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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS PowerPoint PPT Presentation


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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS. BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery. General Data: A.M. 35 –years- old Female Binondo, Manila.

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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

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A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

BY:

Jonathan R. Malabanan, M.D.

Ospital ng Maynila Medical Center

Department of Surgery


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

General Data:

A.M.

35 –years- old

Female

Binondo, Manila


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

Chief Complaint:

Yellowish discoloration of the eyes


History of present illness

HISTORY OF PRESENT ILLNESS

One month PTC=

=RUQ pain, colicky, moderate to severe, radiating to R scapular area

=no fever, no yellowish discoloration of skin and sclerae

=no consult, no meds


History of present illness1

HISTORY OF PRESENT ILLNESS

One week PTC=persistence of colicky right upper quadrant pain

=yellowish discoloration of skin and sclerae

=(+) light colored stool

=(+) consult, HBT- UTZ done: Choledocholithiasis, Cholecystolithiais

Advised OR, and was scheduled for operation


Past medical history

Past Medical History

  • No hypertension

  • No diabetes

  • No PTB

  • No previous hospitalization

  • No allergies to foods and drugs


Family history

Family History

  • unremarkable


Personal and social history

Personal and Social History

  • Unremarkable

  • Occasional alcoholic beverage drinker


Physical examination

Physical Examination

  • General Survey:

    • Conscious, coherent, not in respiratory distress

  • Vital Signs

    BP = 110/ 60 mmHgCR = 81 bpm

    RR = 20 cpm Temp: 37 degrees Celsius


Physical examination1

Physical Examination

  • Skin: yellowish coloration of skin

  • HEENT:

    -Pink palpebral conjuctivae, icteric sclerae, no CLAD, no TPC, no NAD, supple neck.

  • Chest:

    • Symmetrical chest expansion, no retractions,

    • CBS


Physical examination2

Physical Examination

  • Heart

    normal rate, regular rhythm, no murmur

  • Abdomen

    Flat, NABS, soft, with Direct Tenderness RUQ, no organomegaly.


Physical examination3

Physical Examination

  • Extremities:

    • Full and equal pulses, no deformities, no cyanosis

      DRE:

      -light colored stool


Salient features

Salient Features

  • 1.35/Female

  • 2. RUQ pain

  • 3. Yellowish discoloration of the eyes, skin

  • 4. Light colored stool

  • 5. UTZ result of Hepatobiliary Tree: dilated CBD, normal liver, portal vein and tributaries are unremarkable, intrahepatic ducts not dilated, with an intraluminal echogenic focus exibiting acoustic shadowing


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

NON OBSTRUCTIVE

OBSTRUCTIVE

JAUNDICE

INTRAHEPATIC

EXTRAHEPATIC

INTRADUCTAL

COMPRESSION OF BILIARY TRACTS

HEMOLYSIS

HEPATOCELLULAR


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

OBSTRUCTIVE

EXTRAHEPATIC

INTRAHEPATIC

GB/CBD stones

Pancreatic Ca

Primary Biliary Cirrhosis

Sclerosing Cholangitis

Pattern Recognition (90-95%)

RUQ pain

Clinical Jaundice

CBD dilatation


Initial impression

Initial Impression


Para clinical diagnostic procedure

Para clinical Diagnostic Procedure

  • Do I need to perform a Para clinical diagnostic procedure?

    “No”


Pretreatment diagosis

Pretreatment Diagosis


Pre treatment diagnosis

Pre Treatment Diagnosis

Obstructive Jaundice prob secondary to

Choledocholithiasis

Cholecystolithiasis


Goals of treatment

GOALS OF TREATMENT

  • Resolution of obstruction

  • Prevention of complication


Treatment options

Treatment Options

Meta-analysis ofendoscopy and surgery versus surgery alone

for common bile duct stones with the gallbladder in situ, Clayton et.al. University of Athens 2006


Management

Management

  • OPEN CBDE

  • CHOLECYSTECTOMY, IOC


Preoperative preparation

Preoperative Preparation

  • Informed consent

  • Provide psychosocial support

  • Optimize patient’s condition

  • NPO for 6 hours

  • Preparation of OR materials


Operative technique

Operative technique

  • Patient supine under GA

  • Asepsis/Anti-sepsis

  • Sterile drapes placed

  • Right paramedian incision carried down from skin to subcutaneous tissue, fascia and peritoneum entered

  • Intraoperative findings noted


Operative technique1

Operative Technique

  • Cystic artery identified, ligated and cut

  • Cystic duct identified, isolated and tagged

  • Gallbladder removed. Intraoperative findings noted.

