Obstructive Jaundice Diagnosis and Evaluation
•Descargar como PPTX, PDF•
3 recomendaciones•649 vistas
obstructive jaundice work up
Recomendados
Más contenido relacionado
La actualidad más candente
La actualidad más candente (20)
Similar a Obstructive Jaundice Diagnosis and Evaluation
Similar a Obstructive Jaundice Diagnosis and Evaluation (20)
Más de DrHarsh Saxena
Más de DrHarsh Saxena (14)
Último
Último (20)
Obstructive Jaundice Diagnosis and Evaluation
- 1. Obstructive Jaundice :an approach Dr Harsh saxena Pesenter PG 1 Department of Hepatology MMC chennai
- 2. Definition • Jaundice – Yellowish discoloration of skin, mucus membranes and conjunctiva resulting from widespread tissue deposition of the pigmented metabolite bilirubin • Clinically >3mg/dl Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10th ed
- 3. Haemoglobin and other haemoproteins Bilirubin BrG Canalicular membrane OATP MRP3 Bilirubin Albumin Albumin Bile BrG Urine B-UGT MRP2 OATP – Organic anion transporter MRP – Multidrug resistant associated protein UGT – Uridine diphosphate - glucurynyl transferase BrG – Bilirubin glucuronides Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10th ed
- 4. Hyperbilirubinemia Disorders of bilirubin metabolism Conjugated Unconjugated Liver disease Hepatocellular dysfunction Hepatic disorders with prominent cholestasis Bile duct obstruction Bile duct diseases Extrinsic compression
- 5. Cholestasis • Conjugated hyperbilirubinemia due to : i. Impaired bile formation (hepatocytes) ii. Impaired bile flow (bile duct/ductules) • Consequences – Secondary liver damage i. Bile acid induced hepatocyte injury ii. Secondary biliary cirrhosis Failure of substances secreted in bile to reach intestine i. Bile acid deficiency in gut ii. Fat malabsorbtion/fat-solube vitamin malabsorbtion
- 7. Clinically • Pruritus • Fatigue • Xanthomas • Hepatic osteodystrophy • Pale stools or steatorrhea • Evidence of fat soluble vitamin deficiency • Enlarged liver with a firm smooth non tender edge Histologically • Bile plugs • Feathery degeneration of hepatocytes • Small bile duct destruction • Peri cholangitis • Portal oedema • Bile lakes and infarcts • Biliary cirrhosis
- 8. Jaundice Painless – Periampullary carcinoma Cholangiocarcinoma Painful – Ca gall bladder Ca Pancreas Cholangitis: stones, parasites • Intermittent Jaundice: Choledocholithiasis, Periampullary tumour,Duodenal diverticula ,Intra biliary parasites Haemobilia • Persistent Jaundice Onset, progression, history of prodrome
- 9. Pruritus • Irritating sensation which arouses desire to scratch to get temporary relief 1 • Present in 80 – 100 % patients with cholestatic jaundice 2 • 25 % have presenting symptom 3 • Bile salts – Histamine release – irritation of C fibres • Marked in PBC, Cholestatic jaundice of pregnancy • History – Severity (Disturbed Sleep, ADL) 1Arch Dermatol. 2003 Nov; 139(11):1475-8 2J Dtsch Dermatol Ges. 2013 Feb; 11(2):158-68. 3Aliment Pharmacol Ther. 2003 Apr 1; 17(7):857-70. ADL – Activities of daily life
- 10. Evaluation of Cholestatic Jaundice Decide – Intrahepatic or extrahepatic CLUES TO EXTRAHEPATIC CHOLESTASIS • Abdominal pain • Palpable GB • Upper abdominal mass • Evidence of cholangitis • H/O past biliary surgery CLUES TO INTRAHEPATIC CHOLESTASIS • Prodromal- fever, malaise, nausea • Pruritus, as in primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC)
- 11. Extrahepatic causes of cholestatic jaundice Benign • Choledocholithiasis • Post operative biliary strictures • Primary sclerosing cholangitis • Chronic pancreatitis • AIDS cholangiopathy • Mirizzi syndrome • Parasitic disease Malignant • Cholangiocarcinoma • Pancreatic cancer • Ca GB • Ampullary cancer • Malignant involvement of porta lymph nodes
