Surg Oral Exam: 3. Jaundice
Terms in this set (47)
What is the differential diagnosis for jaundice?
Pre-hepatic, hepatic, post-hepatic
What are the pre-hepatic causes of jaundice?
What are the hepatic causes of jaundice?
o Fatty liver
o Primary biliary cirrhosis
Congenital conjugation defect
What are the post-hepatic causes of jaundice?
Primary sclerosing cholangitis
Bile duct injury
o Pancreatic cancer
o Gallbladder cancer
o Ampullary cancer
42 year old female presents to the clinic. "My husband says my skin looks yellow". What are your first steps?
"I would first ask for a set of vitals then go to assess the patient's general appearance and vital signs to determine if there is any need for immediate resuscitation."
What is the pertinent HPI for jaundice?
"I would then take a complete history from the patient. I want to characterize the patient's complaint, ask about associated symptoms, and elicit risk factors from the patient's history:"
• Onset: When did this start? How has it progressed until now? Has this happened to you before?
• If painful, OLDCART; If painless, think malignancy.
• Associated symptoms:
o Constitutional: fever, chills, weight loss, fatigue, night sweats
o GI: nausea, vomiting, diarrhea, constipation
o Extremities: bone pain, weakness, transient swelling, migratory thrombophlebitis (Trousseau's syndrome)
• Symptom groupings to help characterize etiology:
o Dull pain, fatigue, nausea/vomiting: think hepatic
o Colicky and pruritic: think post-hepatic
o Charcot's Triad and Reynold's pentad
What are the pertinent PMH and PSH for jaundice?
Pre-hepatic: "Do you have any blood disorders? Have you required recent blood transfusions?"
• Hemolytic anemias (sickle cell, G6PD deficiency, hereditary spherocytosis), Recent transfusions, Recent trauma
Hepatic: "Do you have any liver disease? Have you received hepatitis vaccinations?"
• Hepatitis, Cirrhosis, Primary sclerosing cholangitis, and associated inflammatory bowel disease, Primary biliary cirrhosis
Post-hepatic: "Have you ever had problems with your gallbladder or pancreas?"
• Gallstones, Acute/chronic pancreatitis, Recent onset diabetes mellitus
PSH: Cholecystectomy, abdominal surgeries, recent surgical complications (post-op hematoma), ERCP.
What are the pertinent Meds/allergies, SH, FH, ROS for jaundice?
Meds: Acetaminophen use, hepatotoxic medications (NSAIDS, statins, methotrexate, rifampin), new medications.
Allergies: G6PD deficiency flare ups: IS PAIN (Isoniazid, Sulfonamide, Primaquine, Aspirin, Ibuprofen, Nitrofurantoin).
SH: Smoking, alcohol, IV drug use, Sexual history, tattoos, Recent travel, sick contacts
FH: Malignancy: pancreatic, colon, Autoimmune diseases: hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis/IBD, hereditary hemolytic disease
Review of Systems: "I would complete a 14-point review of systems focusing on the constitutional, GI, and extremities systems."
What is the pertinent physical exam for jaundice?
"I would then move on to perform a complete head to toe physical exam focusing on HEENT, abdominal, and skin components. I would begin my exam by reassessing the patient's vital signs and again determining the need for resuscitation."
• Vitals/General: Obesity, fetor hepaticus
• HEENT: scleral icterus, sublingual jaundice, lymphadenopathy (Virchow's node)
o Distension, caput medusa, ascites
o Tenderness to palpation in RUQ or epigastrium, peritoneal signs (rebound tenderness/involuntary guarding), Courvoisier's sign (enlarged, non-tender gallbladder with mild jaundice; suggests malignancy), hepatosplenomegaly
• Rectal: Occult blood, presence of hemorrhoids
• Skin: Assess extent and character of jaundice, spider angiomata, palmar erythema, gynecomastia
• Extremities: Asterixis, muscle wasting
What are the pertinent labs for jaundice?
• CBC, comprehensive metabolic panel, amylase/lipase, +/- peripheral smear (if suspecting anemia)
o Low hemoglobin/hematocrit, abnormal smear: pre-hepatic
o Elevated AST/ALT, abnormal LFTs/Coags: hepatic
o Elevated alkaline phosphatase: post-hepatic
o Elevated amylase/lipase: post-hepatic
• Fractionated bilirubin
o Elevated indirect bilirubin: pre-hepatic
o Elevated direct bilirubin: post-hepatic
• Hepatitis panel (if +risk factors for hepatitis)
o Positive hepatitis panel: hepatic
• Toxin screen (if suspecting alcohol and/or acetaminophen)
o Positive alcohol/acetaminophen with elevated AST/ALT suggests hepatic
• Tumor markers -> CEA, CA 19-9, AFP (if suspecting malignancy or metastasis) - Positive markers suggests post-hepatic
What are the pertinent studies for jaundice?
Start with non-invasive tests, then move to invasive tests.
