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Transcript of investigations and management of obstructive jaundice secondary to stone disease
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SHER-E-KASHMIR INSTITUTE OF MEDICAL SCIENCES
DEPARTMENT OF GENERAL SURGERY
INVESTIGATIONS AND MANAGEMENT OF OBSTRUCTIVE JAUNDICE SECONDARY TO STONE
DISEASE
MODERATOR: PROF FAZL Q PARRYPRESENTER: IFRAH AHMAD QAZI
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DEFINITION Jaundice – derivative of ‘ Jaune’ meaning yellow
Yellowish discolouration of skin ,sclera, mucous membrane
Clinically detected at bilirubin levels > 3.5 g/dl
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BILIRUBIN METABOLISM
Heme
Biliverdin
Unconjugated bilirubin
Conjugated bilirubin
Urobilinogen
Stercobilin
Globin
Heme oxygenase
Biliverdin reductase
UDPGT
Intestinal bacteria
LIVER
INTESTINE
KIDNEYUrinary Urobilinogen
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CLASSIFICATION
Prehepatic jaundice
Hepatic jaundice
Post hepatic jaundice/ Obstructive jaundice/ Surgical jaundice
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OBSTRUCTIVE JAUNDICE Obstructive jaundice is interruption to the drainage of bile
in the biliary system
Symptoms
Yellowish discolouration Clay coloured stools Tea coloured urine Pain abdomen Fever Pruritis
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Signs
Scratch marks Hepatomegaly Distended palpable GB Abdominal distension Dilated abdominal veins Edema
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CAUSES OF OBSTRUCTIVE JAUNDICE INTRALUMINAL CAUSES
CBD stones ( most common)
Parasites ( Ascariasis)
TRANSMURAL CAUSES
Cholangiocarcinoma
Choledochal Cyst
Strictures
EXTRALUMINAL CAUSES
Ca head of pancreas
Periampullary tumour
Lymph node
Mirrizi Syndrome
Accidental ligation of CBD
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EFFECTS OF OBSTRUCTIVE JAUNDICE
Alteration in:
Systemic and renal hemodynamics
Hepatic function ( protein synthesis, reticuloendothelial function,hepatic metabolism)
Hemostatic mechanism
Immune function
Wound healing
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MANAGEMENTObjectives
To establish cause.
To plan appropriate intervention.
To prevent complications.
To prevent recurrence.
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INVESTIGATIONS
Biochemical test
Imaging Studies
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BIOCHEMICAL TESTSThese tests can be used to:
Detect the presence of liver disease
Distinguish between various types of liver disorders
Gauge the extent of liver damage
Follow the response to the treatment
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Shortcomings :
Normal in a patient with serious liver disease
Abnormal in a patient with no liver disease
Rarely suggest a diagnosis
Measure only a limited no. of liver functions.
Thus no single test enables the clinician to accurately assess the liver’s total functional capacity
Battery of tests used.
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The tests commonly employed include :
Bilirubin
Aminotransferases
Alkaline phosphatase
GGT
Coagulogram
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Liver Function Test
Based on excretory and detoxification function
Serum Enzymes
Based on biosynthetic function
Serum Bilirubin Urine Bilirubin Globulin Coagulation
factorsAlbumin
Normal < 1 mg/dlUnconjugated
Conjugated (30%) *
*markedly ^ed in Obstructive
juandice
Half life 15-20 days
Serum levels not specific
for liver function
derangements
• Mostly synthesised
in liver• Vit K
dependent factors II, VII,
IX, X• PT/INR/aPTT
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Serum Enzymes
ASPARTATE AMINOTRANSFERAS
EALANINE
AMINOTRASFERASEALKALINE
PHOSPATSASE5’
NUCEOTIDASE GGT
• Diagnosis of hepatocellular
injury• Mildly elevated
in obstructive jaundice
• Present in liver, bile duct, kidney,
bone and placenta• Normal level 20-
140 IU/L• > 3 fold ^ in
biliary obstruction• Not specific for
liver diseas
• ^ed in biliary obstruction
• Not ^ed in infancy, pregnancy, osteoblastic disease of bone
15-85 IU/L (men)
5-55 IU/L (women)
Increased in diseases of liver, biliary
tract and pancreas
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BILIARY IMAGING Role in identification and detailed assessment of major bile duct
obstruction.
The questions to be addressed :
Is bile duct obstruction present?
What is the anatomical level of obstruction?
What is the cause of the obstruction?
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IMAGING STUDIES
Transabdominal Ultrasonography Computed Tomography ERCP MRI / MRCP Endoscopic Ultrasonography PTC Intraoperative Cholangiography
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TRANSABDOMINAL ULTRASONOGRAPHY
Initial investigation
Non-invasive, Painless, No radiation Exposure and provides real time images.
