=95

=20

Name of the = Speciality:=20 Anaesthesia =

Case: &n= bsp; &nb= sp; =20 OBSTRUCTIVE=20 JAUNDICE

Name of the = Expert: Ravinder = Kumar Batra=20 Professor

&n= bsp; &nb= sp; &nbs= p; =20 and

&n= bsp; =20 &n= bsp; Divya=20 Sethi=20

All India = Institute of=20 Medical Sciences, New Delhi: 110029

JAUNDICE- yellowish = discolouration skin=20 & mucous membranes due to excess of

&n= bsp; =20 plasma bilirubin

=95 =20 Normal range = of plasma=20 bilirubin : Total :0.3-1 mg/dl

= {(Indirect)=20 0.2-0.7mg%, and (Direct)=20 0.1=970.4mg%)

=95 =20 Clinically = obvious 2-2.5=20 mg/dl

=95 =20 Sites to look for jaundice=96 = Sclera,=20 undersurface of the tongue, palms, nails, skin

=95 =20 Bilirubin=20 has high affinity to elastin ( collagenous tissue), therefore scleral = icterus is=20 a more sensitive sign of hyperbilirubinemia than generalised jaundice=20

=95 =20 D/D of = jaundice=96=20 Carotemia, treatment with Quinacrine =20 (scleral icterus =96 absent)

HISTORY =

=B7 =20 Jaundice - onset:=20 sudden or gradual, =20 progress

=B7 =20 Prodromal = symptoms at of=20 before onset:=20 Suggestive of viral hepatits/drug induced hepatitis. Due to release of=20 endogenous interferon

=B7 =20 High coloured = urine,=20 clay coloured stool , pruritus (obstructive=20 jaundice)

=B7 =20 Anorexia, = weight loss,=20 easy fatigability (prodromal=20 symptoms-alcoholic/drug induced hepatitis, significant weight loss-=20 malignancy)

=B7 =20 Fever = (Fever=20 at onset with arthralgias-viral hepatitis; fever with = rigors-cholangitis; low=20 grade fever-=20 neoplasm)

=B7 =20 Abdominal = Pain

=B7 =20 Biliary=20 colic:=20 severe intermittent colicky pain

=B7 =20 Pancreatic=20 pain:=20 Dull, continuous pain = radiating to=20 back, aggravated by food, and =20 relieved by sitting up or leaning forward

Hepatomegaly -Dull, = continuous, dragging=20 type of pain in right hypochondrium- stretching of Glisson capsule=20

=95 =20 Gastro-Intestinal=20 bleeding (ampullary=20 malignancy or development of portal HT )

=95 Intake of=20 medications

=95 =20 Alcohol abuse (alcoholic=20 hepatitis)

=95 =20 Injections = ,transfusion=20 of blood or blood products , promiscuous sexual behavior = (hepatitis=20 B&C)

=95 =20 Contact with = jaundiced=20 individuals

=95 =20 Travel to=20 hepatitis-endemic areas (=20 enterally transmitted hepatitis A&E)

=95 =20 Recent upper = abdominal=20 surgery

=95 =20 GI=20 Bleeding or upper abdominal pain

PAST HISTORY=20

=95 =20 Recent upper = abdomen=20 surgery (retained=20 or recurrent stone, biliary stricture, recurrent obstruction from = enlarging=20 tumor)

=95 =20 Anaesthesia = exposure=20 (postoperative=20 hepatic dysfunction, halothane hepatits)

=95 =20 H/o jaundice = =96=20 relapsing=20 hepatitis, choledocholithiasis

=95 =20 Recurrent = Biliary colic:=20 Cholithiasis:=20 Asymptomatic 75%, Biliary colic 20%, Cholecystitis 10%, = Cmplications < 5%. 15% gall stones have = CBD=20 syones, 95% of CBD stones have gallstones, Normal CBD pressure 10-15cm=20 H₂O. Bile flow stops at 30cm=20 H₂O.

=95 =20 Past H/o = hepatotoxic=20 drugs

=95 =20 Past H/o = contact with=20 jaundiced patient

=95 =20 H/o = cholestasis during=20 jaundice

FAMILY HISTORY =

Family=20 history of Cholestasis;

=B7 =20 Progressive=20 Familial Intrahepatic Cholestasis syndrome (Dublin Johnson & Rotor=20 syndrome)

=B7 =20 α₁=20 antitrypsin deficiency

Family=20 history of jaundice

=B7 =20 Wilson=92s=20 disease

=B7 =20 Progressive=20 Familial Intrahepatic Cholestasis syndrome (Dublin Johnson & Rotor=20 syndrome)

