IKTERUS OBSTRUKTIF

Anamnesis : Hall of Mark Obstructive Jaundice :Jaundice; Dark Urine; Pale Stool; Generalized PrutitusCholangitis / Choledocolithiasis :Fever; Colic Bilier; Intermitten JaundicePancreatic Ca:↓ BB; Abdominal mass: Pain radiating to back; Progressive JaundicePeriampullary Ca:Deep Jaundice (Greenish); Fluctuate in IntensityExtrahepatic Ca:Palpably enlarged gall bladder (Couvosier’s sign (+))(sumber:ptolemy.library.utoronto.com)Pemeriksaan Fisik

1. Nyeri tekan murphy`s sign2. Ikterik :

a. 2.5 mg/dl ---- sklerab. 5 mg/dl ---- kulit

2. Demam, takikardia, muscular guarding, perut kembung

3. Ssesak nafas, gg hemodinamik, hematemesis&melena

4. Cullen sign, Grey turner sign,nodul kulit eritematosa.

5. Purtscher retinopathy6. Demam

Pemeriksaan penunjang :1. Lab :

a. darah lengkap (leukositosis)b. SGOT/SGPTc. Bilirubin direct/indirectd. Alkaline Fosfatasee. Aminotransferase

2. Radiologia. Foto polos abdomenb. USG Abdomenc. Oral colecistografyd. CT Scane. Colangiographyf. Laparoskopyg. FDG PET Scan

ATALANTA Classification 1992

Patogenesis pembentukan Batu

Triangular-phase diagram with axes plotted in percent cholesterol, lecithin (phospholipid), and the bile salt sodium taurocholate. Below the solid line, cholesterol is maintained in solution in micelles. Above the solid line, bile is supersaturated with cholesterol and precipitation of cholesterol crystals can occur. Ch, cholesterol. (From Donovan JM, Carey MC: Separation and quantitation of cholesterol “carriers” in bile. Hepatology 12:94S, 1990.)

(Sabiston)

The pathogenesis of cholesterol gallstones is clearly multifactorial but essentially involves three stages: (1) cholesterol supersaturation in bile, (2) crystal nucleation, and (3) stone growth.

For gallstones to cause clinical symptoms, they must obtain a size sufficient to produce mechanical injury to the gallbladder or obstruction of the biliary tree. Growth of stones may occur in two ways: (1) progressive enlargement of individual crystals or stones by deposition of additional insoluble precipitate at the bile-stone interface or (2) fusion of individual crystals or stones to form a larger conglomerate.

Child – Pugh ClassificationVariable 1 2 3Ensefalopati Nil Slight to moderate (1, 2) Moderate to severeAsites Nil Slight Moderate to severeBilirubin (mg/dl) <2 2 – 3 >3Albumin(g/dl) >3,5 2,8 – 3,5 <2,8Prototrombin index >70% 40% - 70% <40%

Ranson criteria for prognostic implication of acute pancreatitisAdmission After 48 H onset interpretation

GDS > 200Age > 55LDH > 350AST (SGOT) > 250WBC > 16000

Ht turun > 10%BUN > 5Ca > 8pO2 < 60Base deficit > 4 mEqSequeatrasi cairan > 6 L

< 3 mortalitas 1%3-4 mortalitas 16 %5-6 mortalitas 40%>6 mortalitas 100%

TOKYO GUIDELINE(1) Diagnostic criteria for acute cholangitisA. Clinical manifestation- Riwayat penyakit bilier- Demam dan atau

menggigil- Jaundice- Nyeri perut (RUQ atau

upper abdominal)

B. Lab finding- Bukti inflamasi- LFT abnormal

C. Imaging finding- Dilatasi bilier, atau bukti

obstruksi (batu, striktur atau stent)

Interpretasi :Suspected : 2 atau > criteria (+)Definite : triad charcots 2 atau > dari A + salah satu dari B atau C

a Abnormal WBC count, increased serum CRP level, and other changes indicating inflammation b Increased serum ALP, γ-GTP (GGT), AST, and ALT levels

Severity assessment criteria for acute cholangitis GRADE I (MILD)Mild (grade I)” acute cholangitis is defined as acute cholangitis that responds to the initial medical treatmenta

GRADE II (MODERATE)“Moderate (grade II)” acute cholangitis is defined as acute cholangitis that does not respond to the initial medical treatmenta and is not associated with organ dysfunction

GRADE III (SEVERE)“Severe (grade III)” acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems:1. Hipotensi (dengan dopamine ≥

5µ/KgBB/’, dan atau dobutamiin)

2. Penurunan kesadaran3. Gangguan respirasi

(PaO2 / F1O2 ratio < 300)4. BUN > 2 mg/dl5. PT-INR > 1,56. Trombositopenia

(<100.000/mm3)Note: compromised patients, e.g., elderly (>75 years old) and patients with medical comorbidities, should be closely monitoreda General supportive care and antibiotics

(2) Diagnostic criteria for acute cholecystitis LOCAL FINDING(1) Murphy’s sign, (2) RUQ mass/pain/tenderness

SYSTEMIC SIGN(1) Fever, (2) elevated CRP, (3) elevated WBC count

IMAGING FINDINGImaging findings characteristic of acute cholecystitis

Definite diagnosis(1) One item in A and one item in B are positive(2) C confirms the diagnosis when acute cholecystitis is suspected clinically

Imaging findingUltrasonography

• Sonographic Murphy sign (tenderness elicited by pressing the gallbladder with the ultrasound probe)

• Thickened gallbladder wall (>4 mm, if the patient does not have chronic liver disease and/or ascites or right heart failure)

• Enlarged gallbladder (long axis diameter >8 cm, short axis diameter >4 cm)

• Incarcerated gallstone, debris echo, pericholecystic fluid collection

• Sonolucent layer in the gallbladder wall, striated intramural lucencies, and Doppler signals

MRI

• Pericholecystic high signal

• Enlarged gallbladder

• Thickened gallbladder wall

CT

• Thickened gallbladder wall

• Pericholecystic fluid collection

• Enlarged gallbladder

• Linear high-density areas in the pericholecystic fat tissue

Tc-HIDA scan (technetium hepatobiliary iminodiacetic acid scan)

• Non-visualized gallbladder with normal uptake and excretion of radioactivity

• Rim sign (augmentation of radioactivity around the gallbladder fossa)

Severity assessment criteria for acute cholecystitis GRADE I (MILD)defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure.

GRADE II (MODERATE)1. WBC > 180002. Palpable mass RUQ3. Complaints > 72 ha

4. Marked local inflammationa Laparoscopic surgery should be performed within 96 h of the onset of acute cholecystitis

GRADE III (SEVERE)“Severe (grade III)” acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems:1. Hipotensi (dengan dopamine

≥ 5µ/KgBB/’, dan atau dobutamiin)

2. Penurunan kesadaran3. Gangguan respirasi (PaO2 /

F1O2 ratio < 300)4. BUN > 2 mg/dl5. PT-INR > 1,56. Trombositopenia

(<100.000/mm3)

Algoritma Ikterik (Sabiston)

PENATALAKSANAAN

BATU : laparotomi / papilotomi per endos atau per lapOBSTRUKSI STRIKTUR / STENOSIS : dilatasi, sfingterotomi

TUMOR : drainage externalBilio-digestif by pass

Kolesistektomi (batu dalam vesica felea)BATU Sfingterotomi / papilotomi (batu dalam ductus kholedokus)

operable (reseksi tumor)TUMOR inoperable (pembedahan paliatif, ex: drainage)

Pada advanced malignant disease (ACS, 2007)

(Sabiston)