Operator dependent , Visualisation may be difficult in Obese patients, ascites, or distended bowel
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71-80% accuracy for identifying cause of obstruction
The extrahepatic bile ducts are well visualized by ultrasound, except for the infraduodenal portion.
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Ultrasonography visualizes CBD
stones in only about 50% of cases
Dilatation of the CBD to a diameter greater than 6 mm is seen in about 75% of cases
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COMPUTED TOMOGRAPHY Integral part in diagnosis of obstructive jaundice.
Sensitivity of CT in detection of CBD stones is about 22 %
Investigation of choice
suspected malignancy of the gallbladder, the extrahepatic biliary system, or nearby organs, in particular, the head of the pancreas
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CT CHOLANGIOGRAPHY
Involves IV contrast agents excreted preferentially by the liver
Excretion and subsequent passage of a contrast agent, provides a functional dimension not obtained with conventional magnetic resonance cholangiography.
Demonstration of bile leaks, biliary communication with cysts and segmental obstruction
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CT-IVC shows a small stone within the opacified distal common bile duct
CECT carcinoma of the pancreatic head.
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MRI/MRCP
Non invasive
Investigation of choice for detecting biliary pathology.
No intravenous contrast
Purely diagnostic
C/I pt with pacemaker, cerebral aneurism clips, other metal implants
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CONTD..
MRCP uses T2-weighted imaging with parameters designed to afford best view of bile duct
Bile has a long T2 relaxation time and hence a high signal intensity, so that bile ducts are easily distinguished from vessels on heavily T2-weighted images
Fast, effective, non-invasive way to image biliary tract
Demonstrates ductal dilatation and strictures with 95% sensitivity
Sensitivity for stone visualization - 75-95%, better than CT or US
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CHOLEDOCHOLITHIASIS
MRC (MR cholangiography) Bile: Very bright signal Ductal stones: Decreased signal
intensity foci
Low-signal filling defects within increased signal intensity bile
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MRCP in a case of PSC showing a long stricture( arrow)
MRCP showing dilated hepatic ducts with tumour causinga blockage at the confluence
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ERCP Provides dynamic information during contrast
medium introduction and drainage CBD Stones
Sensitivity 90-95 % Specificity 92-98 %
Offers the option of intervention
Stone extraction Sphincterotomy Placement of biliary stent
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Advantages :
Diagnostic and therapeutic Find out obstruction especially in the lower part of biliary
passage Opportunity to take tissue sample
Disadvantages :
Invasive
Bleeding, pancreatitis, cholangitis, perforation( 10 %)
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ERCP showing multiplecalculi (filling defects) withincystic and common bile ducts
ERCP following endoscopicpapillotomy shows a wire basket being used to fragment, snare and extract biliary calculi
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ENDOSCOPIC ULTRASOUND Detailed imaging of organs in close
proximity to the digestive tract.
Sensitivity (94%) and specificity (95%) --diagnosis of choledocholithiasis
Tissue sampling by EUS-guided fine needle aspiration (EUS-FNA)
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EUS and EUS-FNA are sensitive (overall 73 %) -cholangiocarcinoma and very specific (97%) in predicting unresectability
High detection rates (96%-100%) and staging accuracy of EUS with respect to duodenal or CBD wall involvement, invasion of the pancreas and portal vein, and spread to regional lymph nodes.
More accurate than CT and MRI in tumor staging of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%).
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PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY Preferred technique
proximal obstruction ERCP not possible
Option of tissue biopsy Intervention with drain or stent
Largely replaced by non-invasive techniques like MRCP
Role in post Bilio-enteric anastamotic strictures
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INTRAOPERATIVE CHOLANGIOGRAPHY Mirizzi described the procedure in 1937 Most commonly used during elective cholecystectomy
assess retained stones and to provide clarification of the biliary anatomy.
Diagnosis : Choledocholithiasis Biliary Injury (earlier recognition and correction of biliary
injury )
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TREATMENT
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CONSERVATIVE Fluid and electrolytes
Urine output monitoring
Correction of coagulation defects
Prevention of infection
Nutrition ( enteral nutrition preferred)
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FLUID AND ELECTROLYTE THERAPY AND URINE OUTPUT MONITORING Dehydration occurs in obstructive jaundice:
Recurrent vomitting Decreased intake Fever
Prevention of dehydration
Liberal fluid therapy with correction of electrolytes
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CORRECTION OF COAGULATION DEFECTS
Coagulopathy due to: Decreased absoption of Vit K Liver injury
Assessment by Prothrombin time / INR.
Inj Vit K 10 mg i/v OD for three days ( in elective procedures)
Trasfuse FFPs ( in emergency situation)
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PREVENTION OF INFECTION
Cholangitis and sepsis :
Gram negative org ( E.coli, K. pneumonae, P. mirabilis,etc) Anaerobes
Cephalosporins ( second and third generations) Floroquinolones Metronidazole
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SURGICAL MANAGEMENT
Definitive treatment of the obstructive jaundice.
