Acholic, congestive, obstructive or obstructive jaundice, extrahepatic cholestasis - all this is the name of the same disease caused by mechanical obstruction of the bile ducts, which results in the reflux of bile into the bloodstream.
The bilirubin contained in it negatively affects the nervous system, circulatory system and heart, and damages the kidneys. That is why obstructive jaundice cannot be regarded as a condition that only affects the appearance of the skin and mucous membranes. It may conceal serious diseases of the liver, gallbladder and bile ducts that require urgent treatment.
Screening
Multifactorial analysis of clinical, laboratory and instrumental data allowed us to identify several indicators that allow us to reasonably suspect the presence of choledocholithiasis and continue to search for it using invasive research methods. These include dilation of the extrahepatic bile ducts (more than 8 mm) according to ultrasound, clinical signs of cholangitis, increased levels of aminotransferases and direct fraction of bilirubin in the blood serum, small stones in the gall bladder (less than 5 mm). It is also recommended to evaluate anamnestic data (the presence of episodes of jaundice, exacerbations of chronic cholecystitis or pancreatitis).
Prevention
Obstructive jaundice can affect any organism. However, there are a number of factors that can trigger its appearance. In this regard, it is recommended to follow simple preventive measures.
These include:
- timely detection and competent treatment of gallbladder diseases, as well as any malfunctions in the functioning of the hepatobiliary system;
- maintaining a healthy diet that excludes the consumption of fatty, fried, and excessively sweet foods;
- giving up alcohol;
- moderate physical activity;
- body weight regulation.
Classification
Causes of obstruction of the biliary tract:
- Benign diseases (80%): - choledocholithiasis; - cholangitis; - stenosis of the major duodenal papilla; - acute papillitis; - polyps of the large duodenal papilla; - pancreatitis; — cicatricial stricture of the main bile ducts; - peripapillary diverticula; - rare causes (congenital anomalies of the bile ducts, pericholedocheal lymphadenitis, parasitic lesions, etc.).
- Malignant neoplasms (20%): - pancreas; - large duodenal papilla; - bile ducts; - liver (primary or metastatic lesion).
The nature of the course of jaundice:
- full,
- incomplete,
- intermittent.
Severity of liver failure:
- light,
- average,
- heavy.
Forecast
A favorable outcome guarantees compliance with the sequence of treatment stages if they are successfully implemented. Full recovery does not always occur, as it is associated with chronic diseases and impaired salt metabolism, which changes the structure of bile, increasing its lithogenicity.
Obstructive jaundice due to cancer has a poor prognosis because the tumor is difficult to completely remove. In addition, it is difficult to eliminate cholestasis, which forces patients to operate, despite the likelihood of complications.
Etiology
Obstruction of the bile ducts, leading to obstructive jaundice, can occur against the background of benign diseases (in 80% of cases) and some malignant neoplasms (20%). The most common cause of obstructive jaundice is choledocholithiasis, less often - “benign” jaundice, which can be caused by stenosis of the large duodenal papilla, its polyps and papillitis, cholangitis, acute and chronic pancreatitis, cicatricial stricture of the bile ducts, parapapillary diverticula of the duodenum and other rare causes ( congenital anomalies of the bile ducts, pericholedocheal lymphadenitis, parasitic lesions, etc.). “Malignant” obstructive jaundice can occur with cancer of the head of the pancreas, large duodenal papilla, bile ducts, primary or metastatic liver cancer.
Other types of surgical treatment
Direct surgical interventions allow you to create full access to the gallbladder and eliminate obstructive jaundice of any complexity. The surgeon can perform anastomoses, install stents, and perform reconstructive operations. The intervention can be performed using laparoscopic instruments or the classic open cavity method. The latter option is the most traumatic, requires long-term rehabilitation and is accompanied by an increased risk of complications, so it is used only in the treatment of complex cases of obstructive jaundice.
General principles of treatment of obstructive jaundice
Generally speaking, the treatment tactics for obstructive jaundice include two stages. At the first stage, conservative therapy and minimally invasive methods of surgical treatment are prescribed. It is recommended to carry out such treatment in the first 2-3 days from the moment the patient is admitted to the hospital. If these methods are ineffective, then move on to the second stage of treatment of obstructive jaundice, which involves more radical methods. Treatment at the peak of jaundice is associated with a high risk of developing postoperative complications, so it is carried out only if there are vital indications.
