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Case analysis clinic
Case Analysis ROGER D. WILLIAMS,
M.D.,
ATIENT
Clinic Columbus, Obio
negative; blood volume (radioactive iodinated albumin method), 1,400 cc. deficit. Problems. DifferentiaI diagnosis, preoperative preparation, postoperative complication. Diflerential diagnosis: The cIear history of painIess, progressive jaundice with severe pruritus and weight loss strongly suggested extrahepatic biliary obstruction. Although pain is common with maIignancy, carcinoma of the pancreas is the most common cause of painless jaundice with significant weight 10~s. Absence of pain is rare with icterus due to common duct stone. There was no history of previous surgery or bIood transfusions, and any injections given at another hospitat two months earlier following the cataract Surgery were considered given with needIes adequate1.y sterilized against hepatitis virus. The physica findings also corroborated to some degree obstructive jaundice, aIthough the gaIIbIadder was not felt. An enIarged, non-tender gaIlbladder is palpated, however, in only about one-third of patients with jaundice due to extrahepatic malignant) (positive Courvoisier’s law). The liver was not greatly enIarged or tender; the icterus was a deep yeIIow-green and the patient was malnourished; spIenomegaIy and skin angiomas were absent. Therefore, both the history ant1 physical findings weighed heaviIy for the diagnosis of surgica1 jaundice. results corroborated this The laboratory initiai impression of obstructive (surgica1 j jaundice. In the presence of progressive, severe icterus the aIkaIine phosphatase had remained eIevated y-et onI>- minima1 liver parenchyma1 injury had developed. The cephaIin fIoccuIation and th>-mo1 turbidity were normal. The cholesterol and cholesterol esters were low; however, the prothrombin remained normal. In the face of these findings, interpretation of the upper intestinal x-ray studies led to a preoperative diagnosis of obstructive jaundice due to maIignancy in the pancreas or hiIe ducts.
B. MC., a seventy-three year old man, was admitted with the history of pruritus, a 40 pound weight loss and progressive severe icterus of two months’ duration. Pruritus began just prior to his discharge from another hospital where he had uneventfully undergone bilatera1 cataract extractions. He had had no pain, nausea, vomiting or intoIerante to fatty foods. There had been no previous abdomina1 surgery and no transfusions were given during his previous hospitalization for eye surgery. He did have several injections while in the hospita1. Physical Examination. Physical examination showed a somewhat emaciated, elderly, severely icteric man with blood pressure of 100/:8o mm. Hg and otherwise normal vital signs. There were superficia1 excoriations of the skin but no spider angiomas. The Iiver was felt 3 cm. below the costal margin on inspiration; it was firm, smooth and non-tender. The spIeen and gaIIbIadder were not feIt. The remainder of the phvsica1 examination was negative for abnormaIi”ties. Laboratory Data. Upper gastrointestinai x-ray films showed a constant indentation along the medial aspect of the duodenum in the region of the ampulla without change in the mucosal pattern. This was interpreted as indicative of a pancreatic tumor. The urine had an acid reaction (pH 5.4) and specific gravity of 1.015; otherwise it was normal. The hemogIobin was 10.8 gm. per cent, the red bIood ceI1 count 3.89 million per cu. mm. and the white blood cell count 7,000 per cu. mm. The blood urea nitrogen was 15 mg. per cent. Icterus index, zoo; cephaIin flocculation test, trace; thymo1 turbidity test, 20 units; alkaline phosphatase, 22.8 Bodansky units; prothrombin, 90 per cent. The total protein was 7.1 gm. per cent, atbumin 3.9 gm. per cent and gIobuIin 3.2 gm. per cent. The choIestero1 was 150 mg. per cent, esters 21 per cent. Stool guaiac was
P white
469
American
Journal
of Surper~,,
Volume
96, September,
1058
Williams Preoperative preparation: A high protein, 3,000 caIorie diet was encouraged, nearIy threefourths of which the patient was able to eat daiIy. Since both pancreatic and biIe ducts were considered obstructed, pancreatic extract and biIe saIts were given to aid the absorption of ora food. WhoIe bIood, 1,500 cc., was given to restore bIood volume to normaI. Vitamin K, therapeutic muItivitamins were 10 mg., and given daiIy. The day before surgery tetracycline, IOO mg. every six hours, was begun to obtain preoperative bIood and biIe IeveIs in order to prevent postsurgical choIangitis. Surgery: Through a right paramedian incision carried high into the xiphocosta1 angIe the Iiver was found to be onIy sIightIy enIarged. The gaIIbIadder was thin-waIIed and contained only a few smaI1 stones. The common biIe duct was of normaI size. The gaIIbIadder was removed and the common duct explored. No obstruction was noted either in the dista1 portion of the common duct or the hepatic ducts. In order