Jaundice: Ovais Qureshi FY1

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Jaundice

Ovais Qureshi FY1

History

38 Male

Progressive jaundice

Pruritus

Weight loss

Pale stools

No abdominal pain

No nausea and vomiting

No PR bleeding or hematemesis

No recent travel

Systems enquiry - nil

PMH- Nil

FH-Nil

DH Nil

Allergies NKDA

SH- smoker , Alcohol not drunk for


>3 years.

Not an IVDU

On examination

Visibly jaundiced

Yellow sclera and skin

Abdo exam

Soft non-tender

No hepatosplenomegaly

No palpable masses

HS 1+11 - 0

Respiratory
Chest clear
Good air entry , bilaterally

Jaundice

Pre hepatic

Hepatocellular

Obstructive

Differentials
Pre hepatic

Hepatic

Obstructive

Haemolytic anaemia

Viral hepatitis

Gallstones

Gilberts syndrome

CMV

Pancreatic cancer

Crigler-Najjar syndrome

EBV

Cholangiocarcinoma

ALD
Cirrhosis
Liver mets
Autoimmune hepatitis
Drug induced hepatitis

PSC
PBC
Choledochal cyst
Mirrizi syndrome

Investigations

Hb- 140

WCC 8.4

Bilirubin (0-21) 249 ---------- 284

ALT (3-53) 223 -------------- 193

ALP (30-130) 725 ---------------752

Albumin 38-----------------------39

Ca 19-9 65

CEA normal

AFP- normal

Na-141
K+- 4.5
Urea 8.0
Creatinine 91
INR- 0.9
PT- 10.3
APTT 1.09

Investigations

USS abdomen -??

MRCP / MR liver
No gallstones,

Mid and distal CBD stricture with sparing distal CBD.

Mild dilatation of intrahepatic bile ducts

No liver lesion

CT

Moderate to significant intrahepatic biliary dilatation seen. The


common hepatic duct where it joins cystic duct appears thick-walled
and narrow

ERCP

EUS

Cholangiocarcinoma

Cholangiocarcinomas are malignancies of the biliary duct system that may


originate in the liver and extrahepatic bile ducts, which terminate at the
ampulla of Vater

Peri-hilar tumours are the most common. If they occur at


the bifurcation of the right and left hepatic duct its known
as a Klatskins tumour.

Epidemiology

Incidence of 1-2 per 100,000

Higher incidence in Japan and Israel

Usually presents in patients in their 60-70s.

Male :female 1:2.5

Presentation

Jaundice

Pale stools

Dark urine

Pruritus

Weight loss (30-50%)

Abdominal pain (30-50%)

Hepatomegaly

Fever (20%)

Courvosiers sign - states that in the presence of an enlargedgallbladderwhich is


non-tender and accompanied with mildjaundice, the cause is unlikely to be
gallstones

Causes

Inflammatory bowel disease


Ulcerative colitis
primary sclerosing cholangitis, 10-20% risk of developing cholangicarcinoma.

Chronic infections with liver flukes (Clonorchis sinensisand Opisthorchis viverrin)

Choledochal cysts

Caroli disease group of rare inherited disorder characterized by dilation of the


intrahepatic bile ducts.

Industrial chemical exposure: chemicals used in the aircraft, rubber and woodfinishing industries have been implicated.

Thorium exposure is associated with an increase in cases of cholangiocarcinoma

Investigations

Bloods

Bilirubin

ALP

Gamma GT

AST, ALT ,albumin and PT time are usually normal or minimally raised

Prolonged obstruction can cause raised PT time

Tumour markers CA 19-9, CEA, AFP not produced

Investigations

Imaging

Ultrasound ductal dilatation, limited in PSC due to ductal fibrosis

MRCP -

ERCP

Endoscopic ultrasound

Percutaneous trans hepatic cholangiography (PTC)

Biopsy - well to moderately differentiated adenocarcinomas

Treatment

Medical

Stenting will help relieve biliary obstruction, stents in situ for 3 months

Photodynamic therapy useful in non-resectable disseminated disease

Radiotherapy neo-adjuvant to help reduce tumour size, adjuvant post op


therapy can increase survival duration from 8 months to 19 months.

Chemotherapy used in conjunction with radiotherapy for non-resectable


disease. No benefit with chemotherapy alone.

Treatment

Surgical

Only 10% of cases are operable

Intrahepatic and Klatskin tumours require liver resections

Distal tumours require a whipples procedure.

Prognosis

Usually poor

Poor for patients with intrahepatic tumours

Distal extrahepatic tumours 5yr survival of 40%, usual survival approx. 17-28
months.

Inoperable with chemo/radio therapy 7-17 months

Palliative 2-8 months

Complications post treatment 1)Cholangitis 2)Cirrhosis (10-20%) 3)Surgical complications

Some good news

Biliary brushings benign epithelial cells

FNA benign reactive lymphadenopathy

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