Varies with the cause of obstruction and condition of patient.
Performed in physically fit and optimised patients.
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CHOLEDOCHOLITHIASIS
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Pre-op diagnosis of CBD stones
Lap(-)ERCP(-)
Lap(-)ERCP(+)
Lap(+)ERCP(+)
Lap(+)ERCP(-)
OC with CBDE
Transfer patient ERCP
LC
LC with CBDE
LC
ERCP
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Intra-op diagnosis
of CBD stones
Lap(-)ERCP(-)
Lap(-)ERCP(+)
Lap(+)ERCP(+)
Lap(+)ERCP(-)
LC only
ERCP
LC with CBDE
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ERCP ERCP with sphicterotomy f/b extraction
Dormia basket ( stone > 1cm) Balloon catheter
Success rate 80-90 %
Papilla and sphincter divided with a sphincterotome
ERCP with balloon sphincteroplasty ( 6-8 mm dia balloon)
High failure rates (22 %) and pancreatitis ( 3 fold of sphincteroromy)
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In case of large stones > 1.5cm , impacted stones
Mechanical lithotripsy
Electrohydraulic lithotripsy
Laser lithotripsy
Extracorporeal shock wave lithotripsy
Large balloon dilatation
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Mechanical Lithotripsy:
Most commonly used method of fragmentatation
Basket used to trap stone f/by crushing against the metal sheath
Success rate 80 to 90 %
Most important factors resulting in failure : Stone impaction Stone composition : hard calcified stones resist fragmentation
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Intraductal Shock Wave Lithotripsy:
Done with the help of a flexible lithotripsy probe passed through the working channel of cholangioscope
Two types : Electrohydraulic lithotripsy Laser Lithotripsy
Impulses are fired on stone surface under cholangioscopic guidance
Success rate 80-95 %
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Extracorporeal Shock Wave Lithotripsy:
Used in Patients with major medical comorbidities Technical difficulties in standard endoscopic stone extraction
Multiple session are needed
Stone targeting by either fluoroscopy or ultrasound
Complete clearance – 90%
Most patients require fragment extraction by endoscopy
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Large balloon dilatation:
When other standard methods unsuccessful
10-20 mm diameter balloon used f/by basket/balloon extraction
Complications 7 – 33 % :
Cholangitis, pancreatitis, bleeding
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ERCP WITH SPHINCTEROTOMY
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LAPAROSCOPIC CBD EXPLORATION Transcystic approach Trasductal approach
Transcystic CBD Exploration
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INDICATIONS OF TRANSDUCTAL APPROACH
Stones > 6 mm
Intrahepatic stones
Cystic duct diameter < 4mm
Cystic duct entrance either posterior or distal
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MANAGEMENT OF CHOLEDOCHOTOMY
Primary closure
T-tube decompression
Choledochoduodenostomy
Transduodenal sphincterotomy
Roux-en-Y choledochojejunostomy
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CBD EXPLORATION WITH T TUBE INSERTION
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Indications :
Decompression of CBD in incomplete clearence Residual stones Postoperative biliary study
T tube cholangiogram is done usually after 7 to 10 days
Removed usually after 10 days if no residual stones seen
In case of residual stones , tube kept for 6 weeks
Burhenne technique can be stones to retrieve stones under flouroscopic guidance
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COMPLICATIONS OF T- TUBE
Dislodgement
Bacteraemia
Fracture of tube
Bile leak and peritonitis at removal
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TRANS DUODENAL SPHINCTEROTOMY
Indications :
Impacted stone in ampulla
Papillary stenosis
Multiple stones with nondilated duct
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Ampulla localised by passing Fogarty catheter through CBD
Longitudinal duodenotomy made
Entrance to pancreatic duct identified
Absorbable sutures placed on each side of ampulla
Sphincterotomy started at 11 o’clock
Opening made wide enough for biliary dilator of size of CBD
Last ampullary suture placed at apex
Duodenotomy closed in transverse direction
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CHOLEDOCHODUODENOSTOMY
Indications:
Recurrent stones requiring repeated interventions Impacted stones Ampullary stenosis Funnel syndrome
Side to side anastomosis most commonly used.
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COMPLICATIONS OF CHOLEDOCHODUODENOSTOMY
Cholangitis
Sump syndrome
Wound infection
Anastomotic leaks
Intraabdominal abscess
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CHOLEDOCHOJEJUNOSTOMY
Two methods : Loop choledochojejunostomy Roux en Y choledochojejunostomy
End – side anastomosis made Intestinal content reflux prevented by
Side to side jejunojenostomy in loop CDJ Using 60 cm afferent Roux en Y brought retrocolic in Roux en Y
CDJ
Anastomosis decompressed by T tube or transhepatic stents
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ATTENTION..