=B7 =20 α₁=20 antitrypsin deficiency

Personal/ = Social=20 History

=B7 =20 Alcohol=20 =96 Alcoholic hepatitis can lead to cholestasis

GENERAL = PHYSICAL=20 EXAMINATION

=95 =20 Body mass=20 index

=95 =20 Vital=20 signs

=95 =20 Pallor:=20 GI bleeding, Hemolysis

=95 =20 Icterus=20 :Sclera, = undersurface of=20 the tongue, palms, nails, skin

Lemon = yellow =96=20 hemolytic

= Greenish yellow=20 =96 obstructive

Orange = yellow =96=20 Hepatocellular

=95 =20 Pedal oedema:=20 hypoproteinemia,=20 development of cirrhosis

=95 =20 Scratch marks=20 :=20 pruritis

=95 =20 Xanthoma/ = xanthelesmas:=20 hypercholesterolemia

=95 =20 Bruises:=20 coagulopathy

=95 =20 Clinical = findings=20 associated with fat soluble vitamin deficiency: Vitamin=20 A - Bitot spot, hyperpigmentation, Ecchymosis- Vitamin K =

=95 =20 Stigmata of = chronic=20 liver disease : secondary=20 biliary cirrhosis due to long standing biliary = obstruction

=95 =20 Lymphadenopathy -=20 Troisier=92s sign(enlargement=20 of left supraclavicular = lymph node=20 d/t secondary involvement seen in malignancies of G.I.T., breast = and=20 testis.)

ABDOMINAL=20 EXAMINATION

=95 = Inspection:=20 Abdominal distension & dilated abdominal vessels-=20 cirrhosis

= Operative=20 scar

=95 =20 Palpation

Rt = upper=20 quadrant tenderness (Murphy=92s sign)-cholecystitis,=20 cholangitis

= Hepatomegaly:=20 tender-Rt heart failure, acute hepatitis; nontender=20 nodular=96

malignancy or infilterative = process e.g.=20 amyloidosis

Splenomegaly-infective = hepatitis,=20 portal=20 HT due to cirrhosis, Rt = heart=20 failure,

= haemolytic=20 anaemia

Distended = palpable GB=20 (Courvoisier=92s law) - in malignant = obstruction of=20 distal

=20 common bile duct=20

=20 Free fluid: = Malignant=20 ascites or non malignant ascites

Diff=E9rences=20 between extrahepatic/intrahepatic Cholestasis

Extrahepatic

Intraheatic

Abdominal=20 Pain

Fever

Prodrome

Drugs

History=20 of surgery

Risk=20 factors like transfusion

Family=20 History

Stigma=20 of cirrhosis

Encephalopathy

PT=20 Normalizing with Vitamin K

Present=20

Present

Absent

Present

Absent

Present

Absent

Present

Absent

Present

Present=20

Present

Absent

Viva- voce: = Questions=20 and Answers (Obstructive Jaundice)

Q. What are the causes of = Progressively=20 worsening jaundice and Intermittent

= jaundice?=20

Progressively = worsening=20 jaundice - Malignant=20 obstruction, primary biliary cirrihosis, familial cholestasis, primary = sclersing=20 cholangitis, advanced end stage liver disease

Intermittent=20 jaundice - = choledocholithiasis,=20 ampullary carcinoma, biliary ascariasis, relapsing viral=20 hepatitis

Q. Name the = drugs that=20 lead to Cholestatic Jaundice?

Cholestatic=20 =96 oral contraceptives, anabolic steroid, chlorpromazine, = carbamazepine,=20 antibiotics- erythromycin, rifampicin

Hepatitis-=20 INH, halothane, phenytoin, methyldopa, = acetoaminophen

Fatty=20 liver-=20 tetracycline, valproate

Toxic=20 necrosis-=20 acetoaminophen, CCl4

Q. Name the conditions where = family history=20 of jaundice is present?

=B7 =20 Wilson=92s=20 disease,

=B7 =20 Familial=20 Intrahepatic Cholestasis syndrome (Dublin Johnson &Rotor syndrome),=20

=B7 =20 α₁=20 antitrypsin deficiency =20

Q: Define = jaundice and=20 where all you will look for it?

&n= bsp; =20 Yellowish discolouration skin & mucous membranes due to = excess=20 of

&n= bsp; =20 plasma =20 bilirubin

&n= bsp; =20 Sites to look for = jaundice=96=20 Sclera, undersurface of the tongue, palms,

&n= bsp; =20 nails, skin

Q: What is the = mechanism=20 of pruritis in Jaundiced patient?

&n= bsp; =20

Central=20 mechanism: ↑central opioidoergic tone in patients with cholestasis =

Peripheral=20 Mechanism: accumulation of numerous substances e.g. bile=20 acids,

histamine,=20 serotonin & endogenous opioids in the systemic=20 circulation

subsequent=20 to failure of elimination

Treatment:=20 Opioid antagonists, Cholestyramine, Rifampcin( Induce CP450 which = inactivates=20 pruritogen), Phenobarbitone, Oral guar gum, 5-HT antagonist, UDCA, = Propofol,=20 Lidocaine, Charcoal hemofiltration, Pasmapheresis, Ileal diversion, = Liver=20 transplantation.

