Obstructive Jaundice

Cholangitis: 

  • CBD obstruction + secondary infection of biliary tree
  • Charcot’s triad: RUQ pain + jaundice + fever (+chills)
  • Reynolds’ pentad: Charcot’s triad + shock (hemodynamic instability) + mental obtundation (change of sensorium)

 

Biliary Colic:

  • RUQ pain and tenderness, radiating to scapula
  • Negative murphy’s sign

 

Cholecystitis:

  • RUQ pain and tenderness, radiating to scapula
  • Positive murphy’s sign
  • Anorexia, N\V
  • No jaundice

 

Mirizzi Syndrome:

  • Obstruction of extrahepatic biliary tree (CBD, mainly) by a stone in gallbladder neck or cystic duct
  • A stone compressing on extrahepatic biliary tree -> obstructive jaundice
  • Two walls fuse -> fistula

 


CASE: all liver and biliary tests are normal except alkaline phosphatase, what does it mean?

  • Alkaline phosphatase can be from other sources:
    1. Bones: growing children, immobilized pt due to bone resorption, bone mets
    2. Placenta: pregnancy, early postpartum

 


  • To diagnose acute pancreatitis, you need 2 out of 3:
    • Clinical picture of acute pancreatitis
    • Labs: pancreatic enzymes (amylase 3 folds)
    • Radiologic evidence

Gallstone complications 3

 

Investigations:

  • Ultrasound:
    • Radiologic signs of acute cholecystitis:
      • Thickened wall due to edema (Chronic cholecystitis: thick with tissue -> chronic irritation)
      • Pericholecystic fluid
      • Stones (if impacted at the neck of the gallbladder and managed conservative (fluid, antispasmodics), this is biliary colic -> it might fall back into the gallbladder. However, if persistent -> stagnation of bile and bacterial proliferation -> progress to acute cholecystitis)
      • Positive US Murphy’s
    • In US, we need to comment on 3 organs:
      • Liver (abscess, tumors, hepatomegaly)
      • Gallbladder (stone, impacted or not, infections)
      • Biliary tree (comment on 3 things):
        • CBD stones
        • CBD dilatation
        • Intrahepatic duct dilatations
  • An inherent limitation of US: most stones are impacted at the distal part of CBD, which is hidden behind the duodenum, where US waves can’t traverse gas. So, if there’s only CBD\intrahepatic ducts dilatation without stone visualization -> still positive!

 


 Management of Acute Biliary Pacreatitis W\ Obstructive Jaundice: 

  1. Hydration (pancreatitis causes third-spacing of fluids -> leads to dehydration)
  2. Control the pain: NSAIDS, tramadol (non-narcotic), antispasmodic (avoid morphine -> causes spasm of sphincter of oddi and worsens the symptoms, however; there’s no strong evidence)
  3. Anti-emetic if vomiting is an issue
  4. Fat free diet: to decease pancreatic enzymes (if you have a functional GIT, USE IT! there’s no evidence saying that feeding the inflamed pancreas will worsen pancreatitis, and keeping the pt NPO will improve it)
  5. NPO only preferred if the patient is not tolerating orally; nauseated or vomiting -> symptomatic relief
  6. Arrange for ERCP for the obstructive jaundice

 


ERCP: Endoscopic Retrograde Cholangio-Pancreatography

  • Therapeutic, how? w\ ERCP, endoscopic sphincterotomy is done “the interventional part” (ERCP+ES)
  • After doing an ERCP -> do cholecystectomy as early as possible w\in same admission

CASE: If the pt has a weak biochemical evidence of an element of obstruction (borderline high bilirubin) but US is negative, what to do?

  • US might be lagging behind!
  • Wait the following day and repeat LFTs
  • If still up -> Go for imaging to get an objective obstruction -> repeat US, endoscopic US or MRCP
  • Avoid doing an ERCP, why? associated w\ morbidity and mortality, so reserve it only for therapeutic purposes and don’t use it for diagnosis

 

ERCP complications:

  • Post ERCP pancreatitis (PEP):
    • Most frequent complication, occurs in 3.5% of pts who underwent ERCP
    • Risk factors:
      • Acute pancreatitis prior to ERCP -> it increases the risk of PEP, however; active acute pancreatitis is no longer a contra-indication, so no need to wait for the pancreatitis to settle before doing an ERCP
      • Age; the younger, the higher the risk
      • Previous PEP
      • The indication for doing it (ERCP done for a stone is less risky than doing ERCP for a tumor or sphincter of oddi dysfunction for example)
      • No biliary dilatation -> makes the procedure more difficult
    • How to diagnose PEP?
      • Worsening of pre-exiting\development of new abdominal related to pancreatitis
      • Persistent hyperamylasemia (3 folds) measured after 24hrs post-procedure
      • Prolongation of hospitalization > 48 hrs
    • Best strategy to prevent PEP?
      • Don’t do ERCP unless indicated .. 🙂
      • Indomethacin suppository
  • Transient Hyperamylasemia: 
    • Extremely common post-ERCP (75%), but not significant unless associated with abdominal pain related to pancreatitis
  • Other complications:
    • Perforation
    • Bleeding
    • Infections

 

 


Download the PDF version: here


References:

  • Dr Alabeidi’s clinical notes

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