Other treatments
Effective treatment of jaundice involves eliminating the underlying disease that led to the development of this symptom. To do this, it is necessary to use either conservative or surgical methods. Other treatment options for obstructive jaundice, in particular traditional medicine, home treatment and self-medication will not help achieve the desired result. For a certain period of time, they will help hide the symptoms and alleviate the patient’s condition, but the main process will continue to progress and lead to the development of complications. Therefore, when the first signs of obstructive jaundice appear, it is necessary to seek qualified medical help, which will help radically solve the problem.
Pathogenesis
Under physiological conditions, the liver secretes up to 250 mg of the bile pigment bilirubin into the bile during the day. It is formed in the cells of the reticuloendothelial system from the released hemoglobin of mature red blood cells. The scheme of biochemical transformations of bilirubin is presented in Fig. . Biochemical transformations of bilirubin (scheme). When the level of bilirubin in the blood serum increases to more than 40 µmol/l, the sclera, mucous membranes and skin become icteric. Bilirubin penetrates almost all fluids and white parts of the body tissues, causing yellow coloration of exudates and transudates, secretions of various glands (pancreas, salivary, sweat, etc.). In patients with anemia and fair skin, jaundice is detected earlier, while in dark-skinned patients it goes undetected longer. Obstructive jaundice syndrome should be considered as a complex pathophysiological complex, manifested by signs of damage to all organs and systems, mainly the liver and kidneys. With obstruction of the biliary tract, as the duration and intensity of jaundice increases, all homeostasis systems undergo increasing pathological changes. In extrahepatic cholestasis, direct bilirubin returns to the blood and lymph from the small intrahepatic bile ducts. As cholestasis progresses, a change in the polarity of hepatocytes occurs, as a result of which the complex of bilirubin with glucuronic acid begins to be excreted through the blood vessels, which leads to an increase in the content of direct bilirubin in the blood. As pressure increases in the bile capillaries, microcirculation and blood supply to liver cells are disrupted, and the membranes of the bile ducts and hepatocytes are damaged. Thus, there is a progressive disruption of the synthetic and metabolic functions of the liver and, as a consequence, the composition of the plasma and the rheological properties of the blood. The severity of clinical manifestations in patients with obstructive jaundice is determined by profound disorders of the liver, kidneys, cardiovascular and nervous systems, as well as disorders of the blood coagulation system and metabolism. Jaundice is a leading symptom only in the initial stages of the disease, reflecting the resulting disturbances in the outflow of the biliary tract. As the intensity of jaundice increases and its duration increases, functional and morphological changes in all body systems gradually intensify. At a certain stage of development, jaundice ceases to be only a symptom; it becomes an independent leading factor, which has its own pathophysiological and clinical characteristics and determines the severity of the patient’s condition and the prognosis of the disease. The duration of obstructive jaundice and its intensity largely determine the development of liver failure and deaths (including postoperative ones). The accumulation of toxic metabolic products in the blood serum (bilirubin, bile acids, ammonia, etc.) leads to endotoxemia, the severity of which is associated with the duration of the disease, therefore early diagnosis of the cause of jaundice and decompression of the bile ducts largely determine the outcome of the disease.
“Physiological jaundice” of newborns
Physiological jaundice occurs in approximately 60% of newborns.
The reason for the increase in bilirubin in the blood of newborns is accelerated hemolysis (decomposition) of red blood cells due to the functional “immaturity” of the liver in the first days of life. Physiological jaundice is a transient condition, appears, as a rule, on the third day, gradually intensifies by the fifth, and slowly disappears by 2-3 weeks of the child’s life.
Increased bilirubin in newborns and “physiological” jaundice are in most cases safe, do not require treatment and do not leave consequences for the child.
Clinical picture
Clinical symptoms that are considered typical manifestations of jaundice are presented in Fig. 45-2. The clinical picture depends on the severity, duration and nature of jaundice.
