Clinical Practice Guidelines Jaundice

Department of Surgery

What is an operational concept of jaundice?

A yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin. Beers M, Berkow R. The Merck Manual of Diagnosis and Therapy, Seventeenth Edition.Sec 4, Chapter 38.

hypercarotenemia or just carotenemia.

A yellow-to-orange color may be imparted to the skin by consuming too much beta carotene, the orange pigment seen in carrots. In this condition, the whites of the eyes remain white, while people with true jaundice often have a yellowish tinge to the eyes. MedlinePlus Medical Encyclopedia.

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Increased quantity of bilirubin

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Increased quantity of bilirubin Decreased transport to liver

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Defective uptake

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Defective uptake Defective conjugation

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Defective uptake Defective conjugation Defective excretion of bilirubin by liver cell

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Etiology
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

Defective Transport of bilirubin by the Bilary duct system

Treatment
Jaundice

PREHEPATIC

HEPATIC

POSTHEPATIC

MEDICAL

SURGICAL

What are reliable symptoms and signs (more than 90% certainty) that will indicate that patients with jaundice will need surgical treatment?
RUQ pain Jaundice Tea-colored urine/ pale stools Fever (+/-) RUQ tenderness No hepatomegaly

What are reliable symptoms and signs (more than 90% certainty) that a patient with obstructive jaundice needs urgent intervention?
Abdominal pain (70%) Jaundice (60%) Tea-colored urine/pale stools Altered mental status (10-20%) Hypotension (30%) Fever, persistent (90%) RUQ tenderness

If a paraclinical diagnostic procedure is needed in a patient with suspected obstructive jaundice, what is the most cost-effective procedure? Ultrasound

Goal of Treatment
Obstructive Jaundice Relief of Obstruction Prevent Complication Prevent Recurrence Ascending Cholangitis Prompt drainage Control infection

Treatment Options
Treatment ERCP Benefit -able to achieve primary treatment objective SR=71-98% CBD Clearance -bleeding -perforation -pancreatitis Risk Cost *12-15,000 pesos at Metropolita n Hospital *2-3,000 pesos at PGH *20-30,000 pesos in private hospitals *free to charity pxs at OM *40-60,000 pesos in private hospitals Availability Not available

Open surgery

-able to achieve primary treatment objective SR=90-100% CBD Clearance

-complications of anesthesia -bleeding -iatrogenic injury to biliary ducts

available

Laparoscopic surgery

-able to achieve primary treatment objective SR=85-100% CBD Clearance

-complications of anesthesia -bleeding -iatrogenic injury to biliary ducts -trocar and needle insufflation injuries

Not available

Treatment Options
Treatment ERCP Benefit -able to achieve primary treatment objective SR=90-98% CBD decompression MtR=10% -bleeding -perforation -pancreatitis Risk Cost *12-15,000 pesos at Metropolita n Hospital *2-3,000 pesos at PGH 10000 Availability Not available

PTBD

SR=90% CBD decompression MtR=15% -able to achieve primary treatment objective SR=90-100% CBD MtR=32-40%

-bleeding

available

Open surgery

-complications of anesthesia -bleeding -iatrogenic injury to biliary ducts

*20-30,000 pesos in private hospitals *free to charity pxs at OM

available

Management of the gallbladder after bile duct clearance

4 RCTs Boerma D, Rauws EA, Keulemans YC, et al. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bileduct stones: a randomised trial. Lancet 2002;360:761-5. Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients. Lancet 1996;347:926-9. Hammarstrom LE, Holmin T, Stridbeck H, Ihse I. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg 1995;82:1516-21. Panis Y, Suc B, Escat J. Surgery versus endoscopic sphincterotomy for choledocholithiasis: results of a prospective randomized study. Gastroenterology 1995;108:A431.

Boerma et al

120 patients aged 18 to 80 years with proved symptomatic common bile duct and concomitant gallbladder stones who underwent ES and bile duct clearance. Patients were randomized to:
LC within 6 weeks of endoscopic stone clearance wait and see approach.

Results
mean follow-up period of 30 months
47% of patients in the wait and see group had recurrent biliary symptoms compared with 2% in the LC group. 37% of the wait and see group needed cholecystectomy.

Targarona et al
randomized 98 elderly and other high-risk patients with symptoms likely caused by bile duct stones
ES alone open surgery

Result
mean follow-up of 17 months,
biliary symptoms recurred in 20% of the ES group and 6% of the surgery group.

Hammarstrom et al
randomized 83 patients with bile duct stones
ES and stone removal open surgery (cholecystectomy and bile duct exploration)

Result
after more than 5 years,
20% of the ES group underwent cholecystectomy because of recurrent biliary symptoms, 2% of patients in the surgery group had recurrent symptoms from bile duct stones. During the follow-up period, nonbiliary mortality was significantly more common in the ES group

Panis et al
randomized 206 patients with common bile duct stones
endoscopic therapy alone surgery

Result
early surgery was required in 19% in the endoscopic group, only 2% of the surgical group needed reoperation.

recommendation
patients with cholangitis should undergo elective Lap Chole after bile duct clearance if they are fit for surgery (unless an open approach is known to be required).