obstructive jaundice
DESCRIPTION
obstructiveTRANSCRIPT
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.
http://www.elevelandclinicmeded.com/
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.
http://www.elevelandclinicmeded.com/
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.
http://www.elevelandclinicmeded.com/
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