Surgical Jaundice Flashcards
Pre-hepatic jaundice
Bili - normal or high
ALT/AST - normal
ALP - normal
Hepatic Jaundice
Bili - high
ALT/AST - elevated (often very high)
ALP - elevated but seldom to very high levels
Post-hepatic jaundice
Bili - high - very high
ALT/AST - moderate elevation
ALP - high - very high
Gallstones
Features - history of biliary colic or episodes of cholecystitis. Obstructive type history and test results.
Pathogenesis - small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly - one of the rare times that cholecystitis may present with jaundice.
Cholangitis
Features - obstructive and will have Charcots triad of symptoms (pain, fever, jaundice)
Pathogenesis - ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.
Pancreatic cancer
Features - painless jaundice with palpable gallbladder (Courvoisier’s Law)
Pathogenesis - direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.
TPN associated jaundice
Features - follows long term use and is usually painless with non obstructive features
Pathogenesis - due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.
Bile duct injury
Features - depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type
Pathogenesis - due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury.
Cholangiocarcinoma
Features - gradual onset obstructive pattern
Pathogenesis - direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.
Septic surgical patient
Usually hepatic features
Pathogenesis - combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.
Metastatic disease
Features - mixed hepatic and post hepatic jaundice
Pathogenesis - combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)
Diagnosis
Ultrasound of the liver and biliary tree is the most commonly used first line test. The most important clinical question is essentially the extent of biliary dilatation and its distribution.
Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option.
Where MRCP fails to give adequate information an ERCP may be necessary.
Management
Depends to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death.
Screen for and address any clotting irregularities.
In patients with malignancy, a stent will need to be inserted.
If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way.
In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult)!
If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP, an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy.
Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).
Stents
These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts.
Main problem with temporary PTC
Propensity to displacement, which may result in a bile leak