- 12. Intrahepatic causes of cholestatic jaundice 1) Viral hepatis a. Fibrosing choleststic hepatitis – Hep B and C b. Hep A, EBV and CMV 2) Alcoholic hepatitis 3) Drug toxicity a. Pure cholestatic – Anabolic steroids and contraceptives b. Cholestatic hepatitis – Chlorpromazine, erythromycin c. Chronic cholestasis – Chlorpromazine and proclhorprazine 4) Primary biliary cirrhosis 5) Primary sclerosing cholangitis 6) Vanishing bile duct syndrome A. Chronic rejection of liver transplant B. Sarcoidosis C. Drugs 7) Non hepatobilary sepsis 8) Benign post operative cholestasis 9)Para neoplastic syndrome 10) Veno-occlusive disease 11) GVHD 12) Inherited A.Progressive familial intrahepatic cholestasis B. Benign recurrent intrahepatic cholestasis 13) Cholestasis of pregnancy 14) Total parenteral nutrition 15) Infiltrative diseases A. TB B. Lymphoma C. Amyloidosis 16) Infections A. Malaria B. Leptospirosis
- 13. Clinical History and causes of cholestasis 1. Pain – Duct stones, tumor or gall bladder disease 2. Arthralgia, myalgia predating jaundice – Hepatitis (Viral) 3. Fever and rigors – Cholangitis d/t duct stone or traumatic stricture (Charcot’s intermittent biliary fever) 4. Contaminated food/ alcohol consumptions 5. H/O hepato – toxins – Drugs/Chemicals 6. Parenteral exposure – Blood transfusion, drug abuse, tattoos, sexual activity 7. H/O Pain and blood mixed stools (Ulcerative colitis) - ?PSC 8. Joint pain, alopecia , thyroid disorders, T1DM- Autoimmune hepatitis 9. Weight loss, loss of apetite – Malignancy
- 14. History • Age , Sex, Occupation • Jaundice – Onset, progressive or intermittent • Pain – Location, radiation, fullness, palpable mass • Pruritus – Generalised • Associated symptoms – Anorexia, weight loss, fever • Gastric stasis – Early satiety, vomiting, belching • History of anaemia • Previous malignancy • Diabetes or diarrhoea of recent onset
- 15. • Jaundice Early – Extrahepatic cholestasis Fluctuating – Periampullary carcinoma Choledocholithiasis Parasites Duodenal diverticula
- 16. • Jaundice Painless – Periampullary carcinoma Cholangiocarcinoma Painful – Ca gall bladder Ca Pancreas Cholangitis
- 17. • Fever – at onset – viral hepatitis with rigors – cholangitis low grade fever - neoplasm • Prodromal symptoms – Viral hepatitis
- 18. History • Age • Sex • Occupation • Jaundice – Duration Progression
- 19. History…cont • Pain abdomen – Site Nature Severity • Can you feel a lump? • Pruritus Pain Type Biliary colic Steady, usually in the epigastrium and right upper quadrant, increases over 15 minutes to 1 hour, plateaus over next 6 hours then subsides Pancreatic pain Dull aching, continuous, epigastrium radiating to the back, relieved by leaning Hepatomegaly Dull aching and dragging type of pain in the right hypochondrium
- 20. History ….cont • Malena • History s/o malignancy • History s/o autoimmune disorders • Prodromal symptoms – Viral aetiology • Fever – at onset – viral hepatitis with rigors – cholangitis low grade fever - neoplasm
- 21. Past history • Recurrent jaundice – relapsing hepatitis • Right upper quadrant surgery – Sticture • Recurrent biliary colic – Cholelithiasis • Hepatotoxic drugs • Contact with jaundiced person • Sexual history
- 22. Risk factors 1. Alcohol intake 2. Medications 3. Pregnancy 4. Sexual contact, drug abuse, needle punctures 5. ICU – Sepsis, shock, Total parenteral nutrition 6. After BM transplantation – Veno occlusive disease or GVHD Family history 1. Benign recurrent intrahepatic cholestasis (BRIC) 2. Progressive familial intrahepatic cholestasis (PFIC)
- 23. Family history • Progressive familial intrahepatic cholestasis (PFIC) • Alpha 1 antitrypsin deficiency • Auto immune disorders
- 24. Personal history • Bowel – Pale stools Alteration in bowel habits • Bladder • Sleep – Pruritus disturbing sleep Hepatic encephalopathy
- 25. Physical examination 1. Anemia – GI blood loss, nutritional deficiency, hypersplenism 2. Nails – Clubbing, shiny nails 3. Itch marks 4. Virchow’s node or sister mary joseph nodule – Abdominal malignancy 5. Jugular venous distension – Hepatic congestion 6. S/O Fat soluble vitamin deficiency • Vit D (Osteomalacia, demineralized bone, kyphosis , fracture) • Vit E (Cerebellar ataxia, posterior column dysfunction, peripheral neuropathy) • Vit A (Night blindness, thick skin) • Vit K (Easy bruisablity, gum bleeding) 6. S/O hepatic osteodystrophy – Loss of height, back pain, collapsed vertebra, fracture of ribs with minimal trauma
