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Post hepatic jaundice

Jaundice : warna kekuningan pada kulit, sclera, mukosa, karena deposisi bilirubin dalam plasma.

( > 2mg/dl)

klasifikasi jaundice :

Category Definition

Pre-hepatic The pathology is occurring prior to the liver.

Hepatic The pathology is located within the liver.

Post-Hepatic The pathology is located after the conjugation of bilirubin in the liver.

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Hallmark posthepatic jaundicejaundice

Dark urine

Pale stools

Generalized pruritus (bile salt in circulation)

Penyakit tersering yang mengakibatkan jaundice :

1. Choledocholithiasischolelithiasischolecystitis2. Cholangiocarcinoma3. Ampullary cancer4. Ca of pancreas5. Billiary strictures

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1. STONESCholedocholithiasis

Common bile duct stones (primary, secondary)Clinical manifestation

Silent Present with

o Biliary colico Cholangitiso Gallstone pancreatitiso Obstructive jaundice

Diagnosis

US MRC ERCP

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2. MALIGNANCYPancreatic Cancer

EtiologySmokers

Fat, Protein, Caffeine, Alcohol diets

GeneticPathophysiologyArise from epithelial cells of pancreatic ducts

Tumour in late stagespread throughout pancreas

Can be result of metastasis disease from

Lung Breast Thyroid Kidney SkinRapid growing with spread to surrounding tissue

Head of pancreas (most common site) Thromboplastic factors

Necrotic pancreatic tumours Results in thrombophlebitis

Clinical Management (Prevent spread of tumour)

Chemotherapy, radiation

Pain control

Total resectionHead of pancreas removal

Whipple procedureNutritional supportTPN, tube feedingFluid, electrolyte replacement

Glucose monitoring

Cholangiocarcinoma

Slow growing malignancyBiliary tract

Infiltrate locally, metastasize late

Extra-hepatic (90%)60-70 y/o, M=F ( Incidence Japan, Israel, Native Americans)

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Etiology

Ulcerative colitisSclerosing cholangitis

Choledochal cysts

Hepatolithiasis

Liver flukesPapillomatosis of bile ducts

Thorotrast exposureTyphoid carrier

Adult polycystic kidney disease

Pathology

AdenocarcinomaTypes

Papillary Nodular SclerosingBest prognosispapillary distal tumours

Cancer of Common Bile Duct (CBD) Bifurcation

Periampullary Carcinoma

PathologyAdenocarcinomaArises from 4 different tissues

of origin

Head of pancreas Distal bile duct Ampulla of Vater Periampullary duodenumTreatment

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Standard Whipple pancreaticoduodenectomy

3. BILLIARY STRICTURESStenosis of Sphincter of Oddi

Inflammation, fibrosis, muscular hypertrophyEpisodic biliary pain

Abnormal LFT

Dilated common bile duct (difficult to cannulate,delayed emptying of contrast)

Causes (Bile duct strictures)Operative injury

Fibrosis (due to chronic pancreatitis)

Common bile duct stones

Acute cholangitis

Biliary obstruction (due to cholecystolithiasis)(Mirizzis syndrome)

Sclerosing cholangitisCholangiohepatitis

Strictures of a biliary-enteric anastomosis

Bile Duct StricturesRecurrent cholangitis, 2 biliary cirrhosis, portal

hypertension

Present withcholangitis, jaundiceUS, CT, MRC, PTC, ERCP

Treatment Endoscopic dilatation Stent placement Roux-en-Y choledochojejunostomy Hepaticojejunostomy Choledochoduodenostomy