JaundiceJaundice

Hilary Sanfey, MDHilary Sanfey, MD

University of VirginiaUniversity of Virginia

Mrs. J.S.Mrs. J.S.

Your patient in the ER is a 55 year-old Your patient in the ER is a 55 year-old female with a short history of upper female with a short history of upper abdominal discomfort and chills. Her family abdominal discomfort and chills. Her family noticed she was jaundiced.noticed she was jaundiced.

What other points of the history What other points of the history do you want to know?do you want to know?

HistoryHistory

Focused HPI and relevant symptomsFocused HPI and relevant symptoms Medications particularly those associated with Medications particularly those associated with

liver damage e.g. fluconazole, acetaminophenliver damage e.g. fluconazole, acetaminophen Alcohol useAlcohol use I.V. drug useI.V. drug use History of biliary surgery and/or malignancyHistory of biliary surgery and/or malignancy Previous transfusions / pregnanciesPrevious transfusions / pregnancies Occupational exposure e.g. to solventsOccupational exposure e.g. to solvents

History, Patient J.S.History, Patient J.S. Consider the following:Consider the following:

Characterization of Characterization of symptomssymptoms

Temporal sequenceTemporal sequence

Alleviating / Alleviating / Exacerbating factorsExacerbating factors::

Associated Associated signs/symptomssigns/symptoms

Pertinent PMHPertinent PMH ROSROS MEDSMEDS Relevant Family Hx.Relevant Family Hx.

HistoryHistory Characterization of SymptomsCharacterization of Symptoms

Abdominal DiscomfortAbdominal Discomfort• Epigastric and right upper quadrantEpigastric and right upper quadrant• Radiating to back / shoulderRadiating to back / shoulder• Dull ache and increasing in severityDull ache and increasing in severity• Quantified as a 5/10Quantified as a 5/10

ChillsChills• Shivering and unable to get warmShivering and unable to get warm

JaundiceJaundice• Associated with pruritus, dark urine and pale stoolsAssociated with pruritus, dark urine and pale stools

HistoryHistoryTemporal sequenceTemporal sequence

PainPain• Started 3-4 days prior to ER presentationStarted 3-4 days prior to ER presentation• Came on gradually and increased in severity Came on gradually and increased in severity • Previous episodes but of lesser severityPrevious episodes but of lesser severity• Some fatty food intoleranceSome fatty food intolerance

ChillsChills• Noticed 24 hours after onset of painNoticed 24 hours after onset of pain

JaundiceJaundice• Noticed by family on day of visitNoticed by family on day of visit

HistoryHistory

Alleviating / Exacerbating factors:Alleviating / Exacerbating factors:• None notedNone noted

PMHPMH• MVA in 1985 received a blood transfusionMVA in 1985 received a blood transfusion• Two children uneventful pregnanciesTwo children uneventful pregnancies• Appendectomy 1970Appendectomy 1970

ROSROS• Non contributoryNon contributory

MEDSMEDS• Antacids (OTC) for “indigestion” which has been Antacids (OTC) for “indigestion” which has been

increasing in frequencyincreasing in frequency

HistoryHistory Relevant Family Hx.Relevant Family Hx.

• Non relevantNon relevant

• Specifically no other family members have been Specifically no other family members have been jaundiced or illjaundiced or ill

Social HistorySocial History• Alcohol 6-8 beers per weekendAlcohol 6-8 beers per weekend

• Smokes 1 pk/day for 25yearsSmokes 1 pk/day for 25years

• Home makerHome maker

• No recent shellfish ingestionNo recent shellfish ingestion

HistoryHistory

Associated signs/symptoms:Associated signs/symptoms:• Pale stoolsPale stools• PruritusPruritus• NauseaNausea• AnorexiaAnorexia• Weight loss nilWeight loss nil• ChillsChills

What is your Differential What is your Differential Diagnosis?Diagnosis?

