OBSTRUCTIVE JAUNDICE

CLINICAL LECTURE DEMONSTRATION(CLD)

DR.S.BRANAVAN CONSULTANT GENERAL SURGEON TH BATTICALOA

42 year old woman who had a prosthetic mitral valve replacement in the past, presented with 3 Days history of fever & abdominal pain. The pain is persistent and mainly located in the Upper quadrant. She vomited few times at the Admission. On further questioning she said that she had experienced episodes of right upper abdominal pain in the past. Her bowels opened one day ago and the consistency was normal. She was not sure about the color of the stools. Her eyes have yellow discoloration since 3-4 days and the Urine is dark in color.

 Based on the history what are your differential diagnosis?

Cholangitis Charcots triad Hepatitis Falciparum malaria Acute cholecystitis with Mirrizi syndrome

On examination her temperature was 39.7C. She was ill and Dehydrated. Her sclera has deep yellow discoloration. There were scratch marks noticed on the body. Her RR was 22/min But the lung fields were clear on examination.

Explain the pathophysiology behind These physical signs on this patient

Fever Jaundice

Scratch marks

Her abdomen was not distended and no surgical scars seen. There were no hernias. She was extremely tender at RHC and Epigastrium. The liver is not distended below the costal margin and the gall Bladder is not palpable. There was no free fluid and her bowel sounds appeared Normal. DER showed little pale stools.

 What are the possible DD now?

 What is the significance GB distention in a jaundiced patient?

 Explain the pathophysiology of pale stools on this patient?

 How would you manage her on admission as an intern house surgeon?

 How would you investigate her?

Her White count was 14000 with the differential count of N77% and L-22%. Her CRP was 102 and the urine was positive for bile. S.Creatinine 1.3g/dl, Na 137 mmol/l, K 4.8 mmol/l, SGOT 87 IU, SGPT 92 IU, Total bilirubin 88 micromol/l with the direct fraction of 53 micro mol/l. Alkaline phosphatase was 845 IU CXR showed minimal pleural effusion on right side

 How would you interpret her blood results? Explain the bilirubin metabolism What is jaundice? When do a patient clinically becomes jaundiced? What is surgical jaundice? What are the serum markers of cholestasis?

 How would you further evaluate her jaundice radiological?

 Her USS showed gall stones in the GB. Gall bladder wall thickness was normal and there is no peri cholic fluid. CBD measured just above the cystic duct junction was 13mm. No CBD stones were visualized. No intra hepatic biliary dilatation noted.

 How sensitive the US in diagnosing Gall bladder stones and CBD stones?

 Why her intra hepatic ducts were not dilated?

 What are the other investigations to identify the cause for the obstruction?

She underwent ERCP. There was a filling defect at the CBD suggestive of a stone. Sphincterotomy and removal of stone done. Her jaundiced and fever settled in 3 days. She was discharged and planned for a laparoscopic cholecystectomy in 4 weeks time.

 What are the causes for obstructive jaundice? How do you prepare a patient for ERCP? List the complications of ERCP?

 How do you pre operatively prepare a jaundiced patient for surgery? What are the surgical complications of jaundice? What is Hepato renal synd?