Q. Discuss the metabolism of=20 Bilirubin.

BILIRUBIN METABOLISM =96 can = be divided=20 into 3 stages

Pre-hepatic=20 stage

&n= bsp; =20

Bilirubin is = first=20 formed in macrophages of the reticuloendothelial system. 70 ~ = 80=20 % = of it is coming from breakdown of =20 hemoglobin of senescent red blood cells by RE system and the = rest 15-20% from destruction of maturing erythroid cells in = bone marrow=20 and turnover of Haem and Haem products in liver. =

Within=20 the macrophage, haemoglobin is broken down to:

=95 =20 Globin=20 chains; broken down into constituent amino acids for recycling=20

=95 =20 Haem=20 group

Then, = the Haem=20 group is cleaved by the enzyme haem=20 oxygenase to liberate:

=95 =20 iron=20 cations; stored in macrophage and recycled to cytoplasmic pool=20

=95 =20 carbon=20 monoxide; expired via lungs

=95 =20 Biliverdin

Biliverdin=20 is converted to bilirubin = by the=20 enzyme biliverdin = reductase. Up to=20 250mg of bilirubin is = produced per=20 day in the healthy adult. This is the uncong. water insoluble bilirubin that combines = tightly with=20 albumin, in the blood stream, and is separated from albumin just before being uptaken into = liver=20 cells. Binding with albumin also shields it from uptake by adipose = tissue with=20 subsequently reduced toxicity.

Hepatic=20 stage

In the=20 liver, bilirubin combine = with=20 ligandin (cytosolic protein , Y-protein) and is then transferred to = smooth=20 endoplasmic reticulum were it =20 combines with = glucuronic=20 acid under influence of the enzyme glucuronyl transferse to=20 form:

=95 =20 mainly=20 bilirubin diglucuronide=20

=95 =20 minimal=20 bilirubin monoglucuronide

The=20 glucuronide conjugated form of bilirubin is water soluble and is = excreted into=20 the bile canaliculus by active carrier-mediated transport (rate limiting = step).

Post-hepatic=20 stage

The conjugated bilirubin is = hydrolyzed=20 and converted to urobilinogen = by the=20 intestinal pathogens.

The=20 urobilinogen is then oxidized to orange-color stercobilin and excreted in = the stool.=20 About 15 ~ 20 % of the urobilinogen is reabsorbed from the intestine = into portal=20 veins and finally 90 % of it is returned to the liver and is re-excreted = in the=20 bile, this is called entero-hepatic=20 circulation of bilirubin. The remainding 10 % gets into the systemic = circulation and finally excreted in the urine through kidney as urobilin. =

Q. Classify=20 jaundice?

CLASSIFICATION=20 OF JAUNDICE=20

A .Based=20 on type of hyperbilirubinemia

Unconjugated=20

=95 =20 Overproduction=20 =96 hemolysis,=20 ineffective erythropoiesis

=95 =20 Decreased=20 hepatic uptake =96 drugs=20 ,prolonged fasting

=95 =20 Decreased=20 glucuronyl transferase activity =96

Hereditary-=20 Gilbert=92s syndrome, Crigler Najjar ,

Neonatal=20 jaundice

Acquired=20 =96 drugs, hepatocellular disease

Sepsis

Conjugated=20

=95 =20 Impaired=20 hepatic excretion

=20 Familial/hereditary - Dublin=20 Johnson syndrome, Rotor syndrome, Cholestatic = jaundice of=20 pregnancy, recurrent intrahepatic cholestasis

=20 Acquired - drugs,=20 hepatocellular disease,sepsis

=95 =20 Extrahepatic=20 biliary obstruction

B. Based=20 on the mechanisms involved in the pathogenesis of the jaundice=20

1. Pre-Hepatic (Haemolytic) = Jaundice =96=20 over production of bilirubin

causes = -Absorption of=20 Haematoma, Haemolytic=20 anaemia

Lab inv - ↑ = unconj. plasma=20 bilirubin , ↑ = urobilinogen in urine ; liver enzymes = =96=20

=20 normal

2. Hepatic / Hepatocellular = Jaundice=20

Impaired hepatic uptake, = conjugation and excretion of bilirubin

causes -=20 Viral/drugs/sepsis/hypoxia/cirrhosis

=20 Lab inv - ↑ unconj/conj plasma bilirubin, ↑ - = ALT/AST=20

3. Post Hepatic = (Obstructive/cholestatic)=20 Jaundice

Obstruction to passage of = conjugated=20 bile into=20 intestine

Q. What are the causes of = Obstructive=20 Jaundice?

A.=20 Intrahepatic causes

Familial/=20 hereditary disorders =96 = Dublin=20 Johnson syndrome, Rotor syndrome, Cholestatic jaundice of pregnancy, = Recurrent=20 intrahepatic cholestasis

Aquired=20 =96cholestatic drugs , = viral and=20 alcoholic hepatitis, ,TPN induced, Biliary Cirrhosis, sclerosing=20 cholangitis