  • French 5 feeding tube inserted into the cystic duct, IOC done, results noted

  • CBD opened logitudinally and explored


Operative technique2

Operative Technique

  • T-tube inserted and anchored

  • Hemostasis

  • Correct sponge and instruments count

  • Layer by layer closure

  • DSD


Operative findings

Operative Findings

  • Intraoperative findings noted

    • GB is distended with thickened walls measuring 10x4cm; on opening up, it contained multiple stone measuring 0.2-0.3cm, cystic duct measures 0.5cm in diameter; CBD measured 12mm in diameter; on IOC, there was a filling defect on the distal CBD, there was visualization of both intrahepatic ducts. On CBDE, 8mm primary stone was noted at the distal common bile duct. Pancreas was normal. Liver was noted to be cirrhotic.


Postoperative diagnosis

Postoperative Diagnosis

Obstructive Jaundice Secondary to Choledocholithiasis

Cholelithiasis

Operation Done

Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy


Postoperative management

Postoperative Management

  • Adequate analgesia

  • Monitoring of VS and hydration.

  • DAT

  • Adequate monitoring: complications

  • Patient was discharged on the 5th post operative day

  • Follow up after a week.


Final diagnosis

Final Diagnosis

  • Obstructive Jaundice Secondary to Choledocholithiasis

  • Cholelithiasis

  • S/P Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy


Course in the ward

COURSE IN THE WARD

  • 1st Hospital Day

    • NPO

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward1

COURSE IN THE WARD

  • 2nd-3rd Hospital Day

    • GL- Soft diet

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward2

COURSE IN THE WARD

  • 4th Hospital Day

    • DAT

    • Adequate Antibiotic

    • Adequate Analgesia

    • DWC


Course in the ward3

COURSE IN THE WARD

  • 5th Hospital Day

    • Patient discharged


Prevention and health promotion

PREVENTION AND HEALTH PROMOTION

  • Advise given to patient regarding

    • Possible complications

    • Proper wound care

  • OPD follow up after 7 days for removal of sutures

  • Anticipate complications

    • Avoid Recurrence

    • Avoid infection


Sharing of informati0n

SHARING OF INFORMATI0N


Common bile duct stones

Common Bile Duct Stones

  • 10% of patients who present for Cholecystectomy

  • definitive treatment is cholecystectomy and ductal clearance either through open CBDE, Lap CBDE, ERCP.

  • Manuevers include administration of glucagon and flushing of ductal system,dilatation of the distal CBD, balloon catheter, basket extraction.


Overview to patient management

Overview to Patient Management

  • CBD stones can be discovered preoperatively, intraop, post-op.

  • Treatment options:

    • ERCP=/-S

    • Lap CBDE

    • Lap Chole + ERCP

    • Open CBDE

    • almost same success rate


Completion cbde

Completion CBDE

  • T tube placement:

    • decompression of the duct, incase of residual obstruction

    • access for ductal imaging postop

    • access for removal of stone

    • left as early as 4 days up to 6 weeks

    • complicatios: bile leaks, peritonitis


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

Post Cholecystectomy CBDE Problems

  • Early Problems

    • bile duct injury: laceration, cystic duct stump leak, liver bed leak

    • bile duct obstruction: retained stone

    • biliary pancreatitis

  • Late Problems

    • stricture

    • postcholecystectomy syndrome

    • GERD


Questions

Questions

#1 (MCQ) Which of the following is the main chemical component of pigment stones? A. CholesterolB. Calcium bilirubinate C. Calcium carbonateD. Calcium phosphate

E: Calcium oxalate


Questions1

Questions

#2 (MCQ) What is the most commonly isolated bacteria in the common duct of patient with primary stone?

A. Escherichia coli

B. Pseudomonas aeruginosa

C. Klebsiella sp.

D. Salmonella typhii

E. Corynebacterium sp.


Questions2

Questions

#3 (MCQ) Which of the following is the best indication for preoperative ERCP in patients with gallstones?

A. Gallstone pancreatitis

B. Obstructive jaundice

C. History of jaundice

D. Increased alkaline phosphatase to twice normal

E. 1.6 cm common bile duct dilatation


Questions3

Questions

(MCR)

Direction: Write

“A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.


Questions4

Questions

#4 (MCR)

The following are drainage procedure after open/laparoscopic CBDE.

1. Sphincteroplasty

2. Choledochojeunostomy

3. Choledochoduodenostomy

4. Choledochotomy


Questions5

Questions

#5 (MCR)

Correct statement about biliary scintigraphy using technetium 99m- labeled derivatives of iminoacetic acid (HIDA) include:


Questions6

Questions

#5 (MCR)

1. Nonvisualization of GB is strong evidence of cystic duct obstruction.

2. The isotope is cleared by Kupffer’s cells

3. The GB in a fasting subject is normally visualized within 60 minutes of the dye injection

4. The scan is the preferred initial step in identifying common duct stones


Journal appraisal

Journal Appraisal

  • Evaluation of primary duct closure vs T-tube drainage following choledochotomy

    Marwah Sanjay, Singh Ishwar, Godara Rajesh, Sen Jyotsana, Marwah Nisha, Karwasra RKDepartments of Surgery, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, IndiaYear : 2004  |  Volume : 23  |  Issue : 6  |  Page : 227-228


Objective

Objective

  • To assess the benefits and harms of primary closure versus routine T-tube drainage in open common bile duct exploration for common bile duct stones.


