Obstructive Jaundice

Obstructive Jaundice
Definition

Obstructive jaundice is not occurred due to deviation of the physiology of the liver by own, rather it is happened either postoperative or congenital or sudden obstruction of the bile channel or by drugs inducing.


Causation / Etiology

A. Intrahepatic Cholestasis

Drugs: Largactil, PAS, Arsenic, Sulphonamides, Nitrofurantoin, etc.
Hormones: Anabolic steroid, Methyltestosterone.
Oral contraceptives

B. Extrahepatic causes(CBD obstruction)

Causes in the lumen
C.B.D stones
Ascaris worm or ova or cysts
Stone in Pancreatic duct

Causes in the wall
Periampullary carcinoma
Stricture of C.B.D or common hepatic duct
Choledochal cyst
Stenosis of a splinter of Oddi
Common bile duct or common hepatic duct growth

Pressure from outside
Ca- head of the pancreas
Chronic pancreatitis
Lymph node of Porta hepatis

Surgical Jaundice:
Jaundice amenable to surgical treatment is surgical jaundice. Most obstructive jaundice or post-hepatic jaundice belong to this group.

Latent jaundice:
Raised serum bilirubin above 1mg to 2mg/dl without clinical jaundice.


Diagnosis

A.
History

Age - Jaundice in newborns and infants is commonly caused by erythroblastosis fetalis, atresia of bile ducts, physiological jaundice, congenital spherocytosis.

Sex - Malignancy and alcoholic cirrhosis are more common in males. Stones are almost equal in males and females.

Duration - Jaundice due to malignancy is usually of shorter duration. Jaundice for a longer duration is most likely to be benign surgical jaundice.

Onset - Insidious in obstructive jaundice. Sudden in a matter of hours in an otherwise healthy individual with nausea, anorexia and aversion to smoking (in smokers) points to infective hepatitis. If anybody nurses the infective hepatitis patient can be affected by obstructive jaundice or hepatitis.


Jaundice following operation - 
On biliary tract suggest residual calculous, traumatic stricture of the bile duct, hepatitis, or postoperative pancreatitis.
For removal of a malignant growth suggest hepatic metastasis.

Jaundice with previous dyspepsia, fat indigestion, and biliary colic suggest cholelithiasis or choledocholithiasis.

Past history - Hepatitis due to blood transfusion or parenteral infection.
Previous difficult cholecystectomy.

Personal history - Alcohol or contact with a patient of infective hepatitis.


B.
Symptomatology

Progressive jaundice - Malignant obstruction
Intermittent jaundice - Commonly C.B.D stone.
Painless - Usually malignant jaundice (Ca- head of the pancreas)
Panful - Biliary colicky pain suggests stone. In pancreatitis, epigastric pain is continuous and radiates to the back. Upper abdominal dull, dragging pain is due to hepatitis and cirrhosis.

Pyrexia or fever - History of influenza-like fever followed by the appearance of jaundice is generally due to hepatitis. Jaundice with spiky temperature and chill usually indicate cholangitis associated with impacted stone in the common bile duct. Fever may also present in cirrhosis and neoplastic diseases.

Pruritus - The presence of pruritus (itchy) along with jaundice is common in obstructive jaundice due to irritation of cutaneous nerves by retained bile salts.

Stool and its color
The voluminous and clay-colored stool is usually prevented in obstructive jaundice due to the absence of stercobilin. In hemolytic jaundice, the stool is yellow-colored.

Swelling or lump abdomen - Palpable gall bladder, Ca- head pancreas, hepatomegaly with splenomegaly.

The desire for food - Marked loss of appetite is more common in Ca and Hepatitis.

Dark urine

Loss of weight


C.
Clinical examination

Eye: (Depth of jaundice) - 
Mild or lemon yellow color - Hemolytic jaundice
Orange-yellow - Hepatocellular jaundice
Greenish-yellow - Obstructive jaundice

Tongue - dry, coated tongue with fetor hepatitis in hepatic failure.
Neck - Vircow's gland ( metastasis left supraclavicular lymph node - Ca head of the pancreas, gastric Ca.
Gynecomastia - Cirrhosis of the liver
Skin - Scratch marks due to itching.
Abdomen - looks normal


Investigation

Examination of urine - Absence of urobilinogen in obstruction in C.B.D.
Stool - Absence of stercobilin in complete C.B.D obstruction
Occult blood- Periampullary carcinoma, alimentary carcinoma, or portal hypertension.
Blood -  Low W.B.C count with lymphocytosis, Low Hb%, in malignancy, Leukocytosis in cholangitis. B.T, C.T, P.T.

L.F.T
Serum bilirubin - In obstructive jaundice, as high up to 20mgm% or more
Serum Albumin - Below 3gm%, suggest gross liver damage
Alteration of A/G ratio- severe liver damage
Serum Alkaline phosphatase - Above 30K-A units suggests obstructive jaundice.
Serum Transaminases (S.G.O.T, S.G.P.T)- very high in hepatitis and liver damage
Prothrombin time(P.T) and Platelet count- severe impairment indication liver damage.

Radiology
Chest X-ray to exclude metastasis
St. X-ray abdomen
USG
Ba-meal X-ray stomach and duodenum
P.T.C - Percutaneous transhepatic cholangiogram)
I.V.C - Intravenous cholangiogram
E.R.C.P - Endoscopic retrograde cholangiopancreatography
C.T scan - Computerized tomography.

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