2. Case Scenario
• A 78 years old, Chinese gentleman, a known case of
cholelithiasis in 2010 was admitted to the ward with a
history of colicky pain at the right upper quadrant of
abdomen for one day, associated with fever,
vomiting and increasing malaise .
• On examination, he had jaundice and tender
hepatomegaly.
• Lab investigation showed a total bilirubin of 151μmol/l.
• Ultrasonography showed multiple calculi seen within
the gallbladder, largest measuring 1.1 cm.
Gallbladder wall is thickened measuring 0.5 cm and
there is presence of minimal pericholecystic
collection.
3. Definition
• Yellowish discoloration of the skin or
sclera due to increase in circulating
bilirubin ( >50 umol/L).
• Three type of jaundice which are :-
• In surgery, we will anticipate mostly in
post hepatic jaundice.
Pre hepatic - Hemolytic jaundice eg.
Spherocytosis, thalassemia,
Gilbert syndrome
Intra hepatic - Hepatocelluar carcinoma,
chronic liver failure, cirrhosis
Post hepatic - cholelithiasis, cholangitis,
cholecystitis
6. Investigation ( Imaging )
1) Ultrasonography – check for duct
dilatation, dilated gallbadder, present of
gallstone.
2) MRCP – non invasive investigation to give
view on anatomy of biliary systems.
3) ERCP – invasive investigation and
therapeutic for obstructive jaundice
( definitive )
4) CT scan – non invasive investigation that
can identify hepatic, bile duct and
pancreatic tumors in jaundiced patients
7. Liver Function Tests
Ultrasound scan
Biliary dilatation
Gallstones Gallstones
Ix further to
exclude medical
cause
MRCP or ERCP CT scan or
MRCP
Biliary stent or surgeryERCP/sphincterotomy or
laparoscopic cholecystectomy as
indicated
Yes No
No
Yes No
9. General pre-operative measures
• AIM: reducing perioperative morbidity
(eg. Infection, massive haemorrhage
etc.)
• Oral cholestyramine 2 to 8 gm – subsides
pruritis (irritation of skin due to high
concentration of bilirubin). Acts by
binding bile salts in within the intestines
• Vitamin K1 5 to 10 mg sc once/daily (2 to
3 days) – treat hypoprothrombinemia
10. • Ca and vitamin D supplements – slow
progression of osteoporosis. Used
with/without biphosphonate.
• Vitamin A supplement – prevent
deficiency, due to lacking of utilization
of fat soluble vitamin A, caused by
deficiency in bile secretion
• Dietary fat – used to minimize the
occurrence of steatorrhea.
11. • Frequent IV hydration and catheterization of
urinary bladder – treating electrolytes
imbalance d/t nausea & vomiting & wash
out the deposition and high concentration
of urobilinogen in the renal tubules
• Mannitol 100 – 200 ml BD IV – forced
natriuresis, preventing hepatorenal
syndrome
• Antibiotic prophylaxis – 3rd
generation
cephalosporin, immunosuppressed patients
12. Specific treatment
Choledocholithiasis (CBD)
- Cholecystectomy, if present.
- Choledochotomy, usually supraduodenal
- T tube is used in certain conditions, to
confirm the clearance of the duct by a
postoperative cholangiogram. Usually
removed after 2 weeks, when an
epithelialzed tract has formed to avoid bile
leak into the peritoneum
13. - ERCP +/- sphincterotomy
A cholangiogram is done after the ampulla of
Vater has been identified and cannulated to
confirm anatomy and the presence of stones.
An adequate sphincterotomy is undertaken
and the duct cleared using a balloon catheter
Success rate is about 90% with low
complications.
15. - Laparoscopic exploration of the
common bile duct
May be done through the cystic duct
(if the gall bladder has not been
previously removed) or common duct
via a choledochotomy
Requires considerable laparoscopic
expertise and is time consuming, more
over it’s expensive due to the need of
proper equipments
16. • Advantages
- Faster and better wound healing
- Better wound appearance
- Can acquire a whole and throughout
view of the body
17. • Cholangiocarcinoma
- Classified into intra-hepatic tumours, (extra-
hepatic) hilar tumours and (extra-hepatic)
distal bile duct tumours.
- Surgery is the only curative option for
cholangiocarcinoma
- Cholecystectomy, lobar or extended lobar
hepatic and bile duct resection, regional
lymphadenectomy are commonly being used
18. • Systemic therapy/palliative care
- The majority of patients with
cholangiocarcinoma present at an advanced
stage or have associated co-morbidity that
preclude surgery
- Biliary endoprosthesis (stent) placement is a
useful option for palliation of jaundice
- Photodynamic therapy, radiation and
chemotherapy are all available as palliative
options
19.
20.
21. Other causes and treatment
• Biliary strictures – stenting,
choledochojejunostomy
• Klatskin tumor – radical resection or
palliative stenting
• Carcinoma periampullary or head of
pancreas – Whipple’s oepration or
triple bypass or ERCP stenting
22.
