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Jaundiced Patient
Alex A. Erasmo, MD, FACS, FPCS
Professor 2, Faculty of Medicine and Surgery
University of Santo Tomas
Jaundice
• Normal serum bilirubin: 0.5-1.3 mg/dl
• Clinical jaundice: bilirubin >2.0 mg/dl
• Causes
• Medical jaundice
• Surgical jaundice
Differential diagnosis of jaundice
Abnormality in Predominant
Examples
bilirubin metabolism hyperbilirubinemia
Choledocholithiasis, benign
stricture, periampullary
Biliary obstruction Conjugated
cancer, cholangiocarcinoma,
chronic pancreatitis
Workup algorithm for jaundice
Direct/indirect bilirubin
AST, ALT, Alkaline Phosphatase
Hepatitis serologies
Ultrasound
Stones
ERCP
Cholecystectomy
and CBDE
Choledocholithiasis
• Epidemiology and pathogenesis
– Usually formed in the GB and pass to the
CBD
– Secondary stones
• Cholesterol or hard black pigmented stones
– Primary stones
• asso. w/ biliary stasis and infection
• brown pigment, soft, crushable
Clinical features
• Signs/symptoms
– Reynold’s pentad
• ERCP
– Diagnostic and therapeutic
– Invasive : acute pancreatitis, bleeding, perforation
• IOC
– Performed at time of cholecystectomy
Treatment
• Get Prothrombin time
• Acute cholangitis
No Sepsis Sepsis
Laparoscopic Open
Cholecystectomy cholecystectomy
and CBDE and CBDE
Surgical removal of CBD stone
Secondary stones
ERCP with stone extraction
Endoscopic removal using
choledoscope
Workup algorithm for jaundice
Direct/indirect bilirubin
AST, ALT, Alkaline Phosphatase
Hepatitis serologies
Ultrasound
• Advanced disease
– OMS <6 months; 5-year SR 0.4-5%
• CT scan
• ERCP
• MRCP
• EUS
• Diagnostic laparoscopy
• PET scan
CA 19-9
• Gold standard serologic marker for pancreatic cancer
– Sensitivity 90%
– Specificity 98%
• Elevated in benign diseases
• Values >200 IU/ml
– Diagnostic of pancreatic cancer
• Values >300 IU/ml
– Unresectable tumor
• Independent predictor of recurrence and survival
• Response to therapy
CT Scan
• Diagnostic and staging modality of choice
• Multidetector CT
– Dual-phase imaging (arterial/venous phase)
– 3D viewing
CT Scan
A. tumor pancreatic head; B. dilated pancreatic duct
CT signs of unresectability
• Distant extrapancreatic spread
• liver, peritoneal implants
• Ascites
• Encasement of SMA
• Occlusion of the SMV-PV confluence
CT scan of APC
Encasement of confluence of the SMV and PV
Accuracy of 3D-CT
Unresectable Margin-positive
Periamp Ca(%) resection(%)
Sensitivity 90 54
Specificity 95 93
PPV 78 72
NPV 98 86
Overall accuracy 94 83
• EUS-guided FNA
– Sensitivity 60%-90%
• Major limitations
– Operator dependence
• Neoadjuvant CRT
Laparoscopic Staging
(Conlon KC Ann Surg, Feb 1996)
Resectable(n=67) 61 6
Unresectable(n=41) 0 41
– Whipple’s procedure
– Pylorus-preserving PD (PPPD)
• Poor-risk
– Endoscopic drainage
Pancreaticoduodenectomy
Resectable Lesion
whipples
stomach
pancreas
• whipples
CHD
PV
IVC
kidney
Specimen after Whipple’s Operation -
pancreatic head carcinoma
•
GB
P
Whipple’s procedure-
ampullary carcinoma
PPPD - duodenal carcinoma
Reconstruction after PPPD
Contraindications to Surgical Resection of
Pancreatic Cancer
Metastases to the liver, peritoneum, omentum, or any extra-abdominal site
• Poor-risk
– ERCP
– PTBD
• Good-risk
– Bypass surgery
• Cholecysto- or hepaticojejunostomy with
gastrojejunostomy
– Endoscopic biliary drainage
• Neoadjuvant chemotx/radiotx (?)
