29 MEI 2007

Obstructive jaundice
Septa Ekanita
PPDS PULMONOLOGI & ILMU KEDOKTERAN
RESPIRASI
FKUI- RS PERSAHABATAN
JAKARTA

Pendahuluan

Obsructive jaundice merupakan sekumpulan

penyakit yang mengakibatkan tersumbatnya
saluran empedu

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

Aetiology of obstructive jaundice

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

Complications of obstructive jaundice

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

Seorang laki-laki, 52 tahun, menikah, TNI

AD, masuk RSPAD GS tgl 28/4/2007
pk.12:00 wib dengan keluhan utama : kulit
kuning
Riwayat penyakit sekarang;
Sejak

1 bulan SMRS kedua mata kuning dan

seluruh tubuh disertai sakit dada yang tidak
menjalar, mual dan muntah serta nafsu
makan berkurang
Bab seperti dempul, bak kuning tua seperti
teh.
Kebiasaan : merokok 2 bungkus (24 btg)/ hr
Pasien kiriman dari RS di Padang dan
dirawat 1 minggu.

Riwayat penyakit dahulu : tidak ada

Riwayat kronik : tidak ada
Lab: HbsAg (-), Anti HbsAg (-), Bil Tot 17,73
(direk 10,23, indirect 750)
Hasil USG tgl 24/4/2007(Padang)
Kesan

: cholectasis intra dan ekstra hepatal

dengan hepar, lien, pankreas,ginjal, kandung
empedu normal

Terapi yang diberikan sebelumnya:

Urdafalk

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:

Tampak sakit sedang,

komposmentis,
Td 110/70 mmHg, N 86 x/mnt, FN 20
x/mnt, suhu 36,4C

Keadaan khusus:

Kepala:
- mata kuning tua seperti kunyit
- THT : dbn

Leher : JVP 5 -2 cm Hg, KGB (-)

Toraks :

Bunyi

jantung I dan II normal, gallop (-),

murmur (-)

Abdomen : datar lemas, hepar dan lien

tidak teraba, turgor baik
Ekstremiti : kuning, refleks fisiologi
normal, tidak kering

Diagnosis masuk

Obstructive jaundice e.c cholestasis

intra & extra hepatic

Rencana diagnostik:
DL,UL,

toraks,

SMA-2, LFT, HbsAg, EKG, foto

Therapy

Instruksi Dr. Ruswandhi Sp.PD

IVFD

Aminofusin : dextrose 10 % :
Asering 1:1:1
Diet hati III
Obat dari RS Padang diteruskan

Daftar masalah
Obstructive jaundice ec. ?
Hiperlipidemia

Therapy yang berikan

IVFD aminofel : D10%: Nacl 0,9% :1;1;1

8 jam / kolf
Inj. Cefotaxim 2 x 1 gr / hari 7 hari
Metronidazole 3 x 500 mg drip / hari 14 hr
Curcuma 3 x 1 tab
Urdafalk 3 x 1 tab
Methioson 3 x 1 tab
Simvastatin 1 x 20 mg / hari
Gemfibrozil 1 x 600 mg / hari

Hasil CT scan abdomen

1/5/2007

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

Hasil MRI tgl 14/05/2007

Sludge yang mengeras / calcified disertai

inflamasi perifokal ukuran 2,1 x 3 cm dalam
lumen kandung empedu, duktus sistikus serta
duktus hepatikus komunis, mengakibatkan
dilatasi duktus hepatikus kanan-kiri
Lumen CBD dan duktus pankreatikus normal
Hepatomegali ringan
Limfa, pankreas,kel.supra renal dan ke 2 ginjal
normal
Tidak tampak massa tumor pada kaput
pankreas

Hasil MRCP tgl 14/05/2007

Kandung empedu kaliber mengecil tampak

lesi lamellar ukuran 2,1 x 3 cm mengikuti
kontur kandung empedu, duktus sistikus
serta duktus hepatikus komunis
Tampak dilatasi suktus hepatikus kanan dan
kiri
Kaliber serta lumen duktus kholedukus
serta duktus pankreatikus normal

