JAUNDICE BY MARJAN GHADIRI 14/8/2010
Definition of Jaundice = Icterus A yellowish straining of the skin, sclerae and deeper tissues with bile pigments which are increased in plasma Can be seen on examination at serum bilirubin levels 27 -35 μmol/L (1. 5 – 2 mg/d. L)
Types of Jaundice • Cholestatic (Obstructive) • Hepatocellular • Haemolytic
Bilirubin Metabolism
Causes of Jaundice Pre-hepatic unconjugated hyperbilirubinaemia Haemolysis Congenital defects: Gilbert’s syndrome (uptake/conjugation defect) Crigler-Najar (conjugation defect)
Causes of Jaundice Hepatocellular Acute Chronic Viral hepatitis A, B, C. . Other viruses: EBV, CMV Drugs Dose-dependant e. g. paracetamol Idiosyncratic Toxins Autoimmune hepatitis Alcoholic hepatitis Tumours Viral hepatitis B, C Chronic AI hepatitis End-stage liver disease (of any cause) Alcoholic Hepatitis B, C Autoimmune Haemochromatosis Wilson’s disease
Causes of Jaundice Cholestatic Extra-hepatic Gallstones Carcinoma of head of pancreas Benign stricture Congenital Traumatic iatrogenic Carcinoma of ampulla of Vater or bile ducts Sclerosing Cholangitis pancreatitis Intra-hepatic Drugs Primary biliary cirrhosis Cholestatic phase of viral hepatitis Alcoholic hepatitis Primary or secondary cancer Lymphoma Pregnancy
History pain Colour of stools and urine Drugs Recent blood transfusion Alcohol intake Contact with hepatitis infection Occupation FHx – anaemia, splenectomy, gallstones
Examination Pale yellow vs. deep yellow Signs of cirrhosis Liver – tender, enlarged, firm, shrunken, irregular Gallbladder – tender (Murphy’s sign), palpable splenomegaly
Investigations Pre-hepatic Hepatic Post-hepatic Urine No Bilirubin Urobilinogen ? Bilirubin Urobilinogen Faeces Dark Pale Blood FBC Reticulocyte count Coombs’ test Bilirubin (up to 100μmol/L) – unconjugated ALP Normal PT Normal Bilirubin – mixed conjugated & unconjugated ALP, γGT AST, ALT PT – not correctable with Vit K Bilirubin (up to 1000μmol/L) – conjugated ALP, γGT PT – correctable with Vit K
Imaging Ultrasound Gallstones Bile duct dilatation Intra-hepatic lesions CT Liver lesions Pancreatic lesions CT-IVC MRI Liver lesions MRCP X-ray Gallstones – only 10% radioopaque PTC, ERCP – can also be means of therapy Isotope scan – HIDA
Management Symptom relief Pain, itch Fluid resuscitation Correction of coagulopathy Treat secondary complications Sepsis, bleeding, anaemia Treat underlying cause Medical or surgical
Surgical Management Post-Hepatic Jaundice Initial therapy Analgesia IV fluids Vit K NBM Consider Antibiotics
Surgical Management Relieve obstruction Definitive or temporising, Curative or palliative ERCP / PTC Remove stones Stent or dilate stricture Surgery Cholecystectomy with bile duct exploration Resection of obstructing tumour Whipple’s procedure Bypass of irresectable lesion
Transcystic Exploration of Common Bile Duct
Transcystic Exploration of Common Bile Duct
Transcystic Exploration of Common Bile Duct
Benign distal CBD stricture
PTC and balloon dilatation of post-cholecystectomy stricture
ERCP and stent insertion for obstructing cholangiocarcinoma
Thank you
Скачать презентацию JAUNDICE BY MARJAN GHADIRI 14 8 2010 Definition of
jaundice_jg.ppt