Obstructive Jaundice

Obstructive jaundiceSepta Ekanita

PPDS PULMONOLOGI & ILMU KEDOKTERAN RESPIRASI

FKUI- RS PERSAHABATAN JAKARTA

29 MEI 2007

Pendahuluan Obsructive jaundice merupakan sekumpulan

penyakit yang mengakibatkan tersumbatnya saluran empedu

Gejala klinisnya : Kuning (ikterus) Mual sampai muntah Rasa tidak nyaman di ulu hati setelah makan

makanan pedas Rasa panas di dada (heartburn) Nyeri perut bag.atas kanan atau sampai perut

atas tengah Feces seperti dempul.

Blood results

Conjugated bilirubin >35 mmol/l Increase in ALP / GGT >> AST / ALT Albumin may be reduced Prolonged PTT

Urinalysis findings

Haemolysis Obstruction Hepatocellular

Conjugated bilirubin

Normal Increased Normal

Urobilinogen Increased Nihil Normal

Aetiology of obstructive jaundice

Common Common bile duct stones Carcinoma of the head of pancreas Malignant porta hepatis lymph nodes

Infrequent Ampullary carcinoma Pancreatitis Liver secondaries

Rare Benign strictures - iatrogenic, trauma Recurrent cholangitis Mirrizi's syndrome Sclerosing cholangitis Cholangiocarcinoma Biliary atresia Choledochal cysts

Complications of obstructive jaundice Ascending cholangitis

Charcot's triad is classical clinical picture Intermittent pain, jaundice and fever Cholangitis can lead to hepatic abscesses Need parenteral antibiotics and biliary decompression Operative mortality in elderly of up to 20%

Clotting disorders Vitamin K required for gamma-carboxylation of Factors II,

VII, IX, XI Vitamin K is fat soluble. No absorbed. Needs to be given parenterally Urgent correction will need Fresh Frozen Plasma Also endotoxin activation of complement system

Hepato-renal syndrome Poorly understood Renal failure post intervention Due to gram negative endotoxinaemia from gut Preoperative lactulose may improve outcome Improves altered systemic and renal haemodynamics

Drug Metabolism Half life of some drugs prolonged. (e.g. morphine)

Impaired wound healing

Tujuan presentasi

Mendiskusikan tatalaksana (obstructive jaundice) obstruksi saluran empedu dengan baik

Ilustrasi kasus

Seorang laki-laki, 52 tahun, menikah, TNI AD, masuk RSPAD GS tgl 28/4/2007 pk.12:00 wib dengan keluhan utama : kulit kuning

Riwayat penyakit sekarang; Sejak 1 bulan SMRS kedua mata kuning dan

seluruh tubuh disertai sakit dada yang tidak menjalar, mual dan muntah serta nafsu makan berkurang

Bab seperti dempul, bak kuning tua seperti teh.

Kebiasaan : merokok 2 bungkus (24 btg)/ hr Pasien kiriman dari RS di Padang dan

dirawat 1 minggu.

Riwayat penyakit dahulu : tidak ada Riwayat kronik : tidak ada Lab: HbsAg (-), Anti HbsAg (-), Bil Tot 17,73

(direk 10,23, indirect 750) Hasil USG tgl 24/4/2007(Padang)

Kesan : cholectasis intra dan ekstra hepatal dengan hepar, lien, pankreas,ginjal, kandung empedu normal

Terapi yang diberikan sebelumnya: Urdafalk 3 x 1 tab Methioson 3 x 1 ta b Curcuma 3 x 1 tab Metronidazole 3 x 500 mg tab

Pemeriksaan fisis Keadaan umum:

Tampak sakit sedang, komposmentis,

Td 110/70 mmHg, N 86 x/mnt, FN 20 x/mnt, suhu 36,4°C

Keadaan khusus: Kepala:

- mata kuning tua seperti kunyit

- THT : dbn

Leher : JVP 5 -2 cm Hg, KGB (-) Toraks :

Bunyi jantung I dan II normal, gallop (-), murmur (-)