Endoskopi tgl 28/05/2007

Esofagoskopi : lumen terbuka, mukosa
normal, Z line utuh, varices (-)
Gastroskopi : lumen terbuka, mukosa
edema, hiperemis, hematin(+), massa pada
corpus curvatura minor, rapuh, mudah
berdarah, permukaan kasar, ukuran
diameter 5 cm
Duodenoskopi : lumen terbuka, mukosa
normal. Papilla vateri sulit di nilai
Kesan : Massa pada gaster corpus curvatura
minor, sedang, berdarah tunggu hasil PA

Algorithmic approach to the evaluation of

patients with jaundice

Singapore Med J 2007; 48 (4) : 364

Algorithm for the Investigation of Obstructive Jaundice

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

Endoscopic retrograde cholangiogram

(ERCP)

Allows biopsy or brush cytology

Stone extraction or stenting

Percutaneous transhepatic cholangiogram

(PTC)

Rarely required today

Performed with 22G Chiba Needle
Also allows biliary drainage and
stenting

Treatment Overview of Common bile duct stone

If the patient has Cholangitis - Analgesia (narcotics)

and IV antibiotics (amoxycillin, metronidazole and
gentamicin) are given.
If the obstruction needs to be relieved, this can
be done using:
- ERCP (Endoscopic Retrograde
Cholangiopancreato graphy) is performed to cut the
sphincter connecting the common bile duct to the
duedenum, to allow the stone to pass into the
intestine relieving the obstuction. If there is any
suspicious pathology this may be biopsied.
- A cholecystectomy may be indicated at the same
time or a later date.
http://www.virtualrheumatologycentre.com/diseases.asp?did=191

Enterohepatic circulation of bile salt. Each

molecule circulates at least once for each meal.

BMJ 2001;323;1170-1173

CHOLANGIOCARCINOMA
DEFINITION

Cholangiocarcinoma is an adenocarcinoma
of the intrahepatic or extrahepatic bile duct.

PREVALENCE

There are 2,000 to 3,000 new cases of

cholangiocarcinoma per year in the United
States, accounting for 10% to 15% of all
primary hepatobiliary malignancies.It is
most common in middle-aged men.
http://www.elevelandclinicmeded.com/

PATHOPHYSIOLOGY

Primary sclerosing cholangitis (PSC) is a major risk

factor for the development of cholangiocarcinoma. In
a large Swedish study, 8% of patients with PSC
developed cholangiocarcinoma over a mean followup period of 5 years.This study might underestimate
the true incidence of PSC-associated
cholangiocarcinoma. Other diseases associated with
the development of cholangiocarcinoma include
choledochal cysts and infection with liver flukes
including Clonorchis sinensis, Opisthorchis felineus,
and Opisthorchis viverrini.

http://www.elevelandclinicmeded.com/

SIGNS AND SYMPTOMS

Patients typically present with jaundice and pruritus and
more generalized symptoms such as weight loss,
anorexia, and fatigue. Cholangiocarcinoma should always
be suspected in a previously stable patient with PSC who
has a rapid clinical decline.
DIAGNOSIS
Initial diagnostic testing for cholangiocarcinoma is similar to
that used for other causes of cholestasis. Ultrasound
examination or CT scanning may reveal areas of focal
biliary dilatation. Direct cholangiography with ERC or
percutaneous transhepatic cholangiography with brush
cytology of the biliary tree can be useful for diagnosis
although the sensitivity for detecting malignancy with
brush cytology is less than 75%.
Blood testing for cancer antigens, particularly CA19-9, has
been shown to be useful in detecting
cholangiocarcinoma, as has an index using CA19-9 and
CEA. Neither method is highly sensitive or specific but
can help confirm suspected cholangiocarcinoma.
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

Mirizzi's syndrome is caused by an impacted cystic

duct stone leading to gallbladder distention and
subsequent compression of the extrahepatic biliary
tree. Occasionally the gallstone erodes into the
common hepatic duct producing a
cholecystocholedochal fistula. The original
classification of Mirizzi's syndrome has been expanded
to include hepatic duct stenosis caused by a stone at
the junction of the cystic and hepatic ducts or as a
result of cholecystitis even in the absence of a
obstructing cystic duct stone.
Patients present with jaundice, right upper quadrant
pain and fever. Ultrasound or CT scan reveals biliary
dilatation above the cystic duct. ERC may reveal the
obstructing stone, which can occasionally be removed,
but the definitive treatment is usually surgical,
consisting of cholecystectomy with surgical repair of
the bile duct if necessary.
http://www.elevelandclinicmeded.com/

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