Diseases Of The Hepatopancreatobiliary Zone, Complicated By Obstructive Jaundice Flashcards
The syndrome of obstructive jaundice
A pathological state caused by the violation of bile outflow through biliary ducts due to the complicated course of a number of diseases accompanied by obturation or compression of biliary ducts.
At clinical signs of obstructive jaundice, the patient is to be hospitalized for the diagnostic procedures specifying the cause of jaundice.
Сholedocholithiasis, tumors of the major duodenal papilla, head of the pancreas, extrahepatic biliary ducts and cholangitis are the most common causes of obstructive jaundice.
Definition: Jaundice
A pathological process which is accompanied by the icteric coloring of mucous membranes and skin due to the inflow of products of exchange of bilirubin and hepatic enzymes to the vasculature.
Causes of jaundice’s development:
A) Hemolytic (prehepatic) jaundices:
a) hereditary - due to various genetic defects in erythrocytes which become functionally defective and unstable (microspherocytosis, autoimmune jaundices);
b) acquired connected with influence of various factors promoting destruction of erythrocytes (hemolytic poisons, mechanical influences).
B) Parenchymatous (hepatocellular) jaundices:
- virus hepatitis;
- leptospirosis;
- poisoning with hepatotoxic poisons;
- sepsis;
- acute and chronic hepatitides.
C) Obstructive (posthepatic) jaundices:
- intrahepatic cholestasis;
- obturation of extrahepatic biliary ducts.
Definition: Obstructive jaundice
A pathological symptom caused by violation of bile outflow from biliary ducts, severe complications of a number of diseases, which proceed with an obturation of biliary tracts.
Causes of obstructive jaundice development:
A) Congenital malformations of biliary tracts (atresias, cysts of the choledoch, hypoplasia of biliary ducts, congenital cystous transformation of biliary ducts).
B) Benign diseases of biliary tracts and pancreas (cholelithic illness, stones in biliary ducts, corrosive strictures of the ducts and the major duodenal papilla), inflammatory diseases (cholangitis, papillitis, acute and chronic pancreatitis).
C) Primary and secondary (metastatic) tumors of organs of the hepatobiliary zone (benign and malignant tumors of biliary tracts and pancreas, porta hepatis metastases, primary and metastatic cancer of the liver), parasitic diseases of the liver and biliary ducts.
Clinical signs of obstructive jaundice:
A) Complaints:
- yellowness of the skin and sclera;
- itching of the skin;
- dark urine;
- light-colored feces.
B) Anamnesis:
- jaundice emergence after the pain attack;
- painless jaundice;
- jaundice onset on the background of cholangitis;
- recurrent episodes of jaundice.
C) Objective data:
a) physical examination:
- at first, the skin color is lemon yellow and then, with the development of jaundice, it turns yellow-green;
- signs of scratching at the skin;
b) palpation of the abdomen:
- pain in the upper abdomen, prevailing on the right side;
- enlarged liver;
- positive Courvoisier’s sign at the distal blocking of the extrahepatic biliary tracts (palpation of the enlarged painless gall bladder).
Formation of preliminary diagnosis according to clinical findings:
(Obstructive jaundice)
Preliminary diagnosis is formed on the basis of the patient’s complaints, anamnesis and its objective signs, confirmed by physical methods of examination.
To confirm or clarify the diagnosis based on laboratory findings the nature of jaundice is to be clarified and the use of instrumental methods allows revealing of its cause.
Diagnosis of obstructive jaundice:
A) Laboratory findings:
a) CBC (leukocytosis with the leukocyte shift to the left, toxic granulation of leukocytes to at inflammatory nature of obstructive jaundice, lowering of the red blood cell levels at the lasting jaundice and jaundice of tumor genesis);
b) urinalysis (presence of bile pigments), missing of stercobilin in feces;
c) blood chemistry:
- the presence of cholestasis (increased levels of bilirubin due to the direct fraction, cholesterol and alkaline phosphatase);
- active course of the inflammatory and degenerative processes within the liver (level of aldolase, amino transaminase, lactate dehydrogenase and sedimentation tests increases with overlay of the liver parenchyma injury);
- the functional state of the liver (the contents of protein and its fractions, prothrombin, blood clotting factors, urea) changes during the development of hepatorenal failure.
B) Instrumental diagnostics:
- Ultrasound examination (assessment of the width of bile ducts and their wall thickness, the presence of concrements there, tumor masses in the pancreas) .
- CT and MRI.
- Duodenoscopy (examination of the major duodenal papilla).
- Endoscopic retrograde cholangiopancreatography(ERCP) (in informational content surpasses ultrasonography, gives a chance to establish localization of the obstruction and quite often its character).
- Percutaneous transhepatic or laparoscopic cholangiography (inferior to ERCP in informational
content but surpasses it by the number of complications). - Radioisotope liver scanning (informative for the diagnosis of hepatic cholestasis and liver disorder).
