IKTERUS OBSTRUKTIF Anamnesis : Hall of Mark Obstructive Jaundice : Jaundice; Dark Urine; Pale Stool; Generalized Prutitus Cholangitis

/ Choledocolithiasis : Fever; Colic Bilier; Intermitten Jaundice Pancreatic Ca: BB; Abdominal mass: Pain radiating to back; Progressive Jaundice Periampullary Ca: Deep Jaundice (Greenish); Fluctuate in Intensity Extrahepatic Ca: Palpably enlarged gall bladder (Couvosiers sign (+)) (sumber:ptolemy.library.utoronto.com) Pemeriksaan Fisik 1. Nyeri tekan murphy`s sign 2. Ikterik : a. 2.5 mg/dl ---- sklera b. 5 mg/dl ---- kulit 2. Demam, takikardia, muscular guarding, perut kembung 3. 4. 5. 6. Ssesak nafas, gg hemodinamik, hematemesis&melena Cullen sign, Grey turner sign,nodul kulit eritematosa. Purtscher retinopathy Demam

Pemeriksaan penunjang : 1. Lab : a. darah lengkap (leukositosis) b. SGOT/SGPT c. Bilirubin direct/indirect d. Alkaline Fosfatase e. Aminotransferase 2. Radiologi a. Foto polos abdomen b. USG Abdomen c. Oral colecistografy d. CT Scan e. Colangiography f. Laparoskopy g. FDG PET Scan

ATALANTA Classification 1992

Patogenesis pembentukan Batu Triangular-phase diagram with axes plotted in percent cholesterol, lecithin (phospholipid), and the bile salt sodium taurocholate. Below the solid line, cholesterol is maintained in solution in micelles. Above the solid line, bile is supersaturated with cholesterol and precipitation of cholesterol crystals can occur. Ch, cholesterol. (From Donovan JM, Carey MC: Separation and quantitation of cholesterol carriers in bile. Hepatology 12:94S, 1990.) (Sabiston)

The pathogenesis of cholesterol gallstones is clearly multifactorial but essentially involves three stages: (1) cholesterol supersaturation in bile, (2) crystal nucleation, and (3) stone growth. For gallstones to cause clinical symptoms, they must obtain a size sufficient to produce mechanical injury to the gallbladder or obstruction of the biliary tree. Growth of stones may occur in two ways: (1) progressive enlargement of individual crystals or stones by deposition of additional insoluble precipitate at the bile-stone interface or (2) fusion of individual crystals or stones to form a larger conglomerate. Child Pugh Classification Variable 1 2 3 Ensefalopati Nil Slight to moderate Moderate to severe (1, 2) Asites Nil Slight Moderate to severe Bilirubin (mg/dl) <2 23 >3 Albumin(g/dl) >3,5 2,8 3,5 <2,8 Prototrombin index >70% 40% - 70% <40% Ranson criteria for prognostic implication of acute pancreatitis Admission After 48 H onset interpretation GDS > 200 Ht turun > 10% < 3 mortalitas 1% Age > 55 BUN > 5 3-4 mortalitas 16 % LDH > 350 Ca > 8 5-6 mortalitas 40% AST (SGOT) > 250 pO2 < 60 >6 mortalitas 100% WBC > 16000 Base deficit > 4 mEq Sequeatrasi cairan > 6 L TOKYO GUIDELINE (1) Diagnostic criteria for acute cholangitis A. Clinical B. Lab finding manifestation Bukti inflamasi Riwayat penyakit LFT abnormal bilier Demam dan atau menggigil Jaundice Nyeri perut (RUQ atau upper abdominal) Interpretasi : Suspected : 2 atau > criteria (+) Definite : triad charcots 2 atau > dari A + salah satu dari B atau C

C. -

Imaging finding Dilatasi bilier, atau bukti obstruksi (batu, striktur atau stent)