B.=20 Extrahepatic causes

Benign=20

Gallstone/=20 Choledocholithiasis - most common cause

Clinical features - = Previous=20 history of dyspepsia, Intermittent Pyrexia/ Rigors, Pain, jaundice=20 (Charcot=92triad), O/e =96 positive murphy=92s sign &n= bsp; &nb= sp; =20

Chronic=20 pancreatitis

Strictures=20 =96 iatrogenic, trauma

Parasitic=20 infections =96 ascariasis, clonorchiasis

Biliary=20 atresia , Choledochal cysts

Malignant=20

Ca.of=20 pancreas/ampulla/bile duct/gall bladder

Clinical=20 features=20 - Painless,=20 progressive deep Jaundice, Weight loss, Courvoisier=92s sign - Palpable=20 Gallbladder (exception ampullary Ca- intermittent jaundice d/t sloughing = of=20 tumour cells)

Lab=20 inv=20 - = ↑ conj. plasma bilirubin , bilirubinuria, = absent=20 urobilinogen in urine ,clay coloured stools, ↑ -=20 ALP,5-NT

Q. How will you biochemically = differentiate=20 different types of

= jaundice?=20

BIOCHEMICAL = TESTS for = differentiating the=20 jaundice biochemically

&n= bsp; =20 Prehepatic=20 Jaundice =20 Hepatic Jaundice Post Hepatic = Jaundice =

1.Serum = bilirubin =20 ↑ (mostly unconj) =20 ↑ (conj. & = unconj.) =20 ↑ (conj. = )

van=20 den Bergh test = indirect reacting &n= bsp; =20 &n= bsp; d= irect=20 reacting

&n= bsp; &nb= sp; &nbs= p; =20 (total - direct)

2.Urine = Urobilinogen=20 ++ =20 =20 &n= bsp; + &n= bsp; &nb= sp; =20 - ( if complete=20 obst.)

3.Urine Bile = Salts = absent &n= bsp; &nb= sp;+=20 / - &n= bsp; =20 +

4.Urine = Bilirubin &n= bsp; -- = &n= bsp; &nb= sp; =20 + / - ++ ↑↑(high = coloured)=20

5.Fecal=20 stercobilinogen =20 ↑↑=20 &n= bsp; =20 N or ↓ &n= bsp; =20 absent (clay=20 colour)

6.Faecal fat = <= SPAN=20 style=3D"mso-spacerun: = yes"> &n= bsp; N=20 &n= bsp; =20 N or ↑ &n= bsp; =20 ↑↑

7. Liver Fxn. = Tests

- Enzymes SGOT / PT N &n= bsp; =20 ↑↑ &n= bsp; =20 N= =20 or ↑

=20 (AST / ALT) =20 &n= bsp; &nb= sp; (>=20 800 IU/L) &n= bsp; =20 50-100 = IU/L

8 Alk PO4 = &n= bsp; N=20 =20 N or ↑ (x 1-2) =20 ↑↑ (x = 3-10)

9 Plasma = albumin N=20 &n= bsp; &nb= sp; =20 ↓ &n= bsp; =20 N=20 or ↓

10. PT =20 &n= bsp; &nb= sp; N=20 &n= bsp; &nb= sp; =20 ↑↑ =20 <= SPAN=20 style=3D"mso-spacerun: yes"> ↑↑ corrected = by vit K

Q. How will you Evaluate a case of = Jaundice?

EVALUATION OF = A JAUNDICE=20 PATIENT

&n= bsp; &nb= sp; =20

Q.=20 Describe the structural/ architectural and =20 the functional units of

=20 Liver.

The lobule=20 is the structural unit of the liver . It is easy to observe under = microscope and=20 roughly hexagonal in shape, with portal triads at the vertices and a = central=20 vein in the middle. Portal lobule comprises of adjoining parts of 3 = hepatic=20 lobule with center around portal triad

The=20 hepatic acinus = represents functional unit because it is oriented around = the=20 afferent vascular system .the hepatocytes in acinus are divided into = zones that=20 correspond to distance from the arterial blood supply .those hepatocytes = closest=20 to the arterioles in zone 1 are the best oxygenated, while those = farthest from=20 the arterioles in zone 3 have the poorest supply of=20 oxygen.

Zone I =96=20 Periportal = =96=20

=95 =20 ↑=20 mitochondria

=95 =20 Oxidative=20 and phase 2 metabolism, =20 glycogen syn.

Zone 3 -=20 Centrilobular =

=95 =20 ↑ SER,=20 cyt-P-450,NADH

=95 =20 anaerobic & phase 1=20 metabolism

=95 =20 Most=20 sensitive to injury from circulatory disturbances and toxic=20 byproducts

Q.=20 Describe the blood supply of liver and different=20 factors

affecting=20 it?

Liver has=20 got a dual blood supply i.e., from Portal vein and hepatic artery. It = receives=20 25% of cardiac output around 1500 ml/min, out of which 30% comes form = hepatic=20 artery and 70% from Portal vein. The oxygen supply is equal from both = the=20 sources.

