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Obstructive jaundice
Septa Ekanita
PPDS PULMONOLOGI & ILMU KEDOKTERAN
RESPIRASI
FKUI- RS PERSAHABATAN
JAKARTA
Pendahuluan
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
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
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
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:
Keadaan khusus:
Kepala:
- mata kuning tua seperti kunyit
- THT : dbn
Bunyi
Diagnosis masuk
Rencana diagnostik:
DL,UL,
toraks,
Therapy
Aminofusin : dextrose 10 % :
Asering 1:1:1
Diet hati III
Obat dari RS Padang diteruskan
Daftar masalah
Obstructive jaundice ec. ?
Hiperlipidemia
Kesan :
Batu
kandung empedu13 mm x 40 mm dg
pelebaran sal. Empedu intra hepatic kanankiri tetapi kandung empedu tidak membesar
Suspeks striktura partial di duktus hepatikus
komunis
Pankreas normal, KGB tidak membesar
Tidak tampak massa intra abdomen
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
BMJ 2001;323;1170-1173
CHOLANGIOCARCINOMA
DEFINITION
Cholangiocarcinoma is an adenocarcinoma
of the intrahepatic or extrahepatic bile duct.
PREVALENCE
PATHOPHYSIOLOGY
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
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 wellto moderately-differentiated tubular
adenocarcinoma
Arch Iranian Med 2007; 10 (2): 264 267