3 min then relieved spontaneously
  after few minutes.
• Frequency of pain was initially 2-3 times a
  day, presently 4-6 times a day.
• Pain was non radiating in nature and increases
  on food intake and pt used to get mild relief on
  taking analgesic .
• Pain was associated with nausea and vomiting .
• Pain was not associated with body posture

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• Pt. also noticed clay colored stool since 12 days
  with yellowish discoloration of urine which
  gradually increased in intensity
• No H/O of burning micturition
• Then he also noticed yellowish discoloration of
  eyes followed by nail and palm.
• Pt. is also giving h/o itching all over body
  since 8 days which was more in night .
• There is also H/O decreased appetite since 4 days
  
• Feeling better with less pain jaundice after
  an endoscopic stenting procedure done 3 days
  ago

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• Negative H/O-
• no H/O fever
• no H/O weight loss
• Past H/O-
• no H/O similar illness previously
• no history suggestive of
• TB,DM ,HTN, any other chronic illness./ bleeding
  diathesis
• no H/O blood transfusion / tattoo

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no H/O surgery/recent travelling Personal H/O
bladder and bowel habits normal
non smoker
non alcoholic
non vegeterian no
Promiscuity Family H/O- Gallstone
disease Drug H/O- no H/O drug intake
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Cholestasis -clinical features

• pain, due to
• gallbladder disease,
• malignancy, or
• stretching of the liver capsule
• fever, due to ascending cholangitis
• palpable and / or tender gallbladder
• enlarged liver, usually smooth

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General signs of cholestasis

• xanthomas
• palmar creases, below the breast, on the neck.
• They indicate raised serum cholesterol of
  several months.
• Xanthomas on the tendon sheaths are uncommonly
  associated with cholestasis.
• xanthelasma -on the eyelids
• scratch marks excoriation
• finger clubbing
• loose, pale, bulky, offensive stools
• dark orange urine

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History taking

• Age and sex
• Viral hepatitis is common in young adults.
• CBD stone neoplastic jaundice seen in
  middle aged or elderly individuals.
• Portal cirrhosis, primary cancer of liver
  pancreatic cancer predominates in males.
• CBD Stone , PBC, carcinoma gall bladder common
  in females.

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Occupation

• Any employment involving handling of hepatotoxic
  agents like
• DDT, heavy metals, beryllium etc should be
  
• inquired.
• Exposure to infection in medical paramedical
  workers ,there is a predisposition to
  leptospirosis among workers in rat infected
  premises.
• Contact with jaundiced patients, if recent ,
  should suggest possibility of infective hepatitis.

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• Family history
• Association with anemia, gall stones removal
  of spleen suggests hemolytic jaundice.
• Past history
• Recent biliary tract surgery
• History of alcohol intake in cirrhosis.
• Use of drugs such as chlorpromazine,
  testosterone.
• Sexual orientation
• Diseases associated with male homosexuality

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Symptoms

• Onset of jaundice
• Sudden Viral hepatitis, gall
  stones
• Gradual more likely with
  cirrhosis,
• pancreatic
  carcinoma, metastasis.
• Progressive typical of malignant
  obstruction.
• Fluctuating Stone in CBD, carcinoma
• ampulla of
  vater or repeated
• hemolytic
  episodes.

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Abdominal pain

• Strong colicky character suggests gall stones
• Severe boring pain passing through back
• suggests pancreatitis
• In older patients, painless but fluctuating
  jaundice suggests intermittent obstruction by
  gall stones or necrotising papillary carcinoma.
• Painless but progressive jaundice is usually due
  to
• malignant obstruction of CBD.

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• Fever chills
• if associated with bacterial viral infection
  ascending cholangitis.
• Pruritus characteristic of cholestasis.
• Morning anorexia , nausea retching suggests
• alcoholism if symptoms are longstanding.
• Urine dark coloured indicates cholestasis.
• Stools pale stools indicate cholestatic
  jaundice.