- Laparoscopy (performed in cases when the diagnosis cannot be made by the means of other methods, and it is necessary to obtain more information on the extent/prevalence of the process).
General principles of obstructive jaundice treatment:
A) Patients with obstructive jaundice are hospitalized in the department of surgery (their examination
has to be fully completed in 5-6 days).
B) Treatment of obstructive jaundice is surgical (time and methods of operation depend on the duration
of jaundice, causes and localization of the obstruction).
C) Preoperative preparation detoxification therapy:
a) natural detoxication (transfusion therapy, hemodilution, forced diuresis);
b) artificial detoxication (hemodialysis, lymphosorption, plasmapheresis, hemosorption).
D) In case of obstructive jaundice minimally invasive surgical interventions aimed at jaundice elimination
are applied:
- endoscopic papillosphincterotomy;
- percutaneous transhepatic cholangiostomy;
- microcholecystostomy or endoscopic cholecystostomy;
- nasobiliary drainage of the choledoch;
- transpapillary endoscopic drainage of the biliary duct (stenting).
E) After the elimination of jaundice and normalization of the main indicators of homeostasis, elective surgery aimed at the removal of the cause of jaundice is performed.
Definition: Choledocholithiasis complicated by obstructive jaundice
Choledocholithiasis is a complication of gallstone disease, which manifests itself by the presence of stones in the common bile duct as a result of primary lithogenesis or migration of the stones from the gallbladder.
Choledocholithiasis is the main cause of obstructive jaundice
Cholelithiasis is accompanied by choledocholithiasis in 10-25%
Clinical signs of choledocholithiasis complicated by obstructive jaundice:
A) Complaints:
- paroxysmal pain in the right upper quadrant;
- jaundice after the pain attack (with jaundice pain decreases or disappears altogether);
- enlargement of the liver;
- clinic of cholangitis (fever, increased body temperature );
- vomiting that brings no relief.
B) Anamnesis:
- similar attacks of pain in anamnesis;
- cholecystectomy in anamnesis;
- intermittent jaundice.
C) Objective examination:
a) visual examination: yellowness of the skin and the sclera;
b) palpation:
- in the acute period tenderness in the upper abdomen, more on the right side;
- failure to move the gallbladder with possible formation of an inflammatory infiltrate;
c) percussion: possible tympanitis over small and large intestines;
d) auscultation: intestine peristalsis is not changed.
Diagnosis of choledocholithiasis complicated by obstructive jaundice:
a) instrumental methods of examination:
- ultrasonography (diameter of the extrahepatic and intrahepatic bile ducts, the presence of stones in them);
- computed tomography;
- endoscopic retrograde cholangiopancreatography ( ERCP ) , if necessary with papillotomy
- percutaneous transhepatic cholangiography (defining of the obstruction level and decompression of the bile ducts).
Differential diagnosis of choledocholithiasis complicated by obstructive jaundice:
a) with an organic lesion of the extrahepatic bile ducts:
- scar stricture of the common bile duct;
- tumor of the extrahepatic ducts;
b) disease of the major duodenal papilla:
- tumor;
- papillitis;
- stenosis;
c) diseases of the pancreas
- chronic obstructive pancreatitis;
- tumors of the pancreas;
d) with inflammatory diseases of the ducts:
- cholangitis.
Clinic-statistical classification of choledocholithiasis
K80.3 Residual choledocholithiasis
Layout clinical diagnosis: Choledocholithiasis after cholecystectomy {complicated by OX}
Complications: O1 jaundice O2 intermittent jaundice O3 cholangitis O4 liver abscesses
K80.4 Choledocholithiasis with cholecystitis
Layout clinical diagnosis: Choledocholithiasis with { BX cholecystitis } {complicated by OX}
Type:
B1 calculous
B2 acalculous
Complications: O1 jaundice O2 intermittent jaundice O3 cholangitis O4 liver abscesses O5 cholecystocholeductal fistula
Treatment of choledocholithiasis complicated by obstructive jaundice:
a) endoscopic papillosphincterotomy;
b) open choledocholithotomy, in the presence of the gallbladder - a cholecystectomy.
Work capacity examination and rehabilitation of patients:
choledocholithiasis complicated by obstructive jaundice
• Depends on the presence of jaundice, cholangitis and type of surgery:
A) Endoscopic removal of common bile duct stones no complications, and jaundice may indicate rehabilitation.
B) After open operations:
• with the formation biliodigestive anastomosis :
sutures are removed on the 10-11th day;
temporary disability - 3-4 weeks;
• external drainage of the common bile duct: drainage of the common bile duct are removed on
14-16th day.
C) Rehabilitation of patients is a diet, spa treatment.
D) Clinical supervision by the surgeon one year and then for 5 years by gastroenterologist or a therapeutist.
E) Identification of organic disorders after cholecystectomy requires examination by the surgeon.