FACTORS=20 AFFECTING LIVER BLOOD SUPPLY

Increased=20 by:

=95 =20 Supine=20 position

=95 =20 Food

=95 =20 Hypercapnia

=95 =20 Acute=20 hepatitis

=95 =20 Drugs:=20 barbiturates, P450 enzyme inducers, b agonists

Decreased=20 by:

=95 =20 Upright=20 position

=95 =20 IPPV/PEEP,=20 Surgery

=95 =20 Hypocapnia,=20 hypoxia

=95 =20 Cirrhosis

=95 =20 Anaesthetics=20 agents volatile,=20 inhalational, b blockers, a =20 agonists

=95 =20 Surgical=20 Manipulations

Q. What=20 are the functions of Liver ?

=95 =20 Protein=20 metabolism =96 synthesis of plasma pr( albumin & α-acid=20 glcoprotein, C-reactive protein, haptaglobin, pseudocholinestrase, = deamination=20 of A.A , formation of urea,

=95 =20 Glucose=20 Homeostasis - gluconeogenesis, glycogenolysis( glucagon), glycogenesis (Insulin)=20

=95 =20 Fat=20 Metabolism - Synthesis of lipoproteins, cholesterol, triglycerides, oxidation of FA to ketone=20 bodies

=95 =20 Reservoir=20 of Blood

=95 =20 Endocrine=20 Function: IGF1, Thrombopoitin, Angiotensinogen, Thyroid homeostasis, = steroid=20 hormone inactivation( Testesterone, estradiol, glucocorticoid,=20 ald.)

=95 =20 Bilirubin=20 formation & excretion

=95 =20 Drug &=20 Hormone Metabolism

= Phase I=20 & II reactions

=95 =20 Hematological=20 function =96 haematopoiesis in fetus, heme synthesis, =

=95 =20 Immunological=20 function =96 largest RE organ, Kupffer cells - phagocytosis of Antigen from GIT. =

=95 =20 Synthesis=20 of Coagulation factors:I,II,V,VII,IX, X,XI, XII,XIII, = prekallikrein,kininogen-=20 Anticoagulants: Antithrombin III, α1antitrypsin,=20 α2=20 antiplasmin,protein C & S, plasminogen, plasminogen activator=20 inhibitor

Q. What=20 are the pathophysiological consequences of Obstructive=20 /

=20 Cholestatic Jaundice?

Pathophysiological=20 Consequences of Obstructive/Cholestatic = Jaundice

Retention of = bile=20 solutes in liver decreases =20 Hepatocyte funcunction and =20 Metabolic Dysfnunction Of Cyto-450, Synthesis of albumin = and clotting factors is hampered = kuffer=20 cell activityis decresed.=20
Bile = constituents in=20 serum leads to Jaundice = and=20 increased conjugated =20 Bilirubinemia , Pruritus ,CVS Depression , Nephrotoxicity,=20 Hypercholesterolemia = artheromas,=20 xanthoma=20
Absence of = bile in=20 intestine, Escape of endotoxins into portal blood Malabsorp. fats & vit A,D, E, K Acoholic = stools

Q. What=20 information will you get from Ultrasound, CT, = ERCP

= & PTC?

Ultrasound

=B7 =20 Determine=20 the presence and level of intrahepatic and extrahepatic biliary=20 dilatation

=B7 =20 For=20 obstructive jaundice ultrasound has a sensitivity 70 - 95% and = specificity 80 -=20 100%

=B7 =20 more=20 sensitive than CT scan to diagnose gallstone

=B7 =20 In future=20 endoscopic ultrasound may become more widely available , more accurate = than=20 combined CT and ERCP

CT=20 Scanning

=B7 =20 Sensitivity=20 and specificity similar to good quality ultrasound =

=B7 =20 Useful in=20 obese or excessive bowel gas

=B7 =20 Better at=20 imaging lower end of common bile duct

=B7 =20 Stages and=20 assesses operability of tumours

Endoscopic=20 retrograde cholangiogram (ERCP)

=B7 =20 Allows=20 biopsy or brush cytology

=B7 =20 Gold=20 standard to diagnose choledocholithiasis

=B7 =20 Therapeutic procedures - = Sphincterotomy ,=20 stone removal, stricture dilatation=20

Percutaneous transhepatic = cholangiogram=20 (PTC)

=B7 =20 Rarely=20 required today

=B7 =20 Performed=20 with 22G Chiba Needle

=B7 =20 Also=20 allows biliary drainage and stenting =

Q. What are the surgical procedures = done for=20 obstructive jaundice?

Ca Gall=20 Bladder: Radical=20 Cholecystectomy with wedge ressection and CBD = excision

Choledocholithiasis: ERCP removal = or CBD=20 exploration/ bilio-enteric anastmosis

Cholangio=20 Ca:=20 Liver resection and or local excision of the lesion or=20 Whipple

