Anatomy of biliary system

Jaundice

Icterus is yellowish of the skin & sclera from accumulation of the pigment bilirubin in the blood and tissue . The bilirubin level has to exceed 35-40mmol\l before jaundice is clinically apparent.

Classification

Pre-hepatic Hepatic Post-hepatic

Prehepatic ( haemolytic ) jaundice :

Excess pproduction of unconjugated bilirubin (from RBC) that exceed the liver capacity to conjugate the extra load e.g heamolytic anaemia( hereditary sherocytosis , sickle cell disease, hypersplenism ,thalasaemia )

clinical features of Pre-Hepatic Jaundice

Jaundice not typically severe unconjugated plasma bilirubin urobilinogen in urine AP. ALT, AST - normal

Hepatic (hepatocellular)jaundice

Hepatic unconjugated hyperbilirubinaemia Failure of transport of uncojugated bilirubin into the cell e.g Giber's syndrome Failure of bilirubin-glucuronyltransferase activity e.g Crigler-najjar syndrome

Hepatic cojugated hyperbilirubinaemia

Hepatocellular injury result in failure of excretion of bilirubin into the biliary system. Causes include: *Infection: viral hepatitis *Poisons: carbon tetrachloride *Drug: paracetamol, halothane

Clinical feature of hepatocellar jaundice

Increased unconj&conj plasma bilirubin ALT/AST urin dark Stool pale

Posthepatic (obstructive)jaundice

Obstruction to passage of conjugated bile Conjugated bilirubin cannot pass into intestine instead enters the bloodstream

Intrahepatic
#Primary Biliary Cirrhosis #Sclerosiing cholangitis #Stenosis/ dilatation of intra hepatic ducts

Extrahepatic

Gallstone Carcinoma of head of pancreas/ampulla/bile duct

Pancreatic cancer

Cholestatic jaundice Weight loss Anorexia Change in bowel habit Haematemesis &melaena in advanced disease

Pancreatic cancer
@Pancreatic ductal adenocarcinoma&orig -inates in the head of pancreas. @Uncommon below 45 years. 80% of cases occur in the 60-80 age group

Pancreatic cancer

Male to female ration is 1.5:1 Risk factors are Smoking High fat diet Chronic pancreatitis Not supported but frequently implicated as risk factors Coffee drinking Alcohol consumption Diabetes

Treatment
Surgical tretment by pancreaticodudenectomy (whipplesopreation)

How can you make a diagnosis of jaundice?

Jaundice is not a disease in itself. Usually it signal symptom of liver damage or an obstruction in the biliary system

#History and physical examination # investigations

Jaundice

Pre hepatic

Hepatocellular

post hepatic

High RBC destruction Malaria Hemolytic anemia Defect in bilirubine metabolism

Hepatits
Biliary cirrhosis

Liver cirrhosis Ca of liver

Gallstone Biliary cirrhosis Ca of head o pancreas Ca of ampulla Pancreatitis

Cardinal features of obst. jaundice

1. H/O dyspepsia ,Pain or biliary colic 3.No premonitory period between malasia and loss of appetite 3.Sudden onset symptom 4.Dark urine , pale stool 5.Skin itching 6.Yellow skin DD: yellow fever hypothyroidism Wilson's Disease antimalarial drugs congenital syphilis carotenemia 7.Yellow eye: DD: yellow fever Wilson's Disease

History
HPC

Age & sex Pain: where, when, what

Q fever., rigor Q loss of appetite, nausea, vomiting, loss of weight Q Lethargy and confusion Q Color of skin: yellowish Q Color of eyes yellowish Q Itching skin Q bowel habits :diarrhea, color of stool(Clay-colored ("acholic") Q urinary symptoms : color of urine . (deep brown)

Associated symptoms;.

History cont.