Differential DiagnosisDifferential Diagnosis

Based on History and PresentationBased on History and Presentation

Cholestatic (obstructive ) JaundiceCholestatic (obstructive ) Jaundice• CholangitisCholangitis• CholecystitisCholecystitis• Cholelithiasis / choledocholithiasisCholelithiasis / choledocholithiasis• Benign or malignant biliary strictureBenign or malignant biliary stricture• Pancreatic or biliary tumorPancreatic or biliary tumor

Cholestatic liver diseaseCholestatic liver disease • Primary Biliary Cirrhosis Primary Biliary Cirrhosis • Primary Sclerosing CholangitisPrimary Sclerosing Cholangitis

Hepatocellular jaundiceHepatocellular jaundice• Hepatitis B / CHepatitis B / C• Alcoholic cirrhosisAlcoholic cirrhosis• Metastatic liver diseaseMetastatic liver disease

Physical ExaminationPhysical Examination

What would you look for?What would you look for?

Physical ExaminationPhysical ExaminationWhat would you look for?What would you look for?

Vital signsVital signs General examination should take note of the General examination should take note of the

presence or absence of jaundice, excoriation, presence or absence of jaundice, excoriation, palmar erythema, spider nevae, or tremorpalmar erythema, spider nevae, or tremor

Focused physical examination should include Focused physical examination should include examination of the abdomen for tenderness, examination of the abdomen for tenderness, masses, hepatosplenomegaly or ascites.masses, hepatosplenomegaly or ascites.

Physical Examination, Patient J.S.Physical Examination, Patient J.S.

HEENT: NCHEENT: NC Genital-rectal: NCGenital-rectal: NC

Chest: NCChest: NC Neuromuscular: NCNeuromuscular: NC

CV: NCCV: NC Breast: NCBreast: NC

Remaining Examination findings non-contributory (NC)

Physical Examination. J.S.Physical Examination. J.S.

Vital Signs:Vital Signs:• TempTemp 38.938.9• HRHR 100/min100/min• BPBP 110/80110/80

Appearance:Appearance:• In mild distressIn mild distress• OverweightOverweight• JaundicedJaundiced• Excoriation of skinExcoriation of skin

Relevant exam findings for a problem focused Relevant exam findings for a problem focused assessmentassessment

AbdomenAbdomen• Epigastric tendernessEpigastric tenderness• Mild distensionMild distension• Decreased bowel soundsDecreased bowel sounds• No ascites or reboundNo ascites or rebound• No massesNo masses Rectal examRectal exam • shows gray stool (Guaiac negative)shows gray stool (Guaiac negative)

Would you like to revise your Would you like to revise your Differential Diagnosis?Differential Diagnosis?

Would you like to revise your Would you like to revise your Differential Diagnosis?Differential Diagnosis?

Primary liver disease is unlikely to cause Primary liver disease is unlikely to cause jaundice in the absence of any stigmata of jaundice in the absence of any stigmata of chronic liver disease.chronic liver disease.• CholangitisCholangitis• CholecystitisCholecystitis• Cholelithiasis / choledocholithiasisCholelithiasis / choledocholithiasis• Benign or malignant biliary strictureBenign or malignant biliary stricture• Pancreatic or biliary tumorPancreatic or biliary tumor

LaboratoryLaboratory

What studies would you obtain?What studies would you obtain?

LaboratoryLaboratory

• CBCCBC

• Comprehensive metabolic panel (includes Comprehensive metabolic panel (includes electrolytes and LFTs)electrolytes and LFTs)

• INRINR

• Blood culturesBlood cultures

Lab Results, Patient J.S.Lab Results, Patient J.S.

HCTHCT 37%37% (35 – 47)(35 – 47)

WBCWBC 16,000 16,000 K/UlK/Ul (4-11)(4-11)

SodiumSodium 142 142 MMol/LMMol/L (135-145)(135-145)

PotassiumPotassium 3.7 3.7 MMol/LMMol/L (3.5-5.0)(3.5-5.0)

ChlorideChloride 101 101 MMol/LMMol/L (98-107)(98-107)

CO2CO2 28 28 MMol/LMMol/L (19-27)(19-27)

INRINR 1.61.6 (0.0-1.2)(0.0-1.2)

Lab Results, Patient J.S.Lab Results, Patient J.S.