Biliary=20 Stricture: = Hepatico-jejunostomy/=20 liver resection

Periampullary=20 Ca:=20 Whipple=92s Procedure

Chronic = Pancreatits with=20 head Mass: Whipple/ = bilio-enteric=20 anastmosis

Q. What are = the steps=20 Surgery in Whipple=92s=20 Procedure?

Exploration=20
Kocherization of=20 Duodenum till IVC is Visualised=20
Assessment = of Local=20 resectibility=20
Gall bladder = mobilization, CBD dissected and slinged, retracted to = right=20
Trace = superior=20 mesenteric vessel and tunnel it to anterior portal = vein=20
Transection = of common=20 hepatic duct above cystic duct insertion=20
Transection = of jejunum=20 10cm from DJ flesure=20
Transection = of neck of=20 pancrease=20
Jejunum = brought=20 retrocolic=20
Pancreaticojejunostomy-=20 end to end=20
Hepatico-jejunostomy =96=20 end to side=20
Gastrojejunostomy =96=20 end to side=20
Feeding = Jejunostomy=20

Q. What are the Anaesthetic = problems in the=20 case of Obstructive

=20 jaundice?

ANAESTHETIC=20 PROBLEMS in Obstructive Jaundice Patient

A. Cardiovascular=20 dysfunction - circulating = bile salts (cholemia) lead=20 to

1. =20 Impaired myocardial=20 contractility

2. Bradycardia

3. Vasodilatation = =AE ↓ ability to mobilise = bld from=20 splanchnic vasculature during hrage

4. ↓ sensitivity to = vasopressors=20

=20 Hypotension & circulatory collapse

Small blood losses are poorly = tolerated;=20 therefore replace volume losses immediately in perioperative=20 period.

B.=20 Renal system - Acute = renal failure=20

Etiology=20 multifactorial &n= bsp; &nb= sp; &nbs= p; =20

1.=20 Arterial hypotension-myocardial depression

2.=20 Reduction in intravascular volume

3.=20 Nephrotoxicity - bile salt, endotoxins & inflammatory=20 mediators

Incidence=20 5 -10%, mortality high 32 =96 100%

Level=20 of hyperbilirubinemia correlates with postoperative decrease in = creatinine=20 clearance

C.=20 Sepsis=20 =96 can be due to

1.=20 Associated cholangitis and bactibilia

2.=20 Absence of bile salts in intestine =AE Escape of endotoxins from = intestine into=20 portal

blood =

3.=20 Retension of bile solutes in liver =AE=20 ↓ kuffer cell activity

Prevention=20 - Perioperative antibiotics and oral bile salts

D.=20 COAGULOPATHY

1.=20 Absence of bile salts in = intestine=20 =AE Vit. K malabsorption (required = for=20 gamma

carboxylation of glutamyl residues of factors II, VII, IX, X) = =AE ↑ = PT

Correction - pre-op. Vit. K 10 = mg OD =D7 3=20 days

2.=20 Long lasting biliary obst = =AE=20 Sec. biliary cirrhosis =AE=20 ↓ syn. of coag factors (poor

prognosis) Correction - transfusion = of FFP=20

E. Multiple Vit.=20 Deficiency=20 - A, D, E, K due to absence of bile salts in = intestine

(A- night blindness, D =96 = osteoporosis and=20 ms weakness, E- leg cramps, K-easy

bruising)

F. Haemorrhagic gastritis = and stress=20 ulcer

G. Impaired wound=20 healing

H. Altered drug handling due to=20 cholestasis

I. Long standing = extrahepatic biliary=20 obstruction > 1yr → biliary cirrhosis = →

problems of liver dysfunction=20

Q.=20 How will you assess Liver functions?

LIVER=20 FUNCTION TESTS

A. Indices of hepatocellular = damage

1. Transaminases SGOT/SGPT - 0 =96 35 IU/L=20

=95=20 SGOT (AST) - extrahepatic sources- heart /sk ms/ kidney/ brain, less = specific=20

=95=20 SGPT (ALP) - primarily found in liver, more = specific

Viral hepatitis -=20 SGOT/SGPT

Alcoholic=20 hepatitis - SGOT/SGPT > 2 (deficiency of=20 pyridoxine-5-PO4)

In=20 advanced liver cell injury transaminases level may actually be normal or = low d/t=20 massive losssof parenchymal tissue

2.=20 LDH =96=20 poor specificity

3.=20 Glutathione- S =96 transferase (GST) isoenzyme B =96 = sensitive=20 indicator of liver damage

B.=20 Indices of Obstructed = Bile=20 Flow

1. Alkaline phosphatase = =96 35 =96 100=20 IU/L

Derived=20 from plasma memberane of bile duct cells

Extrahepatic=20 sources- bone, intestine, liver, placenta

2.=20 5- Nucleotidase - = confirms=20 hepatic origin of ALP , specific for liver disease

3.=20 Gamma glutamyl transferase (GGT) =96 most sensitive indicator of = biliary=20 tract disease, but limited usefulness due to poor specificity=20

