Mechanical jaundice is a clinical syndrome that develops as a result of a violation of the outflow of bile along the biliary tract into the duodenum and manifested by jaundice staining of the skin and mucous membranes, pain in the right hypochondrium, dark urine, acholical feces, and an increase in bilirubin concentration in the blood serum.
The main method of treatment of obstructive jaundice is surgery, the purpose of which is to restore the flow of bile into the duodenum.
Most often, obstructive jaundice develops as a complication of gallstone disease, but may be due to other pathologies of the digestive tract. If untimely medical care is provided, this condition can provoke the development of liver failure and result in a fatal outcome.
Symptoms and diagnosis
Subhepatic jaundice is caused by several causes. Depending on them, the following symptoms are distinguished.
In gallstone disease, patients feel the pain of paroxysmal in the area of the liver. The pain is felt in the right shoulder blade, arm and shoulder. The mucous membranes and skin become yellow after several attacks.
In oncology, pain is localized in the hypochondrium long before the appearance of yellow color on the skin and mucous membranes. The pain is constant, unexpressed.
When mechanical jaundice develops favorably, the symptoms of which are characterized by loss of appetite, gagging, manifestations quickly pass, and then yellowing appears. In cancer, a person suffers for a long time from the previously listed symptoms.
If a person is diagnosed with a cancer of the liver, as well as cancer of the pancreatic head and biliary tract, the patient quickly loses weight. For the favorable course of jaundice is uncharacteristic. For both cases, hyperthermia occurs.
However, for a number of specific signs, you can determine the specific cause of jaundice.
In cancer of the head of the pancreas, pain is felt in the upper abdomen. Human skin in a short period of time becomes gray-yellow or olive. The person complains of an itch of integuments. Metastases grow in the liver, an uneven structure is diagnosed. Blood tests determine anemia, increased white blood cell count and ESR. According to the results of ultrasound and MRI specialist diagnoses an increase in the pancreatic head.
Further radioactive scanning of the body is carried out in order to identify the lesion. The most effective method is retrograde cholangiopancreatography. A special contrast is introduced into the duct of the gland by means of a catheter, which flows through the ducts, and then an x-ray is taken. The pathology of biliary excretion in cancer of the head of the gland is partially not filled.
Malignant tumor of the nipple Vater. The severity of jaundice varies. A person feels pain in the upper abdomen. The palpation of the liver area reveals an increase in the main gland of the body and gallbladder. Chances of intestinal bleeding. X-ray of the duodenum reveals a modification of the walls. Duodenoscopy is designed to sample tissues of the Vater nipple, which allows to confirm the diagnosis.
Cancer of the gallbladder. There are no symptoms at the onset of the disease. Over time, the person feels bitterness in the oral cavity, as well as pain in the area of the organ. The doctor gropes. To confirm the diagnosis prescribed ultrasound, MRI of the gallbladder.
Liver cancer. Itching of the skin, a sharp decrease in weight, constant fever - the characteristic signs of obstructive jaundice. The liver is enlarged, high organ density is noted. As a result, the size of the peritoneum grows in size. Cases of critical hypoglycemia (low blood glucose, ending in a coma) are characteristic of oncology. In the analyzes, the level of hemoglobin and erythrocytes is reduced, leukocytes are increased and high ESR is increased. Mechanical jaundice in liver cancer is characterized by high levels of bilirubin, alkaline phosphatase, and specific acids. Cancer leads to the production of a-fetoprotein. Diagnosis is based on the results of ultrasound, radioisotope scanning and magnetic resonance imaging.
If jaundice caused by mechanical obstructions has a non-oncological cause, then ultrasound of the gallbladder and ducts is prescribed. The presence of parasites is detected by scanning radioisotopes.
Obviously, treatment of obstructive jaundice will succeed only in getting rid of the underlying causes, if possible. The patient is determined in the hospital. For parasitic diseases and pseudotumor pancreatitis, the patient is prescribed drugs against parasites and inflammation. Infusions with intoxication solution are carried out, and also polyenzymes are appointed.
When obstructive jaundice is manifested, treatment occurs through surgery. Among them:
- Drainage of the biliary tract: minor surgery, in which the outflow of bile is restored by expanding the ducts and sphincters.