- 26. GI system examination •Oral cavity – Yellowish discoloration, oral thrush •Hepatomegaly – Alcoholic liver disease, primary or secondary hepatic neoplasm, infiltrative disease •Hard and nodular liver – Metastatic malignancy •Murphy’s sign – Cholecystitis •Enlarged gall bladder – Non calculus biliary obstruction •Other abdominal masses – Primary Ca stomach or colon Courvoisier's law – Presence of a palpably enlarged gall bladder which is non tender and accompanied with jaundice, the cause is unlikely to be gallstones
- 27. • Ascites plus jaundice – Cirrhosis or malignancy with peritoneal spread • Rectal examination and sigmoidoscopy may indicate carcinoma • Marked splenomegaly – Cirrhosis + portal HTN or lymphoproliferative disease
- 28. Suspected cholestatic jaundice Cholestatic pattern: Conjugated hyperbilirubinemia ALP high wrt ALT/AST Ultrasound Dilated ducts (Extrahepatic cholestasis) Non dilated ducts (Intrahepatic cholestasis) CT/ MRCP/ ERCP Serologic testing (AMA, viral hepatitis, Liver biopsy AMA + MRCP/Live r Biopsy AMA - Harrison’s principles of Internal Medicine 19th edition
- 29. What to do next ?
- 30. Choledocholithiasis • Impaction and edema of the common bile duct • Pain – Biliary colic or acute pancreatitis • Rapid rise and decline (within 72 hours) in aminotransferase • Cholangitis – Fever with chills, abdominal pain, jaundice (Charcot’s triad)
- 31. Benign strictures of the bile ducts • Ask for history of gall bladder/biliary surgery • PSC – Multiple or diffuse strictures • Chronic alcoholic pancreatitis – A long stricture in the intrapancreatic portion of the common bile duct • Ampullary stenosis – Trauma during passage of a stone and AIDS • Cholangitis – Frequent in benign than in malignant
- 32. Neoplastic obstruction • Pancreatic carcinoma – commonest • Other tumors – Cholangiocarcinoma, ampulla tumors, Ca GB • Klatskin tumor Abdominal pain Loss of appetite and weight Progressive deep and painless jaundice
- 33. • Ampullary tumors show intermittent jaundice because of sloughing and partial relief of the block • Metastatic cancer , lymphoma may obstruct the bile duct • Hepatocellular carcinoma ruptures into the biliary system throwing tumor emboli obstructing common bile duct • Compression by adjacent tumor/ peribiliary lymph nodes infiltrated by lymphoma, or metastatic ca breast • Direct infiltration by lymphoma
- 34. Drug induced cholestasis Direct hepatotoxicity Idiosyncratic • May mimic viral hepatitis or biliary tract disease • Serum – sickness like features (rash, arthralgia and eosinophilia) Antimicrobial agents Augmentin, Erythromycin, Ethambutol, Dapsone, Fluconazole, Greisofulvin, Ketoconazole Cardiovascular agents Disopyramide beta blockers, ACE inhibitors, ticlopidine, warfarin, methyldopa Endocrine agents Sulfonylureas, estrogens, tamoxifen, androgens, niacin, OCPs, anabolic steroids HAART Zidovudine, protease inhibitors (Indinavir, Ritonavir) Immnosupressive agents Azathioprine, cyclosporine, gold salts, NSAIDS Psychopharmacological agents TCA, BZD, Phenytoin, halothane
- 35. • Primary biliary cirrhosis • Middle aged females (30 – 60 years) • Female : Male – 9:1 • Fatigue and pruritus > Jaundice • Progressive jaundice • Sjogren’s, Scleroderma, Autoimmune thyroiditis • AMA • Primary sclerosing cholangitis • Middle aged males (25- 45 years) • Males 70% • Jaundice more common at presentation • Fluctuating jaundice • Inflammatory bowel disease (UC>CD) • pANCA, anticardiolipin ab • Pre malignant (Cholangio, HCC, Ca GB, Colon)
- 36. Extrahepatic cholestasis Intrahepatic cholestasis Abdominal pain Jaundice Fever Prodrome +++ Early onset Present Absent ++ Late onset Absent Present
- 37. Infiltrative diseases Sarcoidosis, lymphoma, granulomatosis with polyangiitis, amyloidosis, malignancies Cholangiocyte injury Primary biliary cirrhosis, Graft vs host ds, Drugs (Erythromycin, Septran), Cystic fibrosis Miscellaneous conditions Benign recurrent intrahepatic cholestasis, Drugs (anabolic steroids), TPN, paraneoplastic syndromes, Cholestasis of pregnancy Hepatic disorders with prominent cholestasis