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Clinical features
Encephalopathy
Altered sleep rhythm
Icterus
Parotid swelling
Spider nevi
Gynaecomastia
Splenomegaly
Hepatomegaly
Ascites
Tenderness
Dilated veins
Palmar erythema
Testicular atrophy
Asterixis
Loss of hair
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• 
  EXAMINATION
• Conscious cooperative and well
  oriented to T/P/P
• Avg. built / Avg.nutrition
• Hair normal
• yellowish sclera - tongue dry
  and yellowish
• Icterus present / no engorged
  neck vein / no enlarged lymph node / no
  pallor / no clubbing/no koilonychiya / no
  cyanosis / no edema
• No general signs of liver cell
  failure gynecomastia,
• loss axillary hair, spider
  naevi, clubbing, leukonychia,
  
• palmar erythema, hepatic flap

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• VITALS-
• RR- 14/min regular and
  abdominothoracic
• Pulse-84/min (rt radial pulse),
  regular ,normal volume ,
• no R-R delay no R-F delay , all
  peripheral pulses are palpable
• BP- 130/84 (supine) rt arm ,by
  auscultatory method
• Temp Afebrile
• airway MPII, mouth opening -
  adequate
• SYSTEMIC
  EXAMINATION
• RS- AEBE
• No added sounds
• CVS-S1 S2 normal
• No murmur
• CNS- NAD

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• ABDOMEN EXAMINATION-
• INSPECTION- Contour normal flat abdomen
• Umbilicus normal
  in shape and centrally placed.
• scratch mark
  present on abdomen
• no visible
  peristalsis seen
• no any scar mark,
  no dilated vein
• no petechiae ,no
  ecchymosis
• no abdominal
  distension

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• PALPATION
• local temperature
  normal
• soft abdomen
• no tenderness
• no rebound
  tenderness
• no localized
  swelling
• no hepatomegaly
• no splenomegaly
• no palpable gall
  bladder
• no fluid thrill

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• PERCUSSION-
• tympanic note all
  over abdomen
• liver dullness
  present and liver span is 13 cm in
• midclavicular line
• no shifting
  dullness
• AUSCULTATION-
• bowel sound
  present
• no added sound and
  bruit present
• No signs of portal hypertension

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ABDOMEN Inspection
There should be adequate exposure of the abdomen
for proper inspection. The patient should be
exposed from the inferior chest to the anterior
iliac spines bilaterally.

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Abdominal Palpation
128, 129. Palpate lightly in all 4 quadrants.
Press down around 1 cm. Remember to look at the
patients face during palpation to see if any
tenderness is elicited
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Palpation Liver
Stand on the pts right side. Place your left
hand behind the patients R side under the 11th
and 12th rib area. Press upward with the L hand.

Place your R hand on the pts abdomen well below
and start palpating until you feel the edge of
liver
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Palpation of Liver Alternative Method
It is acceptable during palpation of the liver to
use both hands to palpate abdomen. You use the
fingers of one hand to palpate and the other hand
is used to apply pressure to the dorsum of the
other hand. Thus the hand you are using to
palpate does not need to be used to apply
pressure.
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132-133 Palpation Spleen

Palpation Spleen (correctly - position, breaths,
palpating deepest full inspiration, 1 hand under
L side, 1 feeling) Palpation Spleen (if not
palpable, R lateral decubitus)
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PALPATION OF SPLEEN
Right lateral decubitus
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135-136 Palpation of Kidneys

R
L
Right kidney (take a deep breath, capture
kidney, exhale, slowly release kidney
Left kidney (take a deep breath, capture kidney,
exhale, slowly release kidney)
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ASCITES

• SHIFTING DULLNESS

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INVESTIGATIONS

• Before ERCP
• -Total bilirubin level of 26 mg/dL with a
  conjugated bilirubin of 18 mg/dL (normal level lt
  0.7 mg/dl)
• After ERCP
• -Total bilirubin level of 8 mg/dL with a
  conjugated bilirubin of 6.85mg/dl

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• Aspartate aminotransferase 220 IU/L
• Alanine aminotransferase 250 IU/L,
• GGT 60 U/l
• Hemoglobin level of 9 g/dL.
• Albumin 3 g
• CBC Normal limits
• prothrombin time (secs) 45
• Urinalysis positive bilirubin, normal
  urobilinogen

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SUMMARY

• 50 yrs male with complaints of pain in right
  hypochondrium with yellowish discoloration of
  body associated with itching and clay colored
  stool without any history of weight loss, fever
  and chronic alcohol intake .
• Provisional diagnosis obstructive jaundice
  post- ERCP status
• 
  D/D-choledocholithiasis
• 
  periampullary growth which obstruct
• 
  biliary tract.