Abdomen : datar lemas, hepar dan lien tidak teraba, turgor baik

Ekstremiti : kuning, refleks fisiologi normal, tidak kering

Diagnosis masuk

Obstructive jaundice e.c cholestasis intra & extra hepatic

Rencana diagnostik:DL,UL, SMA-2, LFT, HbsAg, EKG,

foto toraks,

Therapy

Instruksi Dr. Ruswandhi Sp.PDIVFD Aminofusin : dextrose 10 % :

Asering 1:1:1Diet hati IIIObat dari RS Padang diteruskan

Daftar masalah

Obstructive jaundice ec. ? Hiperlipidemia

Therapy yang berikan

IVFD aminofel : D10%: Nacl 0,9% :1;1;1 8 jam / kolf

Inj. Cefotaxim 2 x 1 gr / hari 7 hari Metronidazole 3 x 500 mg drip / hari 14 hr Curcuma 3 x 1 tab Urdafalk 3 x 1 tab Methioson 3 x 1 tab Simvastatin 1 x 20 mg / hari Gemfibrozil 1 x 600 mg / hari

Hasil CT scan abdomen 1/5/2007 Kesan :

Batu kandung empedu13 mm x 40 mm dg pelebaran sal. Empedu intra hepatic kanan-kiri tetapi kandung empedu tidak membesar

Suspeks striktura partial di duktus hepatikus komunis

Pankreas normal, KGB tidak membesar Tidak tampak massa intra abdomen

Hasil MRI tgl 14/05/2007 Sludge yang mengeras / calcified disertai

inflamasi perifokal ukuran 2,1 x 3 cm dalam lumen kandung empedu, duktus sistikus serta duktus hepatikus komunis, mengakibatkan dilatasi duktus hepatikus kanan-kiri

Lumen CBD dan duktus pankreatikus normal Hepatomegali ringan Limfa, pankreas,kel.supra renal dan ke 2 ginjal

normal Tidak tampak massa tumor pada kaput

pankreas

Hasil MRCP tgl 14/05/2007

Kandung empedu kaliber mengecil tampak lesi lamellar ukuran 2,1 x 3 cm mengikuti kontur kandung empedu, duktus sistikus serta duktus hepatikus komunis

Tampak dilatasi suktus hepatikus kanan dan kiri

Kaliber serta lumen duktus kholedukus serta duktus pankreatikus normal

Endoskopi tgl 28/05/2007

Esofagoskopi : lumen terbuka, mukosa normal, Z line utuh, varices (-)

Gastroskopi : lumen terbuka, mukosa edema, hiperemis, hematin(+), massa pada corpus curvatura minor, rapuh, mudah berdarah, permukaan kasar, ukuran diameter 5 cm

Duodenoskopi : lumen terbuka, mukosa normal. Papilla vateri sulit di nilai

Kesan : Massa pada gaster corpus curvatura minor, sedang, berdarah tunggu hasil PA

Algorithmic approach to the evaluation of patients with jaundice

Singapore Med J 2007; 48 (4) : 364

Algorithm for the Investigation of Obstructive Jaundice

Ultrasound

Normal CBD <8 mm diameter CBD diameter increase with age and

after previous biliary surgery For obstructive jaundice ultrasound

has a sensitivity 70 - 95% and specificity 80 - 100%

In future endoscopic ultrasound may become more widely available

CT Scanning

Sensitivity and specificity similar to good quality ultrasound

Useful in obese or excessive bowel gas Better at imaging lower end of common

bile duct Stages and assesses operability of

tumours

Endoscopic retrograde cholangiogram (ERCP)

Allows biopsy or brush cytology Stone extraction or stenting

Percutaneous transhepatic cholangiogram (PTC)

Rarely required today Performed with 22G Chiba Needle Also allows biliary drainage and

stenting

Treatment Overview of Common bile duct stone

If the patient has Cholangitis - Analgesia (narcotics) and IV antibiotics (amoxycillin, metronidazole and gentamicin) are given.