Dietary history: fatty food Drug history: antimalarial drugs Past medical history: hepatitis,blood disorder,metabolic disorder Family history:

Social history: smoking, alcoholic,

Risk factors
Age: Increasing age Body habitus: Obesity, rapid weight loss Childbearing : Pregnancy Drugs : contraceptive steroids, Ethnicity: Pima Indians, Scandinavians Family :Maternal family history of gallstones Gender: Females HyperalimentationTotal parenteral nutrition, fasting Ileal disease (Crohn's disease),
Other :diabetes mellitus, truncal vagotomy, hyperparathyroidism, hyperlipidemia (High TAG, low HDL)

Physical examination

Morphys sign Courvoisiers sign.ca Poas sign

Investigation

Laboratory test Radiology Plain x ray US CT MRCP/ERC PTC

Lab testes

CBC: retic. count, Hb, WBC, ESR U&E. LFT:ALT, AST,ALP, GGT, LD, albumine , bilrubin Serum amylase Coagulation profile: PT, APTT Urine tests: proteins (bilirubine, urobilinogen)

Lab result haemolyti hepatocellula obstructiv c r e

Serum billirb. Urine billirb Urinary urobillinoge n Stercobiline Stool color ALP
Unconj. Unconj. conj.

Normal/Hig h Normal/Hig h
High , dark

High
Normal/low

very High
Very Low

Low, pale

Low, pale

Normal Normal Normal

Normal/High High Very High

Very High Very High Normal/Hig h

GGT ALT/ AST

Radiology abd. X ray

10% Gallstones

Radiology conTUS

Indicates presence of :

CalculiDilated biliary tract ,GB site of obstruction 50%

Low cost, no radiation

Withdrawal: Obesity, Ascetic, gaseous distention poorly identify distal gallstone ??(lower part of CBD, head of the pancreas)

Radiology conT CT

identify site and nature of obstruction Useful in obese or excessive bowel gas

More costly, more radiation

Radiology .ERCP

Diagnostic& theraputic

Indication : level of lesion (distal lesion) biopsy stinting and relief of jaundice Useful in pt with ascites or coagulopathy
generally a safe procedure when performed by well trained physician. complication: pancreatitis, infection, bleeding following division of the sphincter, stricture , perforation.

ERCP

ERCP(theraputic)

PTC Radiology

Diagnosticand theraputic Performed with 22G Chiba Needle

Complication: -Bacteremia -Haemorrhage -Contrast reaction -Pneumothorax -Intrahepatic arterioportal fistula -Bile leakage

MRCP

purely diagnostic . rapid, accurate and noninvasive Safe : no contrast material administration no radiation. alternative to diagnostic ERCP. MRCP avoids the complications of ERCP

Case 1: Normal MRCP. Note good delineation of normal caliber pancreatic and bile ducts. Fluid in stomach and duodenum also demonstrated.

Case 2: MRCP. Large common hepatic duct stone (asterisk) within dilated bile ducts. Note multiple gallstones

Complication of obst. jaundice

Depend on the site of obst: Gallbladder: cholycyctitis, empyema ,perforation Common bile duct: cholangitis, liver abscess, liver failure, pancreatitis, perforation intestine: paralytic ileus Clotting disorder Hepatorenal syndrom Delayed wound healing Alter in drug metabolism (morphine)

Management
1-Nonsurgical treatment 2-Surgical treatment Preoperative Intraoperative postoperative

Management of Gallstones
Pt with gall stone Biliary colic /complication of GS GS Good surgical Candidate high surgical risk pt refuse surgury asymptomatic

EPCP non surgical therapy Open expectant management

1-Nonsurgical treatment
Oral dissolution therapy Aim: dissolute small radiolucent stone DX:chenodeoxycholic acid& ursodeoxycholic acid Side effect: diarrhea, pruritus, transient raise in serum transaminases Disadvantage: long term treatment (mnths) high recurrence rate

1-Nonsurgical treatment
Extracorporal shock wave lithiotrepsy Aim: medium sized radiolucent stone DX:+\- ODT Side effect biliary colic as fragments pass through cystic duct

surgical managment

Preoperative management: Broad spectrum antibiotic prophylaxis Parenteral vitamin K +/- fresh frozen plasma IV fluid & manitol .. To prevent HRS

surgical Management
Operation ; 1-gallstone inCBD:ERCP 2-trumatic stricture:bypass via Roux loop of intestinal anastomosed to the proximal dil 3-cholangiocarcinoma:stenting +radiotherapy 4-CA of head of the pancreas or AOV:whipples operation:

postoperative management
Complication Coagulation disorder Renal failure GIT hemorrhage (stress ulcer) Delayed wound healing

the end Thanks