T.BilirubinT.Bilirubin 14 14 mg / dlmg / dl (0.02-1.2 (0.02-1.2 mg/ dlmg/ dl))

Conjugated biliConjugated bili 10.5 10.5 mg / dlmg / dl

Alk phosAlk phos 800 800 U/LU/L (34 – 104 (34 – 104 U/LU/L))

ASTAST 177 177 U/LU/L (13 – 39 (13 – 39 U/LU/L))

ALTALT 195 195 U/LU/L (9 – 52 (9 – 52 U/LU/L))

AmylaseAmylase 208 208 IU/LIU/L (50 – 200 (50 – 200 IU/LIU/L) )

LipaseLipase 1.5 1.5 IU/LIU/L (0 – 1.5 (0 – 1.5 II U/LU/L))

BUN BUN 18 18 mg / dlmg / dl (7 – 25 (7 – 25 mg / dlmg / dl))

CreatinineCreatinine 1.1 mg / dl1.1 mg / dl (.7 – 1.3 (.7 – 1.3 mg / dlmg / dl))

Lab Results, DiscussionLab Results, Discussion

Explain the significance of abnormalities in:Explain the significance of abnormalities in:

• LFT’sLFT’s• WBCWBC• AmylaseAmylase• INRINR

Lab Results Discussion

LFTSLFTSThe elevation in conjugated bilirubin / total The elevation in conjugated bilirubin / total bilirubin / alkaline phosphatase is greater than bilirubin / alkaline phosphatase is greater than the relative increase in ALT /AST in the relative increase in ALT /AST in conditions that cause cholestasis / extra hepatic conditions that cause cholestasis / extra hepatic biliary obstruction. The converse is true in biliary obstruction. The converse is true in hepatocellular injury.hepatocellular injury.

Lab ResultsLab Results WBCWBC An elevated WBC with left shift is consistent with infection or

inflammation Amylase / LipaseAmylase / Lipase Many acute abdominal conditions produce a chemical

hyperamylasemia. Elevated amylase in setting of normal lipase is unlikely to be acute pancreatitis

INRINRThe PT (INR) may be prolonged in patients with obstructive jaundice due to malabsorbtion of Vitamin K

Interventions at this point?Interventions at this point?

Interventions at this point?Interventions at this point?

NPONPO I.V. fluidsI.V. fluids I.V. broad spectrum antibioticsI.V. broad spectrum antibiotics Nasogastric tube if vomiting or distendedNasogastric tube if vomiting or distended AnalgesiaAnalgesia

StudiesStudies

What further studies would you What further studies would you want at this time?want at this time?

Studies, Patient J.S.Studies, Patient J.S.

Obstruction Obstruction Series/Acute Series/Acute Abdominal Series etc.Abdominal Series etc.

CT Scan:Abd/PelvisCT Scan:Abd/Pelvis

CT Scan: OtherCT Scan: Other

Flat/Upright AbdomenFlat/Upright Abdomen MRIMRI

PA/Lat ChestPA/Lat Chest PET SCANPET SCAN

Mammogram/USMammogram/US Extremity FilmExtremity Film

RUQ US XRUQ US X Bone ScanBone Scan

AngiogramAngiogram US PelvisUS Pelvis

HIDA ScanHIDA Scan MRCPMRCP

OTHER:OTHER:

Studies – ResultsStudies – Results

Discussion of imaging studyDiscussion of imaging studyUltrasound is the initial study of choice in most Ultrasound is the initial study of choice in most patients with suspected biliary disease. For gallstones patients with suspected biliary disease. For gallstones the sensitivity and specificity are 95%. U/S can detect the sensitivity and specificity are 95%. U/S can detect stones as small as 3mm in diameter and is highly stones as small as 3mm in diameter and is highly sensitive for detecting intra and extra hepatic biliary sensitive for detecting intra and extra hepatic biliary dilatation but not CBD stones.dilatation but not CBD stones.

Would a flat / upright abdominal Would a flat / upright abdominal film be of any assistance at this film be of any assistance at this

point?point?