- Holitsectomy: elimination of the gallbladder through laparoscopy.
- Papillosphincterotomy: removal of stones from the bladder.
- Hepatectomy: prompt removal of the liver from sites with metastases.
- Choledosolithotomy: removal of the gallbladder with the opening of the walls of the main duct to eliminate stones from it.
- Endoprosthetics of the biliary tract: pre-removal of stones. This method is prescribed for scarring of the paths.
If a person is diagnosed with oncology of the pancreatic head or Vater's nipple, he is prescribed Whipple surgery. The surgeon removes the organ head, common duct, part of the small intestine and stomach. Cancer of the gallbladder becomes an indication for the removal of gallbladder, as well as lymph nodes located nearby. At the same time, chemotherapy and radiation therapy are carried out.
Jaundice is treated with a special diet. Immediately after the operation, you can only drink (sweetened tea, non-carbonated water, compote). Then dietary soups and porridges are introduced into food. Of the products it is permissible to use low-fat varieties of fish and meat, steamed, without oil. Before eating, food should be skipped in a meat grinder.
Prognosis of obstructive jaundice
How dangerous is jaundice? The prediction of quality and longevity depends on the underlying causes of the disease. Even with a non-malignant course of jaundice, a bad outcome occurs, especially if the patient turns too late. In this case, an increased level of toxic bilirubin in the blood is fatal. In cancer, the disease has an unfavorable prognosis. Therapy in this case helps only to improve the patient’s condition for a short time.
Diagnosis of obstructive jaundice
Symptoms are many diseases that make it difficult to recognize the syndrome. Laboratory cholestasis is not suitable for early detection of cholestasis, since an increase in the activity of alkaline phosphatase, cholesterol, and bilirubin is also characteristic of viral hepatitis. Reliably diagnose obstructive jaundice will help instrumental methods of research:
- ultrasound diagnostics,
- relaxation duodenography
- endoscopic retrograde cholangiopancreatography (RCP),
- percutaneous transhepatic cholangiography,
- radioisotope liver scan,
- laparoscopy with the study of tissues: for example, liver microscopic preparations are distinguished by the accumulation of bile of a yellowish-brown hue in both the bile capillaries and the cytoplasm.
Drainage of the gallbladder with obstructive jaundice
Transhepatic percutaneous drainage (HDP) contributes to the flow of bile. External drainage directs the discharge of bile through the catheter into the digestive system so that the loss does not lead to indigestion. Drainage of the gallbladder with obstructive jaundice (external-internal) requires the installation of a catheter outside. When the swelling in the constriction decreases, it is carried out in the duodenum, and the bile is sent to the gastrointestinal tract. Percutaneous arthroplasty: Doctors insert a plastic prosthesis that replaces part of the wall.
Diet for obstructive jaundice
Nutrition eliminates the extra burden on the cells of the liver parenchyma. Diet for obstructive jaundice should include: rich drinks, carbohydrate-rich foods, low-fat dairy products, yesterday's or dried bread, fruits, vegetables, cooked meats and steamed fish. All products and food should be at room temperature, boiled and rubbed. For admission of fat, you can use a small amount of butter and vegetable oil.
Causes of obstructive jaundice
The direct cause of obstructive jaundice is obstruction of the biliary tract. It may be partial or complete, which determines the severity of the clinical manifestations of the syndrome.
Obstructive jaundice can result from the following diseases:
- biliary tract cysts,
- strictures or scars of the bile ducts,
- hepatitis, cirrhosis of the liver,
- tumors of the liver, duodenum, stomach or pancreas,
- parasitic invasions,
- mirizzi syndrome,
- enlarged lymph nodes located in the portal fissure,
- surgery on the biliary tract.
The pathological mechanism of the development of obstructive jaundice is complicated. It is based in most cases the inflammatory process that affects the biliary tract. Against the background of inflammation, edema and thickening of the mucous membrane of the ducts occur, which leads to a decrease in their clearance. By itself, this process violates the passage of bile. If at this moment even a small calculus gets into the duct, the outflow of bile along it may completely stop. Accumulating and stagnating in the biliary tract, bile contributes to their expansion, destruction of hepatocytes, entry of bilirubin and bile acids into the systemic circulation. Bilirubin from the bile duct penetrating the blood is not associated with proteins - this explains its high toxicity to the cells and tissues of the body.