- 38. Choledocolithiasis Bile duct diseases Infection Inflammation Neoplasm AIDS cholangiopathy Primary sclerosing cholangitis, Injury caused by hepatic arterial chemotherapy, post surgery strictures Cholangiocarcinoma Extrinsic compression Neoplasms Pancreatitis Vascular enlargement Pancreatic carcinoma, metastatic lymphadenopathy, hepatocellular carcinoma, ampullary adenoma/carcinoma, lymphoma Aneurysm, cavernous transformation of portal vein Hyperbilirubinemia due to bile duct obstruction
- 39. Examination
- 40. General examination • Consciousness • BMI • Built • Nutrition – Fat soluble vitamin deficiencies (A,D,E,K) • Hair, skin, nails
- 41. • Oral cavity - Yellowish discoloration of mucosa Brittle teeth in Vitamin D deficiency Oral thrush
- 43. Scratch marks in primary biliary cirrhosis Shiny nails due to severe itching Xanthalesma
- 44. Vitals Pulse rate – Bradycardia in jaundice Blood pressure – Shock in cholangitis Respiratory rate Temperature
- 45. • Pallor – Difficult to establish • Icterus – Upper sclera, under surface of tongue, skin • Clubbing • Lymphadenopathy Lemon yellow Greenish yellow Orange yellow
- 46. Systemic examination • Gastro-intestinal system • Respiratory system • Cardiovascular system • Nervous system • Musculoskeletal system • Reticuloendothelial system
- 47. Abdominal examination • Inspection – Flanks Umbilicus Superficial veins Visible peristalsis Scar mark Scar marks of laparoscopic cholecystectomy
- 48. Palpation Liver Gall bladder • Start in RLQ • Examining hand parallel to the rectus muscles • Advance hand superiorly with expirations and anticipate the liver edge • Striking the forefinger on inspiration • Orient hand perpendicular to the costal margin feeling from medial to lateral below the right costal margin (feels bulbous, focally rounded mass that moves downward on inspiration) • Murphy’s sign (cholecystitis) Lump can be palpable : Gall bladder, Liver, stomach lump, pseudocyst pancreas
- 52. Biliary Obstruction Liver disease History Abdominal pain, fever, rigor, prior biliary surgery, older age Anorexia, malaise, myalgias (viral prodrome), blood products receipt, exposure to known hepatotoxin, family history of liver disease Physical examination Fever, abdominal tenderness, palpable abdominal mass, abdominal surgical scar Spider telangiectasias, stigmata of portal hypertension, asterixis Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 10th ed
- 54. Benjamin classification (Obstructive Jaundice) Type 1 Complete obstruction : Tumours – pancreatic head carcinoma, cholangiocarcinoma Ligation of CBD Type 2 Intermittent obstruction : Choledocholithiasis, Periampullary tumour , Duodenal diverticula , Papilloma of the bile duct, Intra biliary parasites, Haemobilia Type 3 Chronic incomplete obstruction : Strictures of the CBD, Congenital Traumatic Sclerosing cholangitis ,Post radiotherapy , Stenosed biliary enteric anastomosis, Cystic fibrosis, Chronic pancreatitis ,Stenosis of the Sphincter of Oddi Type 4 Segmental Obstruction : Traumatic hepatodocholithiasis, Sclerosing cholangitis Cholangiocarcinoma
- 56. Benjamin classification (Obstructive Jaundice) Type 1 Complete obstruction : Tumours – pancreatic head carcinoma, cholangiocarcinoma Ligation of CBD Type 2 Intermittent obstruction : Choledocholithiasis, Periampullary tumour , Duodenal diverticula , Papilloma of the bile duct, Intra biliary parasites, Haemobilia Type 3 Chronic incomplete obstruction : Strictures of the CBD, Congenital Traumatic Sclerosing cholangitis ,Post radiotherapy , Stenosed biliary enteric anastomosis, Cystic fibrosis, Chronic pancreatitis ,Stenosis of the Sphincter of Oddi Type 4 Segmental Obstruction : Traumatic hepatodocholithiasis, Sclerosing cholangitis Cholangiocarcinoma
Notas del editor
- Impairment of gut mucaosal integrity, enhanced inflammation, increased cytokine expression, endotoxin associated down regulation of bile acid transportation
- Split into establishment of jaundice , etiology, complications
- Courversir’s law
- Audience - charcot
- Intermittent jaundice Jaundice more common in Ca GB, less common in HCC Infiltrative jaundice causes less jaundice Lymphoma develops deepening jaundice - porta compression