However it will not be helpful in diagnosing gallstones since 80% of gallstones are not

radiopaque

A plain abdominal x-ray may be a useful screening tool to exclude other acute abdominal conditions

Ultrasound of GallbladderUltrasound of Gallbladder

Gallbladder with stones

RadiologyRadiology

The ultrasound demonstrates:The ultrasound demonstrates: • Multiple stones in gallbladderMultiple stones in gallbladder• Gallbladder is thickened but not distendedGallbladder is thickened but not distended• Intra hepatic and extra hepatic biliary dilatationIntra hepatic and extra hepatic biliary dilatation• The pancreas is not visualizedThe pancreas is not visualized

Would you like to revise your Differential Diagnosis?

Revised Differential DiagnosisRevised Differential Diagnosis

CholangitisCholangitis Cholelithiasis / CholedocholithiasisCholelithiasis / Choledocholithiasis Benign or malignant biliary stricture (distal Benign or malignant biliary stricture (distal

CBD)CBD) Pancreatic tumorPancreatic tumor

Blood Culture FindingsBlood Culture Findings

Preliminary gram stain shows gram Preliminary gram stain shows gram positive cocci later demonstrated to be positive cocci later demonstrated to be enterococcus sensitive to cefazolin and enterococcus sensitive to cefazolin and piperacillin / tazobactam (Zosyn). piperacillin / tazobactam (Zosyn).

What next?What next?

1.1. Additional Imaging?Additional Imaging?

2.2. Endoscopy?Endoscopy?

3.3. OR?OR?

4.4. Other?Other?

What next?What next?

ERCP vs. PTC

ERCP Dilated CBDERCP Dilated CBD

PTCPTC

Advantages of ERCP vs. PTCAdvantages of ERCP vs. PTC

The ultrasound has shown dilatation of both The ultrasound has shown dilatation of both intra and extra hepatic bile ducts suggesting a intra and extra hepatic bile ducts suggesting a lesion in the distal CBD. Therefore an ERCP lesion in the distal CBD. Therefore an ERCP would be the procedure of choicewould be the procedure of choice

If the biliary dilatation was predominantly If the biliary dilatation was predominantly intra hepatic a PTC would be the procedure of intra hepatic a PTC would be the procedure of choice as it will better define proximal biliary choice as it will better define proximal biliary anatomyanatomy

ERCP Patient J.SERCP Patient J.S

ERCP FindingsERCP Findings

ERCP (Endoscopic Retrograde Cholangio- Pancreatography) demonstrates a stone in the common bile at the ampulla. A sphincterotomy is performed and the stone is extracted

What potential complications may occur after ERCP?

ERCPERCP

Complication rate is 10%Complication rate is 10%• BleedingBleeding• Duodenal perforationDuodenal perforation• PancreatitisPancreatitis

Success rate is 90%Success rate is 90%

Final DiagnosisFinal Diagnosis

1. Cholangitis secondary to1. Cholangitis secondary to 2. Choledocholitiasis2. Choledocholitiasis

What are ?What are ?

Charcot’s triadCharcot’s triad

Reynalds’s pentadReynalds’s pentad

Triangle of CalotTriangle of Calot

ANSWERSANSWERS

Charcot’s triadCharcot’s triad• Right upper quadrant painRight upper quadrant pain• JaundiceJaundice• Fever / chillsFever / chills

Reynolds’s pentadReynolds’s pentadIn addition to the above triad the patient may have In addition to the above triad the patient may have

pus in the biliary tree “acute suppurative pus in the biliary tree “acute suppurative cholangitis” withcholangitis” with

• HypotensionHypotension• Mental confusionMental confusion

AnswersAnswers

Triangle of CalotTriangle of Calot This is the three sided area bordered by the This is the three sided area bordered by the

inferior margin of the liver, cystic duct and inferior margin of the liver, cystic duct and common hepatic duct. The cystic artery and common hepatic duct. The cystic artery and right hepatic artery traverse this triangleright hepatic artery traverse this triangle

Further ManagementFurther Management

24 hours after the ERCP the patient has 24 hours after the ERCP the patient has improved LFTs and is now afebrile with a WBC improved LFTs and is now afebrile with a WBC of 12,000.of 12,000.