The patient is recommended to drink at least two liters of fluid per day, this contributes to the rapid removal of bilirubin, thereby reducing its negative impact on the central nervous system, kidneys, and lungs.
Cessation of bile acids in the intestine violates the absorption of fats and fat-soluble vitamins (K, D, A, E). As a result, the blood clotting process is disturbed, hypoprothrombinemia develops.
Prolonged stagnation of bile in the intrahepatic ducts contributes to a pronounced destruction of hepatocytes, gradually leading to the formation of liver failure.
Factors that increase the risk of obstructive jaundice are:
- sharp weight loss or, on the contrary, obesity,
- infections of the liver and pancreas,
- surgery on the liver and biliary tract,
- injuries of the right upper quadrant of the abdomen.
Symptoms of obstructive jaundice
Acute onset is rare, most often the clinical picture develops gradually. Symptoms of obstructive jaundice are usually preceded by inflammation of the biliary tract, symptoms of which are:
Later appears icteric staining of the skin and mucous membranes, which increases with time. As a result, the skin of the patient acquire a yellowish-greenish color. Other signs of obstructive jaundice are dark urine staining, discoloration of feces, and itchy skin.
If the patient is not provided with medical assistance, then on the background of the massive death of hepatocytes, the liver functions are disturbed, and liver failure develops. Clinically, it presents with the following symptoms:
- increased fatigue
- coagulopathic bleeding.
As the liver failure progresses, the patient's brain, kidney, heart, and lungs are impaired, that is, multiple organ failure develops, which is an adverse prognostic sign.
Most often, obstructive jaundice develops as a complication of gallstone disease, but may be due to other pathologies of the digestive tract.
Treatment of obstructive jaundice
The main method of treatment of obstructive jaundice is surgery, the purpose of which is to restore the flow of bile into the duodenum. In order to stabilize the patient’s condition, detoxification, infusion and antibacterial therapy is carried out. To temporarily improve the flow of bile, the following methods are used:
- choledochostomy - the creation of drainage by imposing external fistula on the bile duct,
- cholecystostomy - the formation of external fistula of the gallbladder,
- percutaneous puncture of the gallbladder,
- nasobiliary drainage (installation of a catheter in the biliary tract during retrograde cholangiopancreatography).
If, despite the attempted treatment of obstructive jaundice, the patient’s condition does not improve, percutaneous transhepatic drainage of the bile ducts is indicated.
After stabilization of the patient’s condition, the next stage of treatment of obstructive jaundice is resolved. Endoscopy is preferred because they are less traumatic. In case of tumor strictures and cicatricial stenosis, the biliary ducts are dilated, followed by the installation of stents into their lumen, that is, endoscopic stenting of the choledochus is performed. When the sphincter Oddi stone is blocked, endoscopic balloon dilatation is resorted to.
In cases where endoscopic methods fail to eliminate the obstacle to the outflow of bile, resort to the traditional open abdominal surgery. In the postoperative period to prevent leakage into the abdominal cavity of bile through the sutures perform external drainage of the bile ducts along the Halstead (installation in the stump of the cystic duct of a PVC catheter) or external drainage of the biliary tract along the Keru (installation of a special T-shaped tube in them).
If the patient is not provided with medical assistance, then on the background of the massive death of hepatocytes, the liver functions are disturbed, and liver failure develops.
Prevention of obstructive jaundice includes the following areas:
- timely detection and active treatment of cholelithiasis, chronic infections of the hepatobiliary system,
- proper nutrition (restriction of fried, fatty and rich in extractive substances food, adherence to diet),
- refusal to abuse alcohol,
- active lifestyle
- normalization of body weight.
Other signs of obstructive jaundice are dark urine staining, discoloration of feces, and itchy skin.
With timely start of therapy, the prognosis is favorable. It worsens in case of compression of the bile duct by a malignant tumor. If the patient is not promptly treated with surgical treatment, serious complications develop:
- cirrhosis of the liver,
- bilirubin encephalopathy,
- acute (with complete obstruction of the bile duct) or chronic (with partial obstruction) liver failure.