• Abdominal/RUQ ultrasound
• Pancreatic protocol CT with IV contrast if suspecting post-hepatic etiology
o If positive -> ERCP and biopsy for cytology
o If negative -> EUS for better visualization of pancreatic head
What is the purpose of US in evaluation of jaundice?
Can detect gallbladder pathology, dilated bile ducts indicating obstruction, or presence of liver lesions
What is the purpose of CT with IV contrast in evaluation of jaundice?
Can assess for cystic vs. solid lesion in the pancreas (adenocarcinoma vs. IPMN [intraductal papillary mucinous neoplasm -> high risk of progressing into invasive pancreatic cancer])
What is the purpose of ERCP in evaluation of jaundice?
Can be both diagnostic and therapeutic for choledocholithiasis or gallstone pancreatitis.
What is the purpose of EUS in evaluation of jaundice?
Can assess for tumor invasion for staging (liver/peritoneal mets), lymph nodes, and portal vein involvement.
Patient with colicky RUQ or epigastric pain, jaundice, loss of appetite, nausea/vomiting. Dx and Tx?
• Dx: CBC, LFTs (cholestatic picture), Abdominal US, ERCP
• Tx: Can do laparoscopic or open cholecystectomy. Removal is only necessary if stones >3mm (smaller will pass spontaneously)
What is the pathophysiology of Choledocholithiasis?
Gallstones form in the common bile duct, causing obstruction and jaundice
Patient with fever, jaundice, RUQ pain. Dx and tx?
• Dx: CBC (elevated WBC), LFTs (elevated T. bili, elevated alk phos, +/- elevated AST/ALT), +/- amylase/lipase, abdominal ultrasound, ERCP/percutaneous transhepatic cholangiography (PTC)
• Tx: broad-spectrum antibiotics, IV fluids, supplement electrolytes. ERCP or PTC for drainage of bile, possible stenting/removal of obstruction, +/- sphincterotomy (relieving obstruction at sphincter of Oddi)
What is the pathophysiology of Cholangitis?
biliary obstruction becomes site for bacterial superinfection; most commonly bile cultures are polymicrobial, blood cultures are positive for E. coli (59%), Klebsiella (16%), Pseudomonas (5%), or Enterococcus (4%)
Patient with epigastric pain, +/- history of heavy alcohol/tobacco use, diarrhea, weight loss, loss of appetite, jaundice, possible fullness/mass on abdominal palpation (suggesting pseudocyst). Dx and Tx?
• Dx: Amylase/lipase elevated in acute phase, can be normal or decreased in advanced chronic pancreatitis. CT abdomen, ERCP with direct measurement of pancreatic secretions (amylase, lipase, bicarbonate, and protease).
• Tx: Medically managed, no surgery unless to excise pseudocysts
What is the pathophysiology of Chronic Pancreatitis?
progressive inflammation of the pancreas leads to fibrosis and decreased secretory function; this can be caused by either alcohol or be idiopathic
Patient with RUQ pain, weight loss, long-standing history of hepatitis, symptoms of cirrhosis (jaundice, pruritis, splenomegaly, ascites, hepatic encephalopathy, variceal bleeding). Dx and Tx?
• Dx: CBC (anemia/thrombocytopenia), abnormal liver function tests (total bilirubin, AST/ALT, alk phos, albumin, prothrombin time), consistent with cirrhosis. Hepatitis panel. Tumor marker: elevated AFP (75% of the time; higher AFP, worse prognosis; >400ng/mL diagnostic with imaging), liver US, abdominal CT/MRI, can get chest x-ray to screen for pulmonary metastases.
• Tx: Wedge resection or lobectomy can be done if clean margins can be achieved. If not candidate for surgical resection, then radiofrequency ablation or cryoablation can be used for smaller tumors. Otherwise, transplant if no distant disease.
What is the pathophysiology of Hepatocellular Carcinoma?
chronic liver disease (from hepatitis, alcohol, hemochromatosis, etc) leads to cirrhosis. In tandem with environmental carcinogens (aflatoxin), and genetics (p53, PIKCA, beta-catenin), these factors increase the risk of developing cancer.
Patient with painless jaundice, acholic stools, dark urine, weight loss, nausea, fatigue, history of smoking. Dx and Tx?
o Dx: Courvoisier's sign on physical exam suggests pancreatic head tumor. Tumor markers CA-19-9 (elevated in 75-85% of cases), +/- CEA (elevated in 40-45% of cases). Abdominal US, abdominal CT, EUS to assess for possible blood vessel/lymph node involvement and biopsy vs. ERCP with brush/biopsy for cytology.
o Tx: Surgical treatment depends on location of tumor:
Pancreatic head: Whipple (pancreaticoduodenectomy w/ distal gastrectomy and choledolcojejunostomy); Also Pancreatic body/tail: distal pancreatic resection + splenectomy due to shared vasculature risk mets
Adjuvant chemoradiation with 5-FU and gemcitabine
What is the Whipple procedure?
pancreaticoduodenectomy w/ distal gastrectomy and choledolcojejunostomy - Removes the head of pancreas, gallbladder, common bile duct, gastric antrum and duodenum through 15cm of jejunum.