If the obstruction needs to be relieved, this can be done using:- ERCP (Endoscopic Retrograde Cholangiopancreato graphy) is performed to cut the sphincter connecting the common bile duct to the duedenum, to allow the stone to pass into the intestine relieving the obstuction. If there is any suspicious pathology this may be biopsied. - A cholecystectomy may be indicated at the same time or a later date.

http://www.virtualrheumatologycentre.com/diseases.asp?did=191

Enterohepatic circulation of bile salt. Each molecule circulates at least once for each meal.

BMJ 2001;323;1170-1173

CHOLANGIOCARCINOMA

DEFINITION

Cholangiocarcinoma is an adenocarcinoma

of the intrahepatic or extrahepatic bile duct.

PREVALENCE

There are 2,000 to 3,000 new cases of

cholangiocarcinoma per year in the United

States, accounting for 10% to 15% of all

primary hepatobiliary malignancies.It is

most common in middle-aged men.http://www.elevelandclinicmeded.com/

PATHOPHYSIOLOGY

Primary sclerosing cholangitis (PSC) is a major risk

factor for the development of cholangiocarcinoma. In

a large Swedish study, 8% of patients with PSC

developed cholangiocarcinoma over a mean follow-

up period of 5 years.This study might underestimate

the true incidence of PSC-associated

cholangiocarcinoma. Other diseases associated with

the development of cholangiocarcinoma include

choledochal cysts and infection with liver flukes

including Clonorchis sinensis, Opisthorchis felineus,

and Opisthorchis viverrini.

http://www.elevelandclinicmeded.com/

SIGNS AND SYMPTOMSPatients typically present with jaundice and pruritus and

more generalized symptoms such as weight loss, anorexia, and fatigue. Cholangiocarcinoma should always be suspected in a previously stable patient with PSC who has a rapid clinical decline.

DIAGNOSISInitial diagnostic testing for cholangiocarcinoma is similar to

that used for other causes of cholestasis. Ultrasound examination or CT scanning may reveal areas of focal biliary dilatation. Direct cholangiography with ERC or percutaneous transhepatic cholangiography with brush cytology of the biliary tree can be useful for diagnosis although the sensitivity for detecting malignancy with brush cytology is less than 75%.

Blood testing for cancer antigens, particularly CA19-9, has been shown to be useful in detecting cholangiocarcinoma, as has an index using CA19-9 and CEA. Neither method is highly sensitive or specific but can help confirm suspected cholangiocarcinoma.


THERAPY

Surgical resection of cholangiocarcinoma has resulted in a 5-year survival rate of 16% to 44%. Liver transplantation for cholangiocarcinoma is not offered by most transplant centers because of high recurrence rate after transplantation. Some centers have had a more favorable outcome with radiation and chemotherapy followed by liver transplantation in patients with early stage disease. Palliative therapy includes percutaneously or endoscopically placed biliary stenting. Photodynamic therapy has also been used with some success.


MIRIZZI'S SYNDROME

Mirizzi's syndrome is caused by an impacted cystic duct stone leading to gallbladder distention and subsequent compression of the extrahepatic biliary tree. Occasionally the gallstone erodes into the common hepatic duct producing a cholecystocholedochal fistula. The original classification of Mirizzi's syndrome has been expanded to include hepatic duct stenosis caused by a stone at the junction of the cystic and hepatic ducts or as a result of cholecystitis even in the absence of a obstructing cystic duct stone.

Patients present with jaundice, right upper quadrant pain and fever. Ultrasound or CT scan reveals biliary dilatation above the cystic duct. ERC may reveal the obstructing stone, which can occasionally be removed, but the definitive treatment is usually surgical, consisting of cholecystectomy with surgical repair of the bile duct if necessary.


Klatskin tumor

Klatskin tumor is nominated for those of the hilar type or those occurring at the bifurcation of the left and right hepatic ducts.

This is the most common site for carcinoma. The usual finding is a well- to moderately-differentiated tubular adenocarcinoma

Arch Iranian Med 2007; 10 (2): 264 – 267

Obstructive Jaundice

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