GI diagnosis: Mirizzi's syndrome
Prosthetic jaundice, conjugated bilirubin => direct hyperbilirubin.(indirect is unconjugated)
Possible solution: cholecystectomy?
Look at the pt's medication to determine his condition.
terazosin -> high b.p.
cumadin -> for atrial fibrillation
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Mirizzi's syndrome is a rare cause of acquired jaundice. It is caused by chronic cholecystitis and large gallstones resulting in stenosis of the common bile duct.
Epidemiology
Mirizzi syndrome occurs in approximately 0.7-1.4% of all patients undergoing cholecystectomy and in 0.1% of all patients with gallstone disease.
[edit] Pathophysiology
Multiple and large gallstones can reside chronically in the Hartmann's pouch [1] of the gallbladder, causing inflammation, necrosis, scarring and ultimately fistula formation into the adjacent common bile duct (CBD). As a result, the CBD becomes obstructed by either scar or stone, resulting in jaundice.
[edit] Features
Mirizzi syndrome has no consistent or unique clinical features that distinguish it from other more common forms of obstructive jaundice. Symptoms of recurrent cholangitis, jaundice, right upper quadrant pain, and elevated bilirubin and alkaline phosphatase may or may not be present. Acute presentations of the syndrome include pancreatitis or cholecystitis.
[edit] Diagnosis
CT scan or ultrasonography usually make the diagnosis. Often, ERCP is used to define the lesion anatomically prior to surgery.
[edit] Treatment
The treatment of choice is surgical excision of the gallbladder, and reconstruction of the common hepatic duct and common bile duct.
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Cholecystectomy (/ˌkɔləsɪsˈtɛktəmi/), plural cholecystectomies, is the surgical removal of the gallbladder.
Open cholecystectomy
Traditional open cholecystectomy is a major abdominal surgery in which the surgeon removes the gallbladder through a 4- to 7-inch incision. Patients usually remain in the hospital for about three to seven days and may require several additional weeks to recover at home.
[edit] Laparoscopic cholecystectomy
Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones unless there are contraindications to the laparoscopic approach. Sometimes a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.
Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through separate small incisions. The gallbladder is identified and carefully separated from the liver and other structures. Finally, the cystic duct and the cystic artery are clipped with tiny titanium clips and cut, then the gallbladder is removed through one of the small incisions. This type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an hour.
Laparoscopic cholecystectomy does not require the abdominal muscles to be cut, resulting in less pain, quicker healing, improved cosmetic results, and fewer complications such as infection. Most patients can be discharged on the same day as the surgery, and most patients can return to any type of occupation in about a week.
[edit] Complications
An uncommon but potentially serious complication with the new procedure is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed nonsurgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. At this time it is unclear whether these complications are more common following laparoscopic cholecystectomy than following standard cholecystectomy.
Abdominal peritoneal adhesions, gangrenous gallbladders, and other problems that obscure vision are discovered during about 5% of laparoscopic surgeries, forcing surgeons to switch to the standard cholecystectomy for safe removal of the gallbladder. Converting to open surgery does not equate to a complication.
A Consensus Development Conference panel, convened by the National Institutes of Health in September 1992, endorsed laparoscopic cholecystectomy as a safe and effective surgical treatment for gallbladder removal, equal in efficacy to the traditional open surgery. The panel noted, however, that laparoscopic cholecystectomy should be performed only by experienced surgeons and only on patients who have symptoms of gallstones.
In addition, the panel noted that the outcome of laparoscopic cholecystectomy is greatly influenced by the training, experience, skill, and judgment of the surgeon performing the procedure. Therefore, the panel recommended that strict guidelines be developed for training and granting credentials in laparoscopic surgery, determining competence, and monitoring quality. According to the panel, efforts should continue toward developing a noninvasive approach to gallstone treatment that will not only eliminate existing stones, but also prevent their formation or recurrence.
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Bilirubin is a yellow breakdown product of normal heme catabolism. Its levels are elevated in certain diseases and it is responsible for the yellow color of bruises and the brown color of feces.
Bilirubin blood tests
Bilirubin is broken down by light, and blood collection tubes (especially serum tubes) should therefore be protected from such exposure.
Bilirubin is either in the insoluble form, unconjugated bilirubin (also indirect bilirubin), or bound to glucuronic acid to form the so calledconjugated bilirubin (also direct bilirubin). The indirect form is insoluble and it is transformed into a soluble or direct form, in the liver. Total and direct bilirubin levels can be measured from the blood, but indirect bilirubin is calculated from the total and direct bilirubin.The terms "direct" and "indirect" reflect the way the two types of bilirubin react to certain dyes. Conjugated bilirubin is water-soluble and reacts directly when dyes are added to the blood specimen. The non-water soluble, free bilirubin does not react to the reagents until alcohol is added to the solution. Therefore, the measurement of this type of bilirubin is indirect. Test results may be listed as "BU" for unconjugated bilirubin and "BC" for conjugated bilirubin. Total bilirubin measures both BU and BC. To further elucidate the causes of jaundice or increased bilirubin, it is usually simpler to look at other liver function tests (especially the enzymes ALT, AST, GGT, Alk Phos), blood film examination (hemolysis, etc.) or evidence of infective hepatitis (e.g., Hepatitis A, B, C, delta E, etc).
Bilirubin is an excretion product, and the body does not control levels. Bilirubin levels reflect the balance between production and excretion. Thus, there is no "normal" level of bilirubin.
Interpretation
The reference range for total bilirubin is 2 - 14 μmol/L or 0.3 - 1.9 mg/dL. For direct bilirubin, it is 0 - 4 μmol/L or 0 - 0.3 mg/dL.
Mild rises in bilirubin may be caused by
- Hemolysis or increased breakdown of blood.
- Gilbert's syndrome - a genetic disorder of bilirubin metabolism which can result in mild jaundice, found in about 5% of the population.
Moderate rise in bilirubin may be caused by
- Drugs (especially anti-psychotic, some sex hormones, and a wide range of other drugs).
- Hepatitis (levels may be moderate or high).
Very high levels of bilirubin may be caused by
- Neonatal hyperbilirubinaemia, where the newborn's liver is not able to properly conjugate the bilirubin (see jaundice).
- Unusually large bile duct obstruction, eg stone in common bile duct, tumour obstructing common bile duct etc.
- Severe liver failure with cirrhosis.
- Severe hepatitis.
- Crigler-Najjar syndrome
- Dubin-Johnson syndrome
Cirrhosis may cause normal, moderately high or high levels of bilirubin, depending on exact features of the cirrhosis.