Abnormal WBC count, increased serum CRP level, and other changes indicating inflammation b Increased serum ALP, -GTP (GGT), AST, and ALT levels
a

Severity assessment criteria for acute cholangitis GRADE I (MILD) GRADE II (MODERATE) Mild (grade I) acute Moderate (grade II) acute cholangitis is defined as cholangitis is defined as acute cholangitis that acute cholangitis that does responds to the initial not respond to the initial medical treatmenta medical treatmenta and is not associated with organ dysfunction

GRADE III (SEVERE) Severe (grade III) acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems: 1. Hipotensi (dengan dopamine 5/KgBB/, dan atau dobutamiin) 2. Penurunan kesadaran 3. Gangguan respirasi (PaO2 / F1O2 ratio < 300) 4. BUN > 2 mg/dl 5. PT-INR > 1,5 6. Trombositopenia (<100.000/mm3) Note: compromised patients, e.g., elderly (>75 years old) and patients with medical comorbidities, should be closely monitored a General supportive care and antibiotics IMAGING FINDING Imaging findings characteristic of acute cholecystitis

(2) Diagnostic criteria for acute cholecystitis LOCAL FINDING SYSTEMIC SIGN (1) Murphys sign, (1) Fever, (2) RUQ mass/pain/tenderness (2) elevated CRP, (3) elevated WBC count

Definite diagnosis (1) One item in A and one item in B are positive (2) C confirms the diagnosis when acute cholecystitis is suspected clinically Imaging finding Ultrasonography MRI CT Thickened gallbladder wall Pericholecystic fluid collection Pericholecystic high signal Enlarged gallbladder Thickened gallbladder wall Sonographic Murphy sign (tenderness elicited by pressing the gallbladder with the ultrasound probe) Thickened gallbladder wall (>4 mm, if the patient does not have chronic liver disease and/or ascites or right heart failure) Enlarged gallbladder (long axis diameter >8 cm, short axis diameter >4 cm) Incarcerated gallstone, debris echo, pericholecystic fluid collection Sonolucent layer in the gallbladder wall, striated intramural lucencies, and Doppler signals

Enlarged gallbladder Linear high-density areas in the pericholecystic fat tissue Non-visualized gallbladder with normal uptake and excretion of radioactivity Rim sign (augmentation of radioactivity around the gallbladder fossa) GRADE III (SEVERE) Severe (grade III) acute cholangitis is defined as acute cholangitis that is associated with the onset of dysfunction at least in any one of the following organs/systems: 1. Hipotensi (dengan dopamine 5/KgBB/, dan atau dobutamiin) 2. Penurunan kesadaran 3. Gangguan respirasi (PaO2 / F1O2 ratio < 300) 4. BUN > 2 mg/dl 5. PT-INR > 1,5 6. Trombositopenia (<100.000/mm3)

Tc-HIDA scan (technetium hepatobiliary iminodiacetic acid scan)

Severity assessment criteria for acute cholecystitis GRADE I (MILD) GRADE II (MODERATE) defined as acute 1. WBC > 18000 cholecystitis in a healthy 2. Palpable mass RUQ patient with no organ 3. Complaints > 72 ha dysfunction and mild 4. Marked local inflammatory changes in inflammation a the gallbladder, making Laparoscopic surgery should cholecystectomy a safe be performed within 96 h of and low-risk operative the onset of acute procedure. cholecystitis

Algoritma

(Sabiston)

Ikterik

PENATALAKSANAAN OBSTRUKSI BATU : laparotomi / papilotomi per endos atau per lap STRIKTUR / STENOSIS : dilatasi, sfingterotomi TUMOR : drainage external Bilio-digestif by pass Kolesistektomi (batu dalam vesica felea) Sfingterotomi / papilotomi (batu dalam ductus kholedokus) operable (reseksi tumor) inoperable (pembedahan paliatif, ex: drainage) Pada advanced malignant disease (ACS, 2007)

BATU TUMOR

(Sabiston)