Causes of jaundice: why bile stagnation occurs
In the body, bile is produced continuously, but in the duodenum, it is discharged in portions, most often during a meal. Obstructive jaundice occurs in the event that such an outflow is difficult or stops completely. As a result, bile accumulates in the gallbladder, enters the liver and leads to serious disorders in the body and throughout the body.
The main causes of jaundice in this case are associated with obstruction of the biliary tract. Most often, the blockage is triggered by tumors in neighboring organs - tumors put pressure on the ducts and narrow their lumen. This diagnosis occurs mainly in patients older than 40-45 years. But at a young age, cholelithiasis becomes the cause of jaundice of this type, namely the movement of a calculus (stone), which is stuck in the duct. An important factor in both cases is the inflammation of the biliary tract, since the swelling increases their obstruction.
Other causes of jaundice are less common, but sometimes the following pathologies cause duct overlap:
- Congenital anomalies, in particular stenosis of the biliary tract.
- Complications after surgery - scars, structures.
- Hepatitis, cirrhosis.
- Helminthiasis in the liver and ducts, often with the formation of cysts.
Diagnosis of jaundice and its causes
If the patient has a history of internal organ tumors or cholelithiasis, it is easy to make a preliminary diagnosis. At the same time, it is quite difficult to determine mechanical jaundice by analysis, since their results are similar to other lesions of the liver, including viral hepatitis. For example, a blood test for bilirubin is taken mainly to determine the severity of the condition.
The key diagnostic methods are hardware examinations, primarily, ultrasound diagnostics. On ultrasound, the doctor can detect tumors, calculi, assess liver damage, the condition of the ducts and gall bladder. Additional diagnostics include the following methods:
- Endoscopic retrograde cholangiopancreatography (rCPG) - X-ray with a contrast agent.
- Percutaneous transhepatic cholangiography. Also involves the use of a contrast agent, but in this case it is inserted through the skin with a needle.
- Laparoscopy. During the diagnostic operation can be treated. For example, the removal of stones.
Surgical treatment: laparoscopy and other methods
Only in rare cases to get rid of bile duct obstruction can be conservative methods, most patients undergo surgery. Depending on the cause of jaundice and the stage of obstruction, various operations may be prescribed. The main one is endoscopic papillosphincterotomy, during which stones, cysts and neoplasms blocking the canal can be removed. In case of complicated course, such interventions may be required:
- Removal of the gallbladder (cholecystectomy) is performed if the ducts cannot be unblocked, and the organ has already suffered.
- Removal of pathologically changed liver fragments (hepatectomy), if the organ is already affected.
- Drainage of the bile ducts (choledochostomy, cholecystostomy). If it is impossible to unblock ducts, the flow of bile is provided through the external fistula.
These methods are minimally invasive, that is, operations are performed laparoscopically - through small incisions or punctures in the abdominal wall. However, when this method of removing the cause of obstructive jaundice fails, the patient is prescribed a traditional open surgery.
Complications of violations of the outflow of bile
Although mechanical jaundice is only a consequence of other diseases, stagnation of bile can lead to very dangerous complications. First of all, we are talking about liver tissue damage, destruction of hepatocyte cells. This gradually leads to liver failure and, without treatment, can completely destroy the liver.
The consequence of even a partial lesion may be cirrhosis - the replacement of parenchymal tissue with fibrous (connective) tissue. Liver failure affects the general condition of the body, so the kidneys, heart, lungs, brain, in particular, bilirubin encephalopathy develops on the background of jaundice. Since the liver is responsible for filtering the blood, if the organ functions poorly, the likelihood of sepsis increases - a generalized inflammatory process.
The prognosis also depends on the primary cause of the obstruction. So, with stones in the gallbladder, cholecystitis and pancreatitis, it is favorable. But the presence of malignant tumors, especially in the liver, is prognostically unfavorable factor.
You also need to know that more dangerous for a long period of obstructive jaundice, in which there is an incomplete blockage of the biliary tract. In this case, the symptoms increase gradually, so a person may postpone a visit to the doctor.
What is obstructive jaundice?
Mechanical jaundice is a pathological syndrome consisting in the violation of the outflow of hepatic bile along the biliary tract into the duodenum due to mechanical obstructions.