Treatment for APC
Surgical Bypass vs. Endoscopic Stenting
Methods
• 204 patients with periamp tumors
• Randomized: endoscopic stent or surgical bypass
Results
• Success rate: no difference ( 94 pts vs. 95 pts)
• Lower procedure-related mortality in stented group
(3% vs. 14%)
• Late GOO higher in stented group (17% vs. 7%)
• Poor-risk
– ERCP
– PTBD
• Good-risk
– Bypass surgery
• Cholecysto- or hepaticojejunostomy with
gastrojejunostomy
– Endoscopic biliary drainage
• Neoadjuvant chemotx/radiotx (?)
Annals of Surgical Oncology 8:758-765 (2001) 2001
Pre-CRT Post-CRT
Ampullary, bile duct, and duodenal tumors
• Adenocarcinomas
• Present similar manner to pancreatic head cancer
• Progress from benign adenoma to invasive
adenocarcinoma
• Long-term survival better than pancreatic ductal carcinoma
• 5-year survival rate
– Ampulla, 50%
– Bile duct, 30%
– Duodenum, 25%
Survival Rate
Devascularization
Thermal injury
Direct injury
Infections
Technical problems Grade III Grade IV
• Bismuth
classification
Bile Duct Injuries - Incidence
• Open cholecystectomy
1 in 300 to 500 procedures(0.2% to 0.3%)
• Laparoscopic cholecystectomy
0.6% or 2x that of open cholecystectomy
Bile Duct Injuries - Spectrum
• Bile leaks
• Bile duct lacerations, transections, and
excisions
1. Cystic duct injuries
2. Extrahepatic bile duct injuries
3. Intrahepatic bile duct injuries
Bile Leaks
• Radiology literature – 25% subhepatic fluid collections
30% to 45% with bile
Bilomas
Ascites
Bile peritonitis
Cystic duct injuries
• Cystic duct leak
Most common biliary injury associated with LC
Causes
• Failure to ligate or clip the cystic duct
– Hepaticojejunostomy, Roux-en-Y
• Postoperative diagnosis
– Hepaticojejunostomy, Roux-en-Y
Cholangiocarcinoma
• May arise in the intra- or extrahepatic biliary
system
• 50-70 years old
• Risk factors: PSC, choledochal cysts, liver flukes,
oriental cholangiohepatitis, toxins, biliary
papillomatosis
• Most common
– Adenocarcinoma
– Bifurcation of right and left HD
Clinical features
• Obstructive jaundice, pruritus, RUQ pain
• Weight loss
• Fever, acholic stools
• Dark urine, hepatomegaly
• Diagnosis
– ↑ bilirubin, alk phos, AST, ALT
– ↑ CEA, CA 19-9
Classification - Bismuth
Imaging
• US - initial test
• CT scan
• MRCP
• ERCP
• PTC
• EUS
• PET CT scan
PTC - Hilar cholangiocarcinoma
MRCP - cholangiocarcinoma
Treatment
• Resectable tumors in good-risk patients
– Surgical resection
• Unresectable tumors or poor-risk patients
– Biliary drainage
• PTBD
• Endoscopic biliary stenting
Cysts of the biliary tree
• Isolated or multiple; intra-/extrahepatic or
both; congenital or acquired
• >70% abnormal pancreatobiliary junction
with a long common channel
• ↑ Cholangiocarcinoma
Classification
Type I : cystic or fusiform dilation of
extrahepatic bile duct (most common)
Type II: supraduodenal diverticulum of EHBD
Type III: intraduodenal diverticulum or cystic
dilation of intraduodenal portion
(choledochocele)
Type IVA: multiple cysts in the extra- and
intrahepatic ducts
Type IVB: multiple extrahepatic cysts
Type V: isolated or multiple cystic dilations of
IHBD
Clinical manifestations
• Pain, jaundice, abdominal mass
– 10% of patients
• Chronic intermittent abdominal pain,
intermittent jaundice, acute cholangitis
• Diagnosis
– US, CT, MRCP, EUS
• Treatment
– Type I/II : resection and hepaticoJ
– Type III : endoscopic treatment
– Type IV : resection w lobectomy
Caroli’s disease
• Multiple, segmental dilations of IHBD
• Pathogenesis
– Asso w congenital hepatic fibrosis
• Clinical features
– Cholangitis, hepatic abscess
– Portal HPN, varices, ascites
– Pruritus, abdominal pain
Diagnosis
• Lab studies: ↑ alk phosphatase, bilirubin,
leukocytosis, cholangitis
• Imaging: US, ERCP, MRCP
• Treatment
– Cholangitis : antibiotics
– Stones
• ERCP, ESWL
• Dissolution tx, ursodeoxycholic acid