Jaundice

FC Campbell

 

Objectives

Define Jaundice

Classify Jaundice

Understand

Pathophysiology of Bile Metabolism

Clinical features

Know

intrahepatic and extrahepatic causes

OBSTRUCTIVE JAUNDICE (OJ)

Know

clinical features

benign vs malignant OJ

Protocol for evaluation of jaundice

Information from Radiology

X-ray, USS, CT, ERCP. PTC

Principles of Management

Non Surgical vs Surgical
Definition

Jaundice or icterus,

yellowish discolouration

  • skin, mucous membranes, sclera.
  • excess plasma bilirubin

  • Normal range

    5-17 m mol/l

  • Clinically obvious   

     50 m mol/l 

 

 

Bile metabolism

 

Types of Jaundice

Pre-Hepatic (Haemolytic) Jaundice

Hyperbilirubinaemia

excessive breakdown RBCs

Haematoma

Haemolytic anaemia

SPHEROCYTOSIS

Sickle cell

 
Pre-Hepatic Jaundice

Clinical Features

Jaundice not typically severe

Increased

unconjugated plasma bilirubin

Increased

urobilinogen in urine

AP. ALT, AST - normal

 

 

Hepatocellular Jaundice

Bilirubin production

*Normal

Decreased conjugation

*Hepatocyte damage

Hepatitis

Cirrhosis

Excess bilirubin

*Mixture unconjugated +

conjugated

 

 

Hepatocellular Jaundice

Hepatocyte damage

   jaundice

failure of 80% or more of hepatic function

Clinical features

Liver disease

 

Increased unconj/conj plasma bilirubin

 

Increased

ALT/AST

6-1000X

 

 

 

Post Hepatic (Obstructive) Jaundice

Obstruction to passage of conjugated bile

Conjugated bilirubin cannot pass into intestine

instead enters the bloodstream

 

 

 

 

 

 

 

 

Intrahepatic

Primary Biliary Cirrhosis

Sclerosiing cholangitis

Inflammation/scarring

Stenosis/ dilatation of intra hepatic ducts

 

 

Obstructive Jaundice

Extrahepatic

Gallstone

Carcinoma of head of pancreas/ampulla/bile duct

 

 

Obstructive Jaundice

Clinical features

Dark urine/pale stools

 

 

 

Deep Jaundice

Yellow sclerae

?Progressive/intermittent

?Pain

 

 

Obstructive Jaundice

Clinical Features

Gallstones

Intermittent obstructive jaundice

 

 

Obstructive Jaundice

Gallstones

Previous history of dyspepsia

Pain

Pyrexia/ Rigors

Gallbladder fibrotic

NO DISTENSION

 

 

 

Obstructive Jaundice

Carcinoma

Head of Pancreas/Ampulla/Bile duct

Relentless, progressive Jaundice

Deep

Painless

Weight loss

 

 

Obstructive jaundice

Carcinoma of head of pancreas

Distended biliary tract

Courvoisier’s sign

Palpable Gallbladder

 

 

Evaluation of Jaundice

 

Jaundice - Laboratory Tests

 

 

Radiology - Obstructive Jaundice

 

Plain X- Ray of Abdomen
10% Gallstones
Radio-opague
Faceted

 

Evaluation Protocol

 

Obstructive Jaundice- USS

USS

Indicates presence of

Calculi

Dilated biliary tract

Localise site of obstruction – 50%

Low cost, no radiation

 

 

Obstructive Jaundice

CT

More likely to identify site and nature of obstruction

More costly, more radiation

 

 

Obstructive Jaundice - Invasive Evaluation

Criterion ERCP PTC
Success rate 80-90% 80-90%
Complications 5% 5%
Mortality 0.2% 0.2%
Conditions for use skilled personnel        

distal lesion

ascites or coagulopathy

 failed PTC

 skilled personnel  

proximal lesion   

abnormal anatomy  

failed ERCP

 

ERCP

Endoscopic Retrograde Cholangio-Pancreatography

Diagnostic

 

 

 

ERCP

Endoscopic Retrograde Cholangio-Pancreatography

Diagnostic

 

 

ERCP

Endoscopic Retrograde Cholangio-Pancreatography

Therapeutic

Sphincterotomy

 

 

ERCP

Endoscopic Retrograde Cholangio-Pancreatography

Therapeutic

STENT

 

 

ERCP

Endoscopic Retrograde Cholangio-Pancreatography

Therapeutic

STENT

 

 

PTC

Percutaneous

Transhepatic

Cholangiography

Diagnostic

 

 

PTC

Percutaneous

Transhepatic

Cholangiography

Therapeutic

STENT

 

 

PTC

Percutaneous

Transhepatic

Cholangiography

Therapeutic

STENT

 

 

Management

Intraduct Calculus

ERCP + Laparoscopic cholecystectomy

Carcinoma of head/Ampulla/Bile Duct

>70 yrs ERCP + Stent

<70 Years

Surgery

 

 

 

Objectives

Define Jaundice

Classify Jaundice

Understand

Pathophysiology of Bile Metabolism

Clinical features

Know

intrahepatic and extrahepatic causes

OBSTRUCTIVE JAUNDICE (OJ)

Know

clinical features

benign vs malignant OJ

Protocol for evaluation of jaundice

Information from Radiology

X-ray, USS, CT, ERCP. PTC

Principles of Management

Non Surgical vs Surgical