Aminotransferases=20 A= lk=20 PO4 &n= bsp; Diagnostic Likelihood=20

&n= bsp; &nb= sp; V= iral=20 hepatitis =20 Obstr.Jaundice

> X =20 6 &n= bsp; &nb= sp; =20 < X 2.5=20 90%=20 &n= bsp; &nb= sp; 10%

< X =20 6 &n= bsp; &nb= sp; =20 > x =20 2..5 10%=20 = &n= bsp; <= SPAN=20 style=3D"mso-spacerun: yes"> 80%

C.=20 Indices of hepatic = synthetic=20 function

1.=20 Prothrombin time =96 factors II, V, VII & X =

=95 =20 Coag.=20 Factors have a short t =BD, therefore PT is good indicator of liver = function in=20 both Acute & Chonic liver disease, good prognostic indicator of = outcome of=20 surgery in patients with liver disease

=95 =20 Causes=20 for prolonged PT independently of liver disease - Vit. K deficiency., = Antibiotic=20 therapy, DIC, Fibrinolysis, Coumarin = administration

=95 =20 Obst.=20 Jaundice prolonged PT due to vit. K malabsorption, parenteral vitK admin.→PT normalises in = 24 =96 48=20 hrs

2.=20 Serum albumin

=95 =20 Long=20 t =BD - 14-20days,

=95 =20 Liver=20 =96 substantial reserve for alb. syn., = daily=20 production 10=9715g/d (3.5-5.5gm %)

=95 =20 Functions=20 - Plasma oncotic press. , Tansport vehicle, Drug = binding

=95 =20 Not=20 a good indicator for acute or mild liver = damage

=95 =20 Indicator=20 of severity of chr. Liver disease (<=20 2=B75 gm% - severe damage)

D.=20 Indices of hepatic = blood flow=20 and metabolic capacity

1.=20 Indocyanine green (ICG) elimination test =96 for liver perfusion &=20 function

ICG has high = extraction=20 ratio

2.=20 MERG (monoethylglycinexylidide) test =96 for liver = function.

lidocaine is = metabolised to=20 MERG in liver

Q.=20 What are the other preoperative investigations you will=20 do

before = administering anaesthesia in these patients?

OTHER=20 PREOPERATIVE INVESTIGATIONS

1.=20 Haematological inv=20 - Hb =96 decreased in conceled blood Loss, = haemolysis,

=20 &n= bsp; &nb= sp; TLC,=20 DLC - increased infection =20

&n= bsp; &nb= sp; =20 Platele= t=20 Count, clotting studies = - BT,=20 PT, PTTK

&n= bsp; &nb= sp; &nbs= p; = ; = =20

2.=20 Urine analysis=20 - Urobilinogen absent, Bilirubin & Bile Salts = present

3.=20 Metabolic=20 - Serum proteins, = glucose,=20 Urea - ↓ syn. in liver dis, Electrolyte

4.=20 KFT =96=20 Urea, S. Creatinine,

5=20 Viral markers=20 =96 HBV, HCV

6.=20 Cardiorespiratory=20 - Chest X-ray, ECG, blood gases

=20

RISK=20 FACTORS for operative mortality in obstructive jaundice=20 patients

=95 =20 Hematocrit=20 < 30 %

=95 =20 S.=20 bilirubin >=20 11mg%

=95 =20 Malignant=20 cause of biliary obstruction

=95 =20 Azotemia

=95 =20 Hypoalbuminemia

=95 =20 Cholangitis

Q.=20 What are the risk Factors in the case of obstructed jaundice? =20

&n= bsp; &nb= sp; &nbs= p; = ; =20

In=20 a large retrospective study (Dixon etal =96 GUT 1983) of = 373=20 patients undergoing surgery for obstructive jaundice before 1983 the = mortality=20 rate was 9.1% and multivariate=20 analysis identified Hematocrit = <=20 30 %, S. bilirubin > = 11mg%,=20 malignant cause of biliary obstruction as predictors of periop = mortalily. If all=20 these were present, the = mortality=20 rates approached 60%,whereas none was present the mortality rate was = only=20 5%.Other Preop predictors of poor surgical outcome include =96Azotemia,=20 Hypoalbuminemia and Cholangitis. - Friedman =96Hepatology=20 June1999

Q.=20 What are the anaesthetic goals in this case?