Clinical manifestations of obstructive jaundice. Obstructive jaundice, caused by choledocholithiasis (up to 80% of cases), appears several hours or days after a severe attack of pain in the abdomen. Characterized by rapid progression. The development of jaundice is accompanied by skin itching. Scratching occurs predominantly on the anterior abdominal wall and extensor surfaces of the limbs. Patients pay attention to darkening of urine and the appearance of discolored feces. Obstructive jaundice caused by a tumor of the head of the pancreas or the major duodenal papilla is characterized by the absence of pain and the gradual development of the disease. Courvoisier syndrome is considered pathognomonic, which manifests itself as a palpable enlarged, painless gallbladder against the background of jaundice.
Diet
To get the maximum effect from the operation and not provoke a relapse, the patient must follow a diet before and after the intervention. It is also important to maintain a drinking regime: at least 2 liters of clean water are recommended per day. This rule allows you to quickly remove toxic bilirubin from the body and reduce its effect on other organs.
The diet includes:
- sweetened tea, compote, diluted glucose solution;
- vegetable soups;
- viscous porridge with milk;
- low-fat varieties of fish and meat, steamed or boiled;
- You can gradually introduce white bread (day-old or fresh dried), and butter in small quantities.
All dishes must be served at room temperature.
Diagnostics
The diagnostic search for obstructive jaundice consists of confirming its obstructive nature and determining the immediate cause of obstruction of the biliary tract. At the outpatient stage, up to 20% of diagnostic errors occur, leading to hospitalization of patients in non-core medical institutions. Patients with obstructive jaundice are often initially hospitalized in infectious diseases departments; somewhat less often, patients with hepatitis of various natures or other types of jaundice of non-surgical origin are admitted to surgical hospitals. In both cases, erroneous hospitalization has negative consequences associated with the choice of incorrect management tactics, violations of the anti-epidemic regime, delays in performing bile duct decompression, etc.
Treatment of obstructive jaundice
The decision on how to treat obstructive jaundice depends on the causes of its occurrence and the severity of the symptoms. At the initial stage, therapy consists of procedures aimed at eliminating cholestasis using minimally invasive methods. Also at this stage, treatment with medications (conservative therapy) is practiced in intensive care conditions.
It includes the use of:
- infusions of saline solutions, glucose with insulin, protein drugs, blood substitutes, etc.;
- vitamins and amino acids;
- metabolism stimulants;
- hormonal drugs;
- gastric secretion blockers;
- antacids and coating drugs.
If there are signs of intoxication of the body, extracorporeal detoxification (hemosorption, plasmaphoresis, hemodialysis) is prescribed.
To prevent the development of infectious and inflammatory complications, treatment with broad-spectrum antibiotics that can penetrate the bile is prescribed. The list of drugs used to treat obstructive jaundice is determined on an individual basis. Only after this is surgical or minimally invasive intervention performed:
- lithoextraction;
- bougienage and drainage of ducts;
- therapeutic ERCP (endoscopic retrograde cholangiopancreatography), combined with endoscopic papillosphincterometry;
- percutaneous transhepatic cholangiostomy;
- bile duct stenting;
- laparoscopic choledochotomy according to Kocher, Kerta, Vishnevsky or other methods;
- resection of organs affected by the tumor (for oncological diseases accompanied by obstructive jaundice).
All patients, without exception, are prescribed a diet corresponding to table No. 5a (according to Povzner). The menu includes pureed dishes from boiled cereals and vegetables, dairy products, fruits and berries, and plenty of drink. It is recommended to eat frequently, servings no more than 200 ml.
Possible complications
If you seek medical help in a timely manner, the prognosis for recovery is favorable. However, with prolonged poisoning of the body with bilirubin, damage to the liver, kidneys, heart, blood vessels, central nervous system, and blood coagulation system is possible. If medical recommendations are not followed, complications can arise in any of the listed organ systems.
In the area of the outbreak itself, irreversible processes in the tissue of the liver and pancreas can occur. Gallstone disease tends to recur, so it is especially important to follow the diet prescribed by your doctor.
Why is it necessary to consult a doctor at the first symptoms?
Pain and other signs of illness in the liver area cannot be ignored, especially if there have already been operations in the anamnesis. By self-medicating, we only remove symptoms and waste time. So, in the case of tumors, at an early stage they can be removed and treated. Stones blocking the gap increase in size over time and become more difficult to remove. Timely detection of the cause is 50% of successful treatment.
If the skin and sclera turn yellow, emergency medical attention is needed. Failure to see a doctor promptly can lead to death.