Synonyms of the disease: obstructive jaundice, subhepatic jaundice, acholic jaundice, resorption jaundice, extrahepatic cholestasis.
Mechanical obstruction of the biliary tract develops as a complication of a large group of diseases of the pancreas and biliary system (bile duct and sphincter systems that regulate the flow of bile) and is accompanied by such common symptoms as icteric staining of the skin, mucous membranes and sclera, darkening of the urine, discoloration of feces, skin itching, abdominal pain.
As a consequence of progressive jaundice, liver failure, renal failure, purulent cholangitis, sepsis, biliary cirrhosis or cholangitic abscess of the liver can be fatal, and in severe cases it can be fatal.
Among the most common causes of obstructive jaundice are gallstone disease (29% of cases) and malignant tumors (67% of cases). At the age of 30, cholelithiasis prevails, in the age group of 30-40 years tumors and cholelithiasis as causes of jaundice occur equally often. Patients older than 40 are dominated by tumor neoplasms.
In general, obstructive jaundice is more often diagnosed in women (82%). However, tumor obstruction of the biliary tract is more common in men (54%).
Causes of obstructive jaundice
To date, the causes of obstructive jaundice due to compression of the biliary tract are well studied.
Depending on the etiological factors, they are divided into 5 groups:
Congenital malformations of the biliary system: hypoplasia and atresia of the biliary tract,
Benign changes in the biliary system and pancreas due to cholelithiasis: stones (stones) in the bile ducts, diverticulum (protrusion of the wall) of the duodenum and stenosis of the large duodenal papilla (MDP), inside the descending part of the duodenal intestinal duodenal intestinal duodenal papilla chronic indurative pancreatitis, sclerosing cholangitis,
Strictures of the main bile ducts as a consequence of surgical intervention (formed as a result of accidental damage to the ducts or improper suturing),
Primary and secondary (metastatic) tumors of the organs of the pancreato-hepatobiliary system: gallbladder cancer, pancreatic head cancer and BDS, and the presence of metastasis in the liver of tumors of various localization (common stomach cancer, lymphogranulomatosis),
Damage to the liver and biliary tract by parasites (alveococcosis, hydatid cyst, etc.).
The most common causes of obstructive jaundice are tumor tumors (liver, biliary tract, pancreatic head) and cholelithiasis. Congenital malformations of the biliary system and parasitic diseases are much less common. In old age, calculous (mainly due to gallstones) and tumor impassability are predominantly encountered; at the age of less than 40 years, the cause is more often cholelithiasis.
Duodenal ulcer and acute appendicitis (in the case of the appendix in the area of the gate of the liver) are very rare causes of this pathological syndrome.
Cholestasis (a decrease in the flow of bile into the duodenum) occurs most often due to the migration of calculus into the ducts from the gallbladder. The formation of stones in the ducts themselves is observed much less frequently. They usually fall from the gallbladder into the choledoch (common bile duct) during an attack of biliary colic. Duct blockage occurs when a large stone cannot pass through it. Sometimes due to prolonged spasm of the sphincter of Oddi (a smooth muscle located in the OBD) even small stones get stuck in the terminal part of the common bile duct.
The presence of stones in the ducts is diagnosed in about 20% of patients with gallstone disease. Jaundice with cholestasis due to gallstone disease in 65% of cases is transient. Its symptoms subside after passing the stones into the intestines. The incidence of stenosis (narrowing) BDS is 25%.
Tumors of the pancreatic-hepatobiliary zone cause jaundice in 37% of cases. Cancer of the head of the pancreas and MDP are in the first place in frequency, and tumors of the main biliary tract and gall bladder are in the second place. Tumors of the liver and its ducts are quite rare.
Includes a diet with an emphasis on vegetables, fruits, dairy products. Food should be fractional, dishes - boiled and pureed. It is recommended to drink as much liquid as possible (juices, water).
Intravenous administration of glucose, vitamins of group B, Essentiale, methionine or lipocaine (to stimulate blood circulation in the liver), Vikasola (to prevent bleeding), Trental, glutamic acid. If necessary, antibiotics, plasmapheresis (blood purification), and enterosorption (detoxification procedure) are prescribed.