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PRE HEPATIC (HEMOLYTIC) INTRA HEPATIC (HEPATOCELLULAR) POST HEPATIC (OBSTRUCTIVE)
UNCONJUGATED BILIRUBIN INCREASED NORMAL NORMAL
CONJUGATED BILIRUBIN NORMAL INCREASED INCREASED
AST / ALT NORMAL INCREASED NORMAL
ALKALINE PHOSPHATASE NORMAL NORMAL INCREASED
URINE BILIRUBIN ABSENT PRESENT INCREASED
UROBILINOGEN INCREASED PRESENT ABSENT
PLASMA ALBUMIN NORMAL DECREASED N OR DECREASED
PROTHROMBIN TIME NORMAL INCREASED INCREASED BUT CORRECTED BY VITAMIN K
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Liver function tests

• Detection of hepatocellular injury
• Aminotransferases
• Lactate dehydrogenase
• Glutathione-S-transferase
• Assessment of hepatic protein synthesis
• Serum albumin
• Serum globulin
• Prothrombin time

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• Detection of cholestatic disorders
• (Indices of obstructed bile flow)
• Alkaline phosphatase
• 5 nucleotidase
• Gamma glutamyl transpeptidase
• Serum bilirubin(lt1mg/dl)
• Quantitative liver tests
• (Indices of hepatic blood flow metabolic
  capacity)
• Indocyanine green(ICG)
• MEGX

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• Obstructive Jaundice
• Lab Findings
• Serum Bilirubin?
• Feceal urobilinogen? (incomplete obstruction)
• Feceal urobilinogen absence (complete
  obstruction)
• urobilinogenuria is absent in complete
  obstructive jaundice
• bilirubinuria ?
• ALP ?
• cholesterol ?

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Obstructive Jaundice extrahepatic

• Urinary changes
• bilirubin increased
• urobilinogen reduced or absent
• Faecal changes
• stercobilinogen reduced or absent

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Aminotransferases

• ALT/SGPT-cytoplasmic(5-45 IU/L)18 hrs
• AST/SGOT-cytoplasmic and mitochondrial(5-30
  IU/L)36 hrs
• Elevations
• Mild(100-249IU/l)- non-specific
• Moderate(250-999IU/l)
• Large(1000-1999IU/l)
• Extreme(gt2000IU/l)

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• Mild - steatosis,
• medications,
• alcohol consumption,
• cholestasis, chronic viral
  hepatitis,
• haemochromatosis, neoplasms,
  cirrhosis
• Moderate - acute viral hepatitis,
• drug-induced liver
  injury and
• flare-ups of chronic
  liver diseases

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• Large - acute on chronic active liver disease
• Extreme - fulminant viral hepatitis,
• severe drug induced liver
  injury,
• shock liver,
• hypoxic hepatitis,
• autoimmune hepatitis,
• acute biliary obstruction
• AST/ALT
• gt4 wilsons disease
• 2-4 alcoholic liver disease
• lt1 non-alcoholic steatohepatitis

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Lactate dehydrogenase

• 105-333 IU/L
• Elevated levels may reflect hepatocellular
  injury, extrahepatic disorders or both
• Extreme increases signify massive liver disease
• Prolonged concurrent elevations in LDH and
  AP-malignant infiltration of the liver
• Extrahepatic- hemolysis,
• rhabdomyolysis,
• tumour necrosis,
• renal infarction,
• acute
  cerebrovascular accident,
• myocardial
  infarction
• Hepatocellular injury- accompanied by AST/ALT

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Glutathione-s-transferase

• Sensitive and specific test for drug induced
  liver injury
• Serial measurements can reveal the time course of
  hepatic injury
• In acinar zone 3
• More sensitive than AST or ALT as a marker of
  centrilobular necrosis in its incipient stages.

