Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222

8/14/2019 Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222

1/16

Jaundice

Jaundice

Tad Kim, M.D.

UF Surgery

[email protected]

(c) 682-3793; (p) 413-3222


2/16

Jaundice

Overview

Normal Physiology

Pathophysiology

Broad Differential Diagnosis DDx of Obstructive Jaundice

Work-up for Medical Jaundice

Work-up if Obstructive Jaundice Treatment of Obstructive Jaundice


3/16

Jaundice

Normal Physiology

Bilirubin is from breakdown of hemoglobin Unconjugated bilirubin transported to liver

Bound to albumin because insoluble in water

Transported into hepatocyte & conjugated With glucuronic acid now water soluble

Secreted into bile

In ileum & colon, converted to urobilinogen

10-20% reabsorbed into portal circulation and

re-excreted into bile or into urine by kidneys


4/16

Jaundice

Pathophysiology

Jaundice = bilirubin staining of tissue @ lvlgreater than ~2

Mechanisms:

production of bilirubin hepatocyte transport or conjugation

Impaired excretion of bilirubin

Impaired delivery of bilirubin into intestine

surgically relevant jaundice or obstructivejaundice

Cholestasis refers to the latter two, impairedexcretion and obstructive jaundice


5/16

Jaundice

Broad Differential Diagnosisproduction transport or

conjugationImpairedexcretion

Biliaryobstruction

Unconjugate Unconjugate Conjugated Conjugated

Hemolysis Gilberts Rotors CH/CBD stone

Transfusions Crigler-Najarr DubinJohnson Stricture

Txfusion rxn Neonatal Cancer Cancer

Sepsis Cirrhosis Cirrhosis Chronic

pancreatitisBurns Hepatitis Hepatitis PSC

Hgb-opathies Drug inhibition Amyloidosis

Pregnancy


6/16

Jaundice

DDx: Unconjugated bilirubinemia

production Extravascular hemolysis

Extravasation of blood into tissues

Intravascular hemolysis Errors in production of red blood cells

Impaired hepatic bilirubin uptake(trnsport)

CHF Portosystemic shunts

Drug inhibition: rifampin, probenecid


7/16

Jaundice

DDx: Unconjugated bilirubinemia

Impaired bilirubin conjugation Gilberts disease

Crigler-Najarr syndrome

Neonatal jaundice (this is physiologic) Hyperthyroidism

Estrogens

Liver diseases chronic hepatitis, cirrhosis, Wilsons disease


8/16

Jaundice

DDx: Conjugated Bilirubinemia

Intrahepatic cholestasis/impaired excretion Hepatitis (viral, alcoholic, and non-alcoholic)

Any cause of hepatocellular injury

Primary biliary cirrhosis or end-stage liver dz

Sepsis and hypoperfusion states TPN

Pregnancy

Infiltrative dz: TB, amyloid, sarcoid, lymphoma Drugs/toxins i.e. chlorpromazine, arsenic

Post-op patient or post-organ transplantation

Hepatic crisis in sickle cell disease


9/16

Jaundice

DDx: Obstructive Jaundice

This is the slide to remember for surgeons

Obstructive Jaundice extrahepaticcholestasis Choledocholithiasis (CBD or CHD stone)

Cancer(peri-ampullary or cholangioCA) Strictures after invasive procedures

Acute and chronic pancreatitis

Primary sclerosing cholangitis (PSC) Parasitic infections

Ascaris lumbricoides, liver flukes

Just remember top 5 (not parasites)


10/16

Jaundice

Initial Evaluation: History

Jaundice, acholic stools, tea-colored urine

Fever/chills, RUQ pain (cholangitis)

Could lead to life-threatening septic shock

Reasons to have hepatitis or cirrhosis?

Alcohol, Viral, risk factors for viral hepatitis

Exposure to toxins or offending drugs

Inherited disorders or hemolytic conditions Recent blood transfusions or blood loss?

Is patient septic or on TPN?

Recent gallbladder surgery? (CBD injury)


11/16

Jaundice

Initial Evaluation: Physical Exam

Signs of end stage liver disease (cirrhosis)

Ascites, splenomegaly, spider angiomata, and

gynecomastia

Jaundice evident first underneath the

tongue, also evident in sclerae or skin

Courvoisiers sign = painless, but palpable

or distended gallbladder on exam

Could indicate malignant obstruction


12/16

Jaundice

Screening Labs

NL LFT r/o hepatic injury or biliary tract dz Consider inherited disorders or hemolysis

Alk Phos moreso than AST/ALT implies

cholestasis (intrahepatic vs obstruction) Alk Phos also seen in sarcoid, TB, bone

In this case, GGT is specific for biliary origin

Predominant AST/ALT implies intrinsichepatocellular disease

AST/ALT ratio > 2 in alcoholic hepatitis

albumin or INR c/w advanced liver dz


13/16

Jaundice

Subsequent Labs

If no concern for obstructive jaundice:

Viral (Hep B&C) serologies for viral hepatitis

anti-mitochondrial Ab (PBC)

anti-smooth muscle Ab (Auto-immune)

iron studies (hemochromatosis)

ceruloplasmin (Wilsons)

Alpha-1 anti-trypsin activity (for deficiency)

J di


14/16

Jaundice

Imaging for Obstructive Jaundice

RUQ Ultrasound See stones, CBD diameter

CT scan

Identify both type & level of obstruction ERCP

Direct visualization of biliary tree/panc ducts

Procedure of choice for choledocholithiasis Diagnostic AND- therapeutic (unlike MRCP)

PTC useul of obstruction is prox to CHD

Endoscopic Ultrasound or EUS

J di


15/16

Jaundice

Treatment

If Medical, then treat the etiology If Obstructive Jaundice: Should r/o ascending cholangitis, ABC/resusc

For cholangitis: IVF, IV Antibiotics, Decompression

Stones (remove stones vs stent vs drainage) Done via ERCP or PTC or open (surgery)

Benign stricture (stent vs drainage catheter)

Cancer (Stent vs drainage +/- resect the CA) The key principle is decompression, either

externally(drainage) or internally(stenting)the duct open to allow better drainage

J di


16/16

Jaundice

Take Home Points

Above is a comprehensive approach

For surgery clerkship, all you need toknow is: 1. Broad categories (no specific diagnoses)

2. The four DDx ofobstructive jaundice

3. H&P (ask about fevers/chills, jaundice,acholic stools, dark urine, weight loss for CA),r/o ascending cholangitis = emergency

4. Labs (LFT: ?cholestatic, CBC w diff, BMP)

5. Imaging (U/S, CT, MRCP, EUS)

6. Therapy (ERCP vs PTC vs surgery)

Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222

Documents

Transcript of Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222