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جراحةد.
عدد الاوراق 5
29-11-2012Jaundice
Definition of Jaundice= Icterus
A yellowish staining of the skin, sclerae and deeper tissues with bile pigments which are increased in plasma
Can be seen on examination at serum bilirubin levels (2 2.5 mg/dL)
Clinical marker of defect in metabolism &/or excretion of bilirubin.
Types of Jaundice
Cholestatic (Obstructive)Hepatocellular
Haemolytic
What is bilirubin?
The breakdown product of Hgb from injured RBCs and other heme containing proteins.
Produced by reticuloendothelial system
Released to plasma bound to albumin
Hepatocytes conjugate it and extrete through bile channels into small intest.
Bilirubin Metabolism
What causes ( bilirubin?
Overproduction by reticuloendothelial systemFailure of hepatocyte uptake
Failure to conjugate or excrete
Obstruction of biliary excretion into intestine
Causes of Jaundice
Pre-hepatic unconjugated hyperbilirubinaemiaHaemolysis
Congenital defects:Gilberts syndrome (uptake/conjugation defect)
Crigler-Najar (conjugation defect)
History
painColour of stools and urine
Drugs
Recent blood transfusion
Alcohol intake
Contact with hepatitis infection
Occupation
FHx anaemia, splenectomy, gallstones
Clinical Features
Healthy young person with fever, malaise, myalgias = viral hepatitis (try to locate source)Gradually develops symptoms = hepatic/bile duct obstruction (consider ETOH liver dz/cirrhosis)
Develops acutely with abd pain = acute cholangitis 2 to choledocholithiasis
Painless jaundice in older person with epigastric mass & weight loss = biliary obstruction from malignancy
Hepatomegaly with pedal edema, JVD, and gallop = CHF
Examination
Pale yellow vs. deep yellow
Signs of cirrhosis
Liver tender, enlarged, firm, shrunken, irregular
Gallbladder tender (Murphys sign), palpable
splenomegaly
Investigations
Imaging
Ultrasound
Gallstones
Bile duct dilatation
Intra-hepatic lesions
CT
Liver lesions
Pancreatic lesions
CT-IVC
MRI
Liver lesions
MRCP
X-ray
Gallstones only 10% radio-opaque
PTC, ERCP can also be means of therapy
Isotope scan HIDA
Management
Treatment requires a precise diagnosis of the specific cause and should be directed to the specific problem
Symptom relief
Pain, itch
Fluid resuscitation
Correction of coagulopathy
Treat secondary complications
Sepsis, bleeding, anaemia
Treat underlying cause
Medical or surgical
Surgical Management
Post-Hepatic JaundiceInitial therapy
Analgesia
IV fluids
Vit K
NBM
Consider Antibiotics
Relieve obstruction
Definitive or temporising, Curative or palliativeERCP / PTC
Remove stones
Stent or dilate stricture
Surgery
Cholecystectomy with bile duct exploration
Resection of obstructing tumour
Whipples procedure
Bypass of irresectable lesion
Transcystic Exploration of Common Bile Duct
Benign distal CBD stricture PTC and balloon dilatation of post- cholecystectomy stricture
ERCP and stent insertion for obstructing cholangiocarcinoma
Case Study1History: 68-year-old,jaundice,stomach pain,dark urine, itching of the skin,rapid weight loss of 21lb
Lab data
CBC within narmal limits
Total bilirubin:238μmol/l
GGT:300U/l
ALP:360U/l
AST:80u/l
ALT:75u/l
Urinalysis: positive bilirubin, normal urobilinogen
Serum amylase: elevated
Question:
What is the most probable diagnosis for this patient?
Which labtory tests provided the most information,and which provided the least?
Case Study2
History:38-year-old white female, jaundice, right upper quadrant abdominal pain, nausea, vomiting, itching skin. She has a history of intravenous drug use and alcohol abuse.Lab data
elevated total bilirubin(136 (mol/l)
elevated conjugated bilirubin(102(mol/l)
Urine:orange-brown,3+bilirubin,normal urobilinogen
elevated ALP(1.5ULT),GGT(3ULT),ALT,AST(5ULT)
Modest increase: Serum cholesterol and triglyceride
Question
What is the probable diagnosis for this patient? Why?What other laboratory test would recommend to confirm this diagnosis?
Which laboratory tests ordered provided the most information? Why?