Dr Imtiaz Ahmed Wani
To a layman jaundice is synonym with yellowish discoloration of eyes. This might be noticed by the patient himself or herself or conveyed by his or her fellows. The discoloration, in contention, in jaundice from any etiology is due to elevated serum bilrubin. This is a degradation by product of hemoglobin produced inside the body. Any abnormal alteration in the pathway of metabolism in bilirubin leads to jaundice. Normal level of bilirubin ranges in the human body from 0.2-<2 mg /dl.Serum bilirubin level less than 2mg/dl is subclinical jaundice. Differential diagnosis and management of jaundice has been posing problems of immense magnitude to surgeons from time immemorial. This dilemma is due to the fact that surgical and medical jaundice being two different entities with differing etiologies, pathogenesis and management but manifesting in same way as yellowish discoloration of tissues of the body.
Surgical jaundice usually occurs in any pathology encountered in pathway block for the flow of bile .There may be a block in flow of bile in the gallbladder, common bile duct or ampulla of vater. The incidence of surgical jaundice varies from region to region depending on the etiology. Some common causes are Cholethiasis with choledocholithiasis, Choledocholithiasis, Biliary Ascariasis, stricture of CBD Carcinoma head of Pancreas, Cholangiocarcinoma, Pancreatic duct stone, Gall Bladder carcinoma, Hydatid cyst liver or Portohepatis lymphadenopathy.
Jaundice is more common in females than men, with calcular obstruction being more common in men due to higher incidence of cholelithiasis in females and similar preponderance is observed in malignant jaundice. Benign jaundice accounts for majority of cases with calculi topping the list. Malignant jaundice accounts for mostly of cases of carcinoma of head of pancreas. Biliary ascariasis with or without gallstones is a significant cause of jaundice in countries where ascaridial infestation is very high as in the Valley (with progressive jaundice being the main symptom in both benign and malignant jaundice). The incidence of clay colored stools being higher in malignant than in benign jaundice and is due to more complete obstruction in malignant jaundice.
In diagnostic work up, proper clinical history, detailed physical and systemic examination and are investigated on lines of laboratory parameters with an emphasis on lab parameters of to hepatobiliary system. Ultrasonography of abdomen, CT scan, barium study of the stomach and duodenum, percutaneous transhepatic cholngiography, endoscopic retrograde cholangio pancreatography and magnetic resonance cholangio pancreatography (MRCP) if needed are the desired forms of clinical assessments.
One important clinical practice is to maintain adequate hydration and urine output, reception of parenteral Vitamin K and enough hypertonic dextrose, adequate antibiotic cover and blood transfusion when indicated. Sometimes surgical intervention is needed for relief of jaundice is attended by high complication rate. Morbidity is higher in patients with malignant jaundice than in benign jaundice. Various morbidity factors encountered in surgical jaundice are pneumonia, septicemia, wound infection, intraperitoneal sepsis, intraoperatve harmmorhage, DVT, fistula, and renal impairment. It is endotoxin spillover into circulation due to defective phagocytic kupferr cell function responsible for it. A proper antibiotic cover for jaundiced patients is necessary to decrease the septic post operative complications.
—The author is a surgeon specialist, DHS, Kashmir. He can be reached at: email@example.com