1.2 Jaunisse/ictère obstructif: investig+PEC Flashcards
V/F : Ictère obstructif est UNE URGENCE MÉDICALE ?
VRAI !!!
VUE DES THÈMES A CONNAITRE DANS CETTE SECTION
obstructive jaundice ; cholestasis ; gallstones ; cholangiocarcinoma ; Klatskin tumour ; pancreatic cancer ; bile duct stones ; biliary stricture ; cholecystectomy
Définit jaunisse/ictère + la choléstase
Causé par montée de bilirubine dans le sang, causant manif clinique de l’ictère (peau jaune) ;
Cholestase: obstruction partielle ou complete du flow de la bile
Cholestase peut avoir lieu : dans foie (hépatic cholest), ou extra-hepatic conduits biliaires (extrahepatic cholest, obstructive)
V/F : Ictère obstructif = PAS UN DIAGNOSTIC DÉFINITIF !
VRAI ! il faut investiguer la cause, car des chng patholo 2nd peuvent arriver si non-obstrué (ex: cirrhose biliaire secondaire)
Nomme les 3 classific de la jaunisse.
1) Pre-hepatic jaundice :
due to increased bilirubin load on the hepatocytes (usually due to hemolysis)
= montée bili surtout NC + conc transaminases + PALC = N
2) Hepatic jaundice :
by failure of excretion of bile from hepatocytes.
= montée de biliC + transaminases are raised, dependent on cause (e.g. viral, drug-induced). PALC are lower than 3x N.
3) Cholestatic jaundice (peut être intra ou extrahép) :
caused by failure of formation of bile or its transport. May occur at any point from hepatocyte to Vater ampoule.
= BiliC élevé + PALC monté (+3X N).
Quelles investig à faire pour ictère obstructif ?
Tableau d’enzymes hépatiques AST/ALT + PALC différencie et pointe vers le pattern cholestatique/obstructif vs hépatique.
- Cholestatique = montée de +3X PALC
Investig pour confirmer ddx de ictère ?
1) Bilirubin tot + directe
2) Tests hép : AST, ALT, PALC
3) Imagerie : surtout scopie, IRM, CT-scan
4) parfois biopsie (rare)
- selon hx clinique/sx :
on peut demander frottis (hémolyse)
CBC (si fièvre, sx B)
Sérologie hépatite (si FdeR/suspic) - Coagulogramme (si perte sang, sx de trouble hép grave)
Différencier la présentation des ictères selon l’HMA et histoire
A) pierres dans le conduit biliaire
= Dyspepsie + colique biliaire
*dlr sera: colique, épigastrique au dos mais épisodique ou nil
*perte poids: léger
* prurit: +-
B) Cancer
= Hx négative ou avec sxB, chronique/lent
*dlr sera: epigastrique à dos constante ou nil
*perte poids: bcp+, ou nil
* prurit: +
C) Drug-induced cholestasis
= Usage de drogue ou rx (présentement et dans les 6mois) :
*dlr sera: nil
*perte poids: léger
* prurit: +
D) : Hépatite virale aigue
= post-transf, injx, contact sex à risque
*dlr sera: inconfort QSD ou nil
*perte poids: léger
* prurit: +transient
Différencier les ictères selon les labos/investig.
A) pierres dans le conduit biliaire
Serum bili: 50-150
PALC: > 3×
ALT: <5×
urobil: +
Ultrason: gallstone +dilated ducts
B) Cancer
Serum bili: Steady rise to > 200
PALC: > 3×
ALT: <5×
urobil: -
Ultrason: dilated ducts +- masse et stricture
C) Drug-induced cholestasis
Serum bili: variable
PALC: > 3×
ALT: >5×
urobil: -early
Ultrason: N
D) : Hépatite virale aigue
Serum bili: variable
PALC: - de 3×
ALT: >10×
urobil: -early
Ultrason: splenomegalie
Algorithme pour l’imagerie pour évaluer l’ictère
Faire ultrasonography:
1) Si conduits biliaires dilatés
= Présence de pierre ?
* oui = faire MRCP. Si pierre au CBC = faire ERCP/ES (PTC/surg)
- non = CT pour voir si lésion (et envisager EUS/laparoscopie)
VS
2) Si conduits biliaires non-dilatés
Dépend du tableau clinique. (parenchymateux, maladie du duct?)