ANAESTHETIC=20 GOALS in Obstructive Jaundice patient

=20 Maintain hepatic blood flow and = oxygenation

&n= bsp; &nb= sp; =20 AVOID :

=95 =20 Sympathetic=20 stimulation

=95 =20 Hypotension=20 (decreased venous return / cardiac output) caused by =

=20 Haemorrhage

Cardiac depressant drugs=20

Regional = anaesthesia=20 e.g.; thoracic epidural analgesia

=95 =20 Hypocapnia=20 & Hypoxemia

=95 =20 Pressure=20 effects=20 caused by

Surgical=20 retraction

= Tumors

Ascites /=20 Laparoscopy

=95 =20 Hepatic=20 venous congestion=20 caused by

Head down=20 position

IPPV with PEEP, = Rt. side=20 heart failure

=95 =20 Hepatotoxic=20 drugs e.g. halothane or=20 acetoaminophen

2.=20 Maintain Renal functions

Preoperatively

=95 =20 Avoid=20 NSAIDs and nephrotoxic = antibiotics=20 e.g.; (aminoglycosides)

=95 =20 Oral=20 bile salts to normalize gut flora

=95 =20 Prophylactic=20 antibiotics to prevent sepsis

=95 =20 Drainage=20 stent -↓ Hyperbilirubinaemia

PTC, ERCP or = papillotomy=20

Intraoperatively=20

=95 =20 avoid=20 hypotension & hypoxaemia

=95 =20 avoid=20 dehydration

=95 =20 Renal=20 does dopamine /mannitol / furosemide.

Q.=20 How will you prepare this patient for Anaesthesia?

PREOPERATIVE=20 PREPARATION for Anaesthesia

=95 =20 Anxiolytic=20 =96 oral short acting Benzodiazepine

=95 =20 Oral=20 H 2 antagonist

=95 =20 Vit.=20 K (Obst. J) =96 10 mg OD X 3 day, Fresh Frozen Plasma =

=95 =20 Perioperative=20 broad spectrum antibiotics, oral bile salts

=95 =20 Rehydration=20 and adequate diuresis 1ml/kg/hr

If Bilirubin > 8=20 mg%

=20 I/V fluid =96 1-2 ml/kg/hr.

furosemide/ Mannitol / low dose=20 dopamine

early=20 catheterization & CVP monitoring

Q.=20 How will you manage anaesthetic administration in this=20 case?

ANAESTHETIC=20 MANAGEMENT

Choosing=20 appropriate anaesthetic agent

No=20 drug is contraindicated in Cholestatic liver disease. per=20 se.

Other=20 considerations

Coexisting=20 hepatocellular disorder

Renal=20 dysfunction

Hepatotoxic=20 and cholestatic drugs

Anaesthetic agent of=20 choice

Not dependent on hepatic=20 metabolism

Maintains hepatic O_{2 =}supply =96=20 demand relationship

General=20 anesthesia

Induction=20 agent -=20 Thiopentone/Propofol

=95 =20 slow=20 titrated dose → avoid hypotension

=95 =20 gentle=20 intubation → avoid sympathetic stimulation

Muscle=20 relaxant=20

=95 =20 Suxamethonium=20 - RSI

=95 =20 Atracurium=20 (DOC) - Hoffman=92s elimination =20

=95 =20 Vecuronium=20 0.15mg =

Opioids=20

=95 =20 fentanyl=20 (DOC)- maintains hepatic oxygen supply =96 demand

=95 =20 opioids=20 can cause spasm of sphincter of Oddi (incidence < 3%) leading to = biliary=20 colic=20 , false + cholangiogram

=95 =20 fentanyl>=20 morphine> meperidine> butorphenol

=95 =20 T/T=20 naloxone, glucagon, atropine, nitroglycerine

Volatile=20 Anesthetics

=95 =20 Isoflurane=20 - maintains HBF & oxygen=20 supply

IPPV=20 =96- Maintain eucapnia, Avoid high airway = pressures

Q.=20 What is the role of Regional anaesthesia in this = case?

Regional=20 anaesthesia=20 (Epidural anaesthesia) = as=20 supplement to G.A.

=95 =20 Supplemental=20 for intraoperative analgesia and for postoperative=20 analgesis

=95 =20 Concerns=20 =96 coagulopathy &=20 hypotension

Q.=20 What intraoperative monitoring you will do in this=20 case?

Intra=20 Operative Monitoring

Routine =

=95 =20 Pulse=20 oximetry, ECG, NIBP

=95 =20 EtCO2

=95 =20 Urine=20 output

=95 =20 Core=20 temp

=95 =20 NMJ=20 monitoring

Longer=20 & extensive surgeries

=95 =20 Intra=20 arterial and CVP

=95 =20 Biochemical=20 - B.Sugar, ABGS. Electrolytes

=95 =20 Hematology=20 -Hb, PT,, PTTK,TEG

Q.=20 How will you manage these case = postoperatively?

Postoperative=20 management

=95 =20 Conscious,=20 adequate NM recovery, vitals stable→ extubate → oxygen enriched = air

=95 =20 Else - Continue IPPV=20

&n= bsp; =20 - Correct Fluid & Electrolyte imbalance =

&n= bsp; =20 - Correct hypothermia

&n= bsp; =20 - Achieve CVS stability

=95 =20 Adequate=20 analgesia & chest physiotherapy

=95 =20 Antibiotics=20 and H 2 receptor=20 antagonist

=95 =20 Maintain=20 urine output

=95 =20 Replace=20 blood and blood products