Design

Design:

  • Randomized Control Trial


Patients

Patients:

  • Forty consecutive patients undergoing elective minilap cholecystectomy and CBD exploration for gallstones with CBD stones (proved preoperatively on ultrasonography) were studied prospectively.


Intervention

Intervention:

  • Patients were randomly divided in two groups: Group A underwent primary closure of CBD, group B had T-tube drainage after CBD exploration.


Main outcome measures

Main outcome measures:

  • The duration of hospital stay, mortalities, morbidities and outcome.


Results

Results:


Results1

Results:


Results2

Results:


Results3

Results:


Results4

Results:


Results5

Results:


Conclusion

Conclusion

  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.


Clinical question

Clinical Question

  • In cases of obstructive jaundice secondary to choledocholithiasis, is mandatory t- tube choledochostomy necessary?


Tentative answer

Tentative Answer

  • No

    • mandatory t tube choledochosyomy is not necessary for cases of obstructive jaundice secondary to choledocholithiasis.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

Appraisal Guide


Are the results of the study valid

Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.


Are the results of the study valid1

Are the results of the study valid?

Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.


Are the results of the study valid2

Are the results of the study valid?

Secondary Guides:

Were patients, their clinicians, and study personnel "blind" to treatment?

No.


Are the results of the study valid3

Are the results of the study valid?

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.


Are the results of the study valid4

Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.


Are the results of the study valid5

Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.


Conclusion1

Conclusion

  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.

  • Primary closure of CBD is more safe and physiological and the procedure of choice following routine choledochotomy.


References

References

  • Schwartz et. al Principles of Surgery.8th ed. Chapter 6.

  • Marwah S, Singh I,Godara R, Sen J,MarwahN, Karwasra RK. Evaluation of primary duct closure vs T-tube drainage following choledochotomy.

    Indian Journal of Gastroenterology 2004;23(6):227–8.

  • Wright BE, Freeman ML, Cummings JK et. al.: Current Management of Common Bile Duct Stones. Surgery. 132:729-735, 2002.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES:

UPDATE 2004


Common bile duct stones1

COMMON BILE DUCT STONES

  • 1. What is the recommended ancillary procedure in a patient with suspected

    common duct stone to confirm its diagnosis?


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

Magnetic resonance cholangiography is the recommended procedure for patients with suspected common bile duct stones to confirm the diagnosis.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • 2. What is the recommended treatment for patients with CBD stones without

    cholangitis?

  • The recommended treatment for patient with CBD stones without cholangitis is

    surgical treatment.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • 3. Among the different treatment options for common bile duct stones, which

    procedure has the least recurrence?

  • Choledochoduodenostomy has the least recurrence.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • 4. What is the recommended treatment for patients with gall bladder stones after

    endoscopic common bile duct clearance?

  • The recommended treatment for patients with gall bladder stones after endoscopic

    common bile duct clearance is surgery, to be performed within 24 to 48 hours after

    clearance.


Intrahepatic stones hepatolithiasis

INTRAHEPATIC STONES (HEPATOLITHIASIS)

  • 1. What is the recommended diagnostic tool to confirm the presence of intrahepatic

    stones with or without strictures?


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • Magnetic resonance cholangiography is the recommended diagnostic tool to confirm the presence of intrahepatic stones.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • 2. What is the recommended treatment for intrahepatic stones with or without

    strictures?

  • The recommended treatment include surgical management (hepatic resection) and cholangioscopic techniques, whether through a T-tube tract, a percutaneous transhepatic approach (PTBD/PTCS) or a transpapillary approach, singly or in combination.


Cholangitis

CHOLANGITIS

  • 1. What is the antibiotic of choice for patients with cholangitis?

  • The recommended antibiotics for the treatment of cholangitis are: Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID + Metronidazole 500mgs IV TID


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

  • 2. What is the recommended treatment for patients with severe cholangitis?

  • The recommended treatment for patients with severe cholangitis is non-operative biliary drainage (endoscopic).


Retained common bile duct stones

RETAINED COMMON BILE DUCT STONES

  • 1. What is the recommended treatment for retained common bile duct stones?

  • For patients who have had prior cholecystectomy and have a high probability of common bile duct stones, ERCP and sphincterotomy with DORMIA basket extraction is the preferred initial approach.


A case presentation management discussion and sharing of information on obstructive jaundice secondary to choledocholi

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