What next?

Further ManagementFurther Management

Continue IV fluids Continue IV antibiotics Correct INR

What surgical procedure is indicated at this point?

Laparoscopic CholecystectomyLaparoscopic Cholecystectomy

(vs. open cholecystectomy) is now the (vs. open cholecystectomy) is now the procedure of choice.procedure of choice.

Why is rehydration with intravenous Why is rehydration with intravenous fluid of particular importance in the fluid of particular importance in the jaundiced patient?jaundiced patient?

AnswerAnswer

To minimize the possibility of developing To minimize the possibility of developing hepato-renal failurehepato-renal failure

Consent for CholecystectomyConsent for Cholecystectomy

What are the critical elements of What are the critical elements of informed consent?informed consent?

The following criteria are essential for consent to be considered informed:

CCapacity to make a decisionapacity to make a decision Absence ofAbsence of CCoercionoercion Inform patient re potential Inform patient re potential CComplications omplications

and alternativesand alternatives CContent of message (i.e. imparting knowledge ontent of message (i.e. imparting knowledge

or informing the patient)or informing the patient)

When Discussing Potential Complications When Discussing Potential Complications of Surgery Consider:of Surgery Consider:

Anesthetic (medical ) complications• Drug related• Pneumonia• M.I.• D.V.T.

Complications of any operation• General e.g. bleeding• Incision related e.g. dehiscence / infection

Complications of this specific operation

Potential Complications Following Potential Complications Following Laparoscopic CholecystectomyLaparoscopic Cholecystectomy

Conversion to an open operation (5%)Conversion to an open operation (5%) Trocar injury to major vessels or to the Trocar injury to major vessels or to the

intestineintestine Biliary injury (3-10%)Biliary injury (3-10%)

Frequently asked questions by Frequently asked questions by patients undergoing lap chole.patients undergoing lap chole.

Will I have a tube in my nose when I wake up?

• Usually a nasogastric tube is not indicated post operatively When can I drive ?

• Generally two weeks after surgery if the patient no longer requires narcotics for pain.

When can I go back to work?• One – two weeks for a sedentary job, two to four weeks for

physical labor

QUESTIONS ?QUESTIONS ?

Should patients with asymptomatic gallstones have an Should patients with asymptomatic gallstones have an elective cholecystectomy?elective cholecystectomy?

Approximately two thirds of patients will remain Approximately two thirds of patients will remain symptom free after 20 years therefore the answer is symptom free after 20 years therefore the answer is “No” unless the patient has a calcified gallbladder “No” unless the patient has a calcified gallbladder (increased risk of malignancy) or is a diabetic (increased risk of malignancy) or is a diabetic (controversial), with an increased risk of infection(controversial), with an increased risk of infection

QUESTIONS ?QUESTIONS ?

In a jaundiced patient with an enlarged palp-In a jaundiced patient with an enlarged palp-able gallbladder the most likely diagnosis is:able gallbladder the most likely diagnosis is:

CholedocholithiasisCholedocholithiasis Carcinoma of the head of the pancreasCarcinoma of the head of the pancreas

Explain your answerExplain your answer

Courvoisier’s LawCourvoisier’s Law

““In the presence of jaundice a palpable In the presence of jaundice a palpable gallbladder is unlikely to be due to stone”gallbladder is unlikely to be due to stone”

If the obstruction was due to stone, the thick If the obstruction was due to stone, the thick walled gallbladder would probably not distendwalled gallbladder would probably not distend

Describe some common variations Describe some common variations in biliary anatomyin biliary anatomy

Explain why patients with cholestatic jaundice have dark urine

and pale stools

Cholestasis predominantly increases direct (conjugated) bilirubin but also indirect (unconjugated) bilirubin

Dark urine Since direct bilirubin is water soluble bilirubinuria

develops Pale stools

Biliary obstruction prevents passage of bile into the intestinal tract for deconjugation to urobilinogen, the compound responsible for the dark color of stool

QUESTIONS?QUESTIONS?

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