Considérer MRCP ou biopsie foie
PEC de : pierres au conduit biliaire
Several options after investigations show this. Choice will depend on:
*physical condition
*comorbidity and medical history
*previous attempts at intervention
*if the patient has had a cholecystectomy
*availability of equipment/theatre/anaesthetist/expertise of interventionist
*patient preference.
1) ERCP±sphincterotomy: ERCP has a success rate of about 90% and a low complication rate in experienced hands, but risks such as bleeding from damage to a branch of the superior pancreatico-duodenal artery (1–2%), perforation (1–2%), acute pancreatitis (2–5%; severe 0.1%) are inherent to the procedure. Technical problems such as failure to cannulate/identify the ampulla of Vater and anatomical anomalies (e.g. duodenal diverticulum) can cause difficulties.
Placement of an endoscopic ‘pigtail’ stent can be achieved if multiple stones are present or stones are too large for extraction. This relieves obstruction and prevents impaction of stones at the ampulla of Vater.
VS
ERCP may be definitive treatment for unfit patients, but most will proceed to cholecystectomy.
2) Laparoscopic exploration of the common bile duct
3) Open exploration of the common bile duct
Surgical or percutaneous drainage procedures may be useful. Choledochoduodenostomy may be done by anastamosis of a dilated common bile duct to the duodenum. Alternatively, particularly in a non-dilated duct, a transduodenal sphincteroplasty is undertaken by first carrying out an open sphincterotomy and stone extraction, then suturing the mucosa of the duct and duodenum together to keep the lower end patent; these procedures are rarely undertaken.
Percutaneous stenting may be done in an unfit patient with common bile duct stones that cannot be removed by ERCP.
PEC de : stricture maligne
2) Late recurrent jaundice due to:
If there is a possible malignant cause for obstructive jaundice, the priority in a fit patient is to stage the disease process and assess the potential resectability. Several factors are crucial:
*nature of the primary lesion
*site, spread and extent, as well as local anatomical relationships of the lesion
*liver or peritoneal disease
*ascites
*lymphadenopathy
*fitness, comorbidity and preference of the patient
After initial staging, patients fall into 2 groups : non-resectable and potentially resectable.
How to determine which category pt is in ?
A) Unresectable cases : determined by lesion anatomy, fitness, comorbidity, preference of patient (e.g. elderly, unfit with advanced disease).
*** CAT sera = insertion of biliary stent to alleviate jaundice + sx. Various options to consider.
Complications (immediate and late) of stenting must be known.
Complications of stenting:
#1) Immediate Sepsis
Haemorrhage
Acute pancreatitis
Perforation and bile leak (peritonitis)
Displacement
Sludging
Overgrowth by neoplasm
Erosion into adjacent viscus
B) Potentially resectable cases: only in a specialized units. -Treatment depends on site of malignancy ; divided into distal or proximal lesions.
- involves finding a duct to form a enteric–biliary bypass above the tumour, often utilizing the left hepatic or segment III duct to form a hepaticojejunostomy.
Lister les causes des strictures biliaires bénignes
Trauma:
Iatrogenic injury (cholecystectomy)
Infective:
Parasitic infections (e.g. Echinococcus (hydatid disease), Ascaris (roundworm), Clonorchis (liver flukes))
Recurrent Oriental :cholangiohepatitis (pyogenic cholangitis)—Escherichia coli
HIV cholangiopathy
Inflammatory
Pancreatitis acute/chronic
Sclerosing pancreatitis
Primary sclerosing cholangitis
Inflammatory pseudotumour
Gallstone-related (Mirizzi’s syndrome)
Post-op CARE + FOLLOW-UP
2) Malignant disease: the value of regular follow-up has been questioned due to the poor prognosis (even after resection); there are no treatments that offer a survival advantage in recurrent disease. Symptomatic patients may benefit from palliative intervention or chemotherapy and many surgeons offer follow-up.
MONITORER est crucial :
*fluid balance
*urine output and renal function
*drainage fluid output and appropriate replacement
*sepsis
*pain control.
FOLLOW-UP:
#1) Benign disease: as stated above, chronic cholestasis runs the risk of secondary biliary cirrhosis, and life-long follow-up may be appropriate after correction of a benign stricture due to the risk of recurrent stricture formation and sepsis. Patients with common bile duct calculi who have undergone definitive treatment may be discharged.