23.
24. Post-operative care
• Monitoring prothrombin time, bilirubin,
albumin, creatinine, electrolytes
• Fresh frozen plasma @ blood
transfusion
• Antibiotics
• Care of T tube and drains
• Observation for septicaemia,
haemorrhage, pneumonia, pleural
effusion, bile leak
25. Complications
• Complications of obstructive jaundice
include sepsis especially cholangitis,
biliary cirrhosis, pancreatitis,
coagulopathy, renal and liver failure
27. Case Scenario
A 72 year old Malay gentleman presents to
Emergency Department with complaint of
abdominal pain.
Six day history of increasing abdominal pain in LLQ,
colicky in nature.
Pain is dull and constant with nausea and vomiting
No bowel movements or flatus for the past six days.
Increasing abdominal distention with lack of
appetite.
Over the past several days he has tried laxatives and
enemas. Did not relieve his constipation.
28. Definition
• Impedance to the normal passage of
bowel content through the small
bowel or large bowel.
29. Classification of Intestinal Obstruction
Dynamic
• Peristalsis is working against
a mechanical obstruction.
• The obstruction may be:
1. Intraluminal (Ex. impacted
faeces, foreign bodies,
bezoar, gallstones)
2. Intramural (Ex. malignant or
inflammatory strictures)
3. Extramural (Ex. intraperitoneal
bands and adhesions, hernias,
volvulus or intussusception.)
Adynamic
• Peristalsis is absent (eg.
Paralytic ileus)
• May be present in a non-
propulsive form (eg.
Pseudo-obstruction)
30.
31. Clinical Features
Small bowel Large bowel
Colicky pain
Vomiting
- bile – proximal obstruction
- feculent – distal obstruction
Constipation
Abdominal distension
Signs of dehydration
Constipation/diarrhea
Abdominal distension
Colicky pain
Vomiting
Hematochezia/tenesmus
Signs of dehydration
36. • Admit the patient with high suspicious
of IO
– Acute abd pain + vomiting + constipation
+ abd distension
• Supportive management
– Nasogastric decompression
• Ryles or Salem tube
• On free drainage with 4 hourly aspiration or on
continous or intermittent suction
• To decompress area proximal to obstruction n
also reduce risk of aspiration during induction
of anaesthesia
– Analgesics
• IV Tramal
37. – IV fluids
• To correct the electrolyte imbalance and also
rehydrate if patient is dehydrated
• Main electrolyte imbalance in IO is sodium n water loss
• Use Hartmann’s solution or normal saline
• Electrolyte imbalance is one of the causes of paralytic
illeus
– IV antibiotics
• Is not mandatory except for surgical resection of small
or large bowel
• May use broad spectrum because of high risk of
bacterial outgrowth (e.g. 3rd
generation cephalosporin,
ceftriaxone)
38. Surgical Treatment
• Principles
– Manage segment at the site of obstruction
– Manage distended proximal bowel
– Manage underlying causes of obstruction
• Indications for early surgery
– Obstructed or strangulated external hernia
– Internal intestinal strangulation
– Acute obstruction
39. Small Bowel Obstruction
Causes of obstruction Surgical Procedure
Foreign bodies .e.g hair or gallstones Laparotomy: Removal of foreign bodies
Adhesions IV rehydration n nasogastric
decompression, if failed go for
Laparotomy: Lyse the adhesions
Hernia Laparotomy: Removal of the gangrenous
part and herniorraphy
Disseminated Intraperitoneal Ca that
obstruct small bowel
Bypass the obstruction through
laparomoty of endoscopy, to relieve
symptoms
40. Large Bowel
Causes of obstruction Surgical Procedure
Diverticulitis Laparotomy: Diverticulectomy
Colon Ca Laparotomy: Single stage resection n
anastomosis
Cecal Valvulus Surgical resection and anostomosis/
Cecotomy to recorrect the cecal position
Sigmoid valvulus Decompression by rectal tube followed by
resection of valvulus as it has high recurrence
rate
Fecal impaction Removal of feces by digit (if it is in rectum)
Laparotomy if it is complete obstruction
41. Adynamic Obstruction
Paralytic Ileus
Principles of Management
› Primary cause must be removed (infection,
uremia, hypokalemia)
› GI distension must be relieved by decompression
› Maintain fluid n electrolyte balance
› If resistant, use neostigmine (cholinergic
stimulation)
› If prolong n life threatening, use laparotomy to
decompress n fine hidden causes
42. Pseudo-obstruction
Small intestine pseudo-obstruction
› Treat underlying causes
› Use metoclopramide n erythromycin
Colonic PO
› Colonic decompression or flatus tube
Acute messenteric ischemia
› Early phase
Embolectomy via ileocolic artery
Revascularization of Sup. Messenteric Art.
› Late phase
Surgical resection of affected bowel