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Serum albumin

• To assess hepatocellular function
• To evaluate chronic liver disease
• Half life of nearly 3 weeks

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Prothrombin time

• Procoagulants have short half life
• Factor VII 4 hrs, fibrinogen 4 days
• Levels descend shortly after liver begins to fail
• PT-measures factors II, V, VII and X
• PT/INR
• Prolonged PT- low level of factor VIIa

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Alkaline phosphatase

• 20-140 IU/L(35-115 in males and 25-95 in females)
• Circulating half life 7 days
• To screen diseases of the liver or biliary tree-
  hepatitis, malignancies and cholestatic diseases
• Extreme increases indicate
• a) major block in biliary flow due to
  primary biliary
• cirrhosis and choledocholithiasis.
• b) hepatic malignancy compressing some
• intrahepatic bile ducts.

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5 nucleotidase Gamma glutamyl transpeptidase

• 5nucleotidase-2-17U/L
• Gamma glutamyl transpeptidase 0-51IU/L(lt70 in
  males and lt40 in females)
• To distinguish between hepatic and extrahepatic
  sources of AP
• Changes in AP secondary to hepatobiliary disease
  usually followed by 5NT
• Serum AP and GGTP increase in tandem, whereas
  5NT may not change for days

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Disadvantages of GGTP

• Inducible microsomal enzyme( by alcohol,
  anticonvulsants and warfarin)
• Less specific than 5NT
• Bone contains very little GGTP-therefore
  distinguish between osseous and hepatobiliary
  sources.

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Serum bilirubin

• Most widely used test for hepatic excretory
  function
• Normally below 1mg/dl
• gt4mg/dl-yellowish discoloration of body tissues

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Testing for specific diseases

• Serological testing- viral, microbial and
  autoimmune
• Genetic testing-heritable metabolic disorders
• Tumor marker assays- hepatic malignancies

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Quantitative liver tests

• Total Hepatocellular mass- by measuring the
  clearance of a substance such as indocyanine
  green, bromsulphalein and rose Bengal
• Drug metabolizing capacity
• Caffeine clearance
• Galactose elimination capacity
• Aminopyrine breath test
• Antipyrine clearance
• MEGX

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Problems of hyperbilirubinemia

• Unconjugated bilirubin is toxic for neuronal cell
  whereas the conjugated bilirubin is responsible
  for renal dysfunction in patient with obstructive
  jaundice.
• Bilirubin value rarely exceeds 6mg/dl in
  Haemolytic anaemia.
• Intrahepatic cholestasis to cause rise in
  bilirubin, drainage of
• bile in gt75 parenchyma should be blocked

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• Sepsis or renal failure should be excluded if
  the bilirubin exceeds 30mg/dl in patient with
  CBD stone.
• Serum bilirubin will take atleast 1-2 weeks to
  return to normal following the relief of
  obstruction ( half life of bilirubin is 2weeks).
  

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Effects on cardiovascular system.

• Negative inotropic effect by bile salt.
• Negative chronotropic effect by bile salt.
• Due to activation of RAS, intravascular
  interstitial volume expansion occurs, several
  types of shunts develop ,leading to hyderdynamic
  circulation.
• Decreased vascular resistance( peripheral
  vasodilation, increased arteriovenous shunting)
• Blood volume maintained or increased , but
  redistributed.(splanchnic hypervolaemia, central
  hypovolemia)
• Increased blood flow in splanchnic
  (extrahepatic), pulmonary, muscular and cutaneous
  tissues.

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• Decreased total hepatic blood flow
• maintained hepatic arterial blood flow
• decreased portal venous blood flow
• Beta receptor density reactivity in the
  myocardium of cirrhotic patients diminished, thus
  ionotropic responses to sympathomimetic drugs
  reduced in liver disease.

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Respiratory

• Intrapulmonary shunting caused by intrapulmonary
  vascular dilatations(precapillary or
  arteriovenous)
• triad of chronic liver disease ,increased
  alveolar
• arterial oxygen gradient and evidence of
  IPVD is
• defined as hepatopulmonary syndrome.
• Ventilation perfusion mismatch caused by impaired
  hypoxic pulmonary vasoconstriction, pleural
  effusions, ascites and diaphragm dysfunction.
• Decrease in pulmonary diffusion capacity
  secondary to increased extracelluar fluid,
  interstitial pneumonitis,and/or pulmonary
  hypertension.