Complication rate 25%: anastomotic leak, wound infx, sepsis, pancreatitis, postgastrectomy sx, DVT, abscess, pneumonia
Contraindications to Whipple procedure?
- 180 degree invasion of SMA, portal vein or hepatic artery; SMV can be reconstructed via jugular vein
- Any metastasis (liver, peritoneal or distant lymph node involvement)
What is the treatment for pancreatic cancer that has invaded the portal vein, hepatic artery and/or 180 degrees of SMA?
Biliary obstruction: ERCP/PTC with stent placement
Gastric outlet obstruction: gastrojejunostomy
Malabsorption: pancreatic enzyme replacement
Pain relief: celiac plexus block, chemoradiation
What is the risk factors for Pancreatic Cancer?
Risk factors include advanced age, obesity, and tobacco use. 95% develop from exocrine pancreatic cells; 75% in head of pancreas, 15-20% in body, 5-10% in tail.
Patient with jaundice, acholic stools, dark urine, cholangitis. Dx and Tx?
• Dx: abdominal US & CT, ERCP/PTC with brushings, or MRCP; most commonly at proximal bile duct, histologically 100% adenocarcinoma
• Tx: surgery depends on location of tumor:
o Proximal: resect tumor with Roux-en-Y hepaticojejunostomy (bile duct-jejunal anastomosis) with possible unilateral hepatic lobectomy
o Distal: Whipple
What are the risk factors for Cholangiocarcinoma?
Risk factors include: choledochal cyst, ulcerative colitis, primary sclerosing cholangitis, liver flukes, toxins (agent orange), thorotrast dye
What is the Roux-en-Y procedure?
Gastric bypass for proximal cholangiocarcinoma
Patient with colicky abdominal pain, weight loss, anorexia, +/- acute cholecystitis, but often asymptomatic. Dx and Tx?
• Dx: abdominal US & CT, ERCP +/- biopsy; histologically 90% adenocarcinoma
• Tx: surgical treatment depends on degree of invasion:
o NOTE: do not do laparoscopically; risk of seeding
o Confined to serosa: cholecystectomy
o Confined to muscularis/serosa: radical cholescystectomy, wedge resection of overlying liver, lymph node dissection, +/- chemoradiation
What is the pathophysiology of Gallbladder Carcinoma?
Risk factors include: female (F:M = 4:1), gallstones, porcelain gallbladder (calcifications in gallbladder wall; 50% of cases), cholecystenteric fistula, 60% are located in the fundus of gallbladder
What Congenital defect of bilirubin conjugation is rapidly progressive, can lead to kernicterus, and death; bilirubin ranges from 20-70 mg/dL; oftentimes these children die in early infancy; liver transplantation is only curative therapy
Criggler-Najjar Type 1
What Congenital defect of bilirubin conjugation is slower course, can asymptomatic, hyperbilirubinemia ranges from 7-20mg/dL; may not require treatment, can be managed medically
Criggler-Najjar Type 2
What congenital defect of bilirubin is hyperbilirubinemia often in the setting of fasting, otherwise normal CBC, blood smear, normal LFTs; no treatment necessary.
This is when infants from 3-5 days of life can naturally be jaundiced due to insufficient feeding; manage with increased feeding
Pediatric jaundice due to progressive, idiopathic, fibro-obliterative disease of extrahepatic biliary tree. Infants born at full term with normal birth weight, but present with persistent jaundice, acholic stools and dark urine. Most common cause of neonatal jaundice requiring surgery. Dx and Tx?
o Kasai procedure (hepatoportoenterostomy) is temporizing surgery to restore bile flow from liver to proximal small bowel.
o Orthotopic liver transplantation is curative.
What is the Kasai procedure?
Biliary atresia; temporizing surgery to restore bile flow from liver to proximal small bowel.
What is an orthotopic liver transplantation?
Procedure in which a failed liver is removed from the patient's body and a healthy donor liver is transplanted into the same location. The procedure is the most common method used to transplant livers.
What is the eponym for a cholangiocarcinoma located at the junction of the right and left hepatic ducts?
How is pancreatic cancer staged?
o Stage I: limited to pancreas
o Stage II: extends into bile duct, peripancreatic tissue or duodenum; no lymph nodes or mets
o Stage III: same as stage II, positive lymph nodes
o Stage IVA: extends into stomach, colon, spleen, or major vessels. No mets. Regardless of lymph nodes or tumor size
o Stage IVB: distant metastasis. Regardless of lymph nodes or tumor size
Percentage of patients who undergo successful Whipple will survive to 5 years?
Percentage of patients with pancreatic adenoCA who will survive without Whipple?
What is Courvoisier's Sign?
Palpable nontender distended gallbladder, suggesting tumor in pancreatic head
How do you treat adenocarcinoma in the tail of the pancreas?
Distal pancreatic resection + splenectomy
Do patients with cholecystitis get jaundiced?