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Renal system

• Haemodynamic instability caused by the bile salts
  
• endotoxin on the cardiovascular function.
• Three main functional abnormalities in cirrhosis
  are reduction in sodium excretion,
• reduction in free water clearance,
• decrease in renal perfusion and glomerular
  filtration.
• Direct nephrotoxic effect by bile salt and
  conjugated
• bilirubin .
• Renal tubule blockade of bilirubin cast may
  further
• potentiate the renal injury.

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Hematologic coagulation disorders

• Decreased production of coagulation and inhibitor
  factors
• Synthesis of dysfunctional clotting factors
• Quantitative and qualitative platelet defects
• Vitamin K deficiency
• Decreased clearance of activated factors
• Hyperfibrinolysis
• DIC

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Cholestasisdiagnosis

• elevated serum bilirubin - in proportion to
  duration of cholestasis returns to normal once
  cholestasis is relieved
• raised serum alkaline phosphatase - to more than
  3X upper limit of normal
• LFTs - aminotransferases mildly raised raised
  gamma GT
• increased urinary bilirubin
• urinary urinobilinogen is excreted in proportion
  to amount of bile reaching the duodenum i.e.
  absence of urinobilinogen indicates complete
  biliary obstruction

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Ultrasonography

• The first diagnostic test to use in patients
  whose liver tests suggest cholestasis,
• To look for the presence of a dilated
  intrahepatic or extrahepatic biliary tree or to
  identify gallstones.
• In addition, it shows space-occupying lesions
  within the liver, enables the clinician to
  distinguish between cystic and solid masses.
• Ultrasound with Doppler imaging can detect the
  patency of the portal vein, hepatic artery, and
  hepatic veins and determine the direction of
  blood flow.

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Identification of cause

• Dilated ducts on ultrasound - percutaneous
  transhepatic cholangiograpy
• Undilated ducts on ultrasound - endoscopic
  retrograde cholangio-pancreatography
• Needle biopsy of the liver

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Accompanied Symptoms

• Fever
• Pain, jaundice (charcot s triad)
• Hepatomegaly
• Spleenomegaly
• Ascites
• GI bleeding
• Itch

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Jaundice- Differential diagnosis

• Once Jaundice is recognized, it is important to
  determine whether hyperbilirubinemia is
  predominantly Conjugated B or UnConjugated B?
• Differentiation of hemolytic from other type of
  Jaundice is usually not difficult.
• The laboratory findings are in constant in
  partial biliary obstruction and differentiation
  from intrahepatic cholestesis is particularly
  difficult.

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• Jaundice- Differential diagnosis
• Differential Diagnosis
• UCB or CB
• Exclude UCB (e.g. hemolysis or Gilbert Synd.)
• Distinguish hepatocellular from obstructive
• Distinguish intrahepatic from extra hepatic
  cholestasis

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Risk factors in obstructive jaundice

• DIXON FREIDMAN RISK FACTORS
• S.Bilirubin gt 11mg/dl
• Malignant obstruction
• Haematocrit lt 30
• Renal failure
• Cholangitis
• Hypoalbuminemia
• If at least 3 of above mortality
  60
• If none of above mortality 5

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Modified Child-Pugh Score
Parameters 1 2 3
Albumin(g/dl) gt3.5 2.8 - 3.5 lt2.8
INR lt1.7 1.7 - 2.3 gt2.3
Bilirubin(mg/dl) lt2 2 - 3 gt3
Ascites Absent Moderate Tense
Encephalopathy None Grade I-II Grade III-IV
Class Mortality A 5 to 6 10 B 7 to 9 30 C10 to 15 82
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CHILD SCORE AND SURGERY

• Child A - Safely undergo elective surgery.
• Child B - may undergo elective surgery after
• optimisation with
  caution.
• Child C - Contraindication for elective
  surgery.

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Other risk factor associated with increased post
operative mortality

• Presence of infection
• WBC gt 10,000
• Treatment with gt 2 antibiotics
• PT gt 1.5 sec over control
• Presence of ascites
• Malnutrition
• Emergence surgery

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• SUMMARY
• 50 yrs male with complaints of pain in right
  hypochondrium with yellowish discoloration of
  body associated with itching and clay colored
  stool without any history of weight loss, fever
  and chronic alcohol intake .
• Provisional diagnosis obstructive jaundice
  post- ERCP status
• 
  D/D-choledocholithiasis
• 
  periampullary growth which obstruct
• 
  biliary tract.