to visuaIize the hepatic ducts further, as we11 as the common biIe duct, an operative choIangiogram was performed. No intra- or extrahepatic obstruction was noted. In view of the absence of obstruction there was no hesitation in obtaining a biopsy specimen of the Iiver. MicroscopicaIIy the liver showed marked biIiary stasis with siight periducta1 round ceII infiItration. Postoperative complication: The biopsy of the liver suggested choIangitis. CarefuI questioning of the patient and a review of the medications given him two months earlier at another hospita1 showed that he had received chIorpromazine by injection, 100 mg. daily, for six days foIIowing his cataract surgery. This preoperative diagnosis had been considered but the patient was questioned onIy about ora medications. The pathoIogica1 findings were compatibIe with chlorpromazine jaundice. The x-ray findings Ieave the radioIogist with further expIanations to give! The patient toIerated the operative procedure weI1; however, shortIy after being returned to his room from the recovery room his bIood pressure, preoperativeIy recorded as 130/70 to 160/80 mm. Hg and hoIding above 120/70 during surgery, dropped to between go/60 and 80/50. The mechanism of this bIood pressure decline was unknown. Preoperative bIood voIume deficits were adequately rcpIaced and 500 cc. of whoIe bIood were given during sur-
gery. The surgica1 Ioss was estimated as Iess than 350 cc. and there was no indication of further intra-abdomina1 hemorrhage. Retention of carbon dioxide may have been a factor since the patient had moderate emphysema; however, his respiratory exchange was considered good. With nasa1 oxygen therapy aIone the bIood pressure returned to 128/80 after four hours. Short periods of hypotension may be of no significance in non-icteric patients; however, on the second postoperative day this patient was Iethargic. The bIood urea nitrogen had risen to 37 mg. per cent. Two days Iater the bIood urea nitrogen was 43 mg. per cent. Uremic acidosis was suspected but serum eIectroIytes showed a sodium value of 148 mEq./L. and chIoride vaIue of I IO mEq./L., vaIues which may be noted with dehydration aIone. OnIy the bIood COZ value of 34 voIumes per cent (15.2 mEq.) showed the extent of the acidosis. Uremic acidosis associated with a Iow bIood CO2 and high serum sodium and chIoride had been noted in simiIar cases with poor renaI function foIIowing hypotension in jaundice and required carefu1 ffuid and eIectroIyte management. Even when urine output is Iow, there is usuaIIy a faiIure of urine concentration to above 1.012. An attempt to determine the kidneys’ abiIity to concentrate is unnecessary and contraindicated. A high urine output must be maintained, saline withheId and the acidosis corrected with sodium bicarbonate or sodium Iactate. In this patient Auid therapy (5 per cent dextrose in water intravenousIy, pIus ora intake) was increased to produce a urinary output which ranged between 1,075 and 1,950 cc. daiIy. SmaII amounts (68 mEq.) of NaHC03 were given daiIy for three days. BIood eIectroIyte vaIues remained norma and the bIood urea nitrogen dropped to rg mg. per cent by the tweIfth postoperative day. A significant compIication was forestaIIed and the patient made a progressive recovery, his icterus index having dropping to IOO three weeks folIowing surgery. SUMMARY
This case of apparent obstructive jaundice iIIustrates three important factors in the surgica1 management of the jaundiced patient. I. Despite numerous Iaboratory determinations, a careful history remains the most important factor in the differential diagnosis of 470
Case
AnaIysis
jaundice. Certain medications in widespread use (chlorpromazine, testosterone) can produce jaundice with laboratory results suggesting surgical obstruction and these medications are given by hypodermic injection as we11 as orally. 2. A carefu1 preoperative preparation shouId include attempts to maintain if not restore nutritional deficits by the oral route and the prevention of postoperative infection of the biliary tract by antibiotics which are excreted in the bile. Oral feedings require bile and often pancreatic extract supplements to aid absorption as we11 as the regularIy prescribed vitamins A, B, C, K. Blood volume deficits wiI1 be Iarge and require adequate replacement. 3. Hypotensive episodes, minimized by adequate blood volume replacement before and during surgery, are of serious consequence. The resuIting renal tubular damage Ieads to failure
CIinic of urine concentration and dangerous electrolyte imbalance, usually a uremic acidosis. The often found elevations of serum sodium and chloride are due in part to dehydration and do not contraindicate the giving of further sodium to correct the acidosis. When this complication deveIops, the output of urine must be increased, usuaIIy to I,joo cc. or more daily; saline shouId be withheId and sodium Iactate or bicarbonate grven. REFERENCES
I. ZOLLINCER, R. M. and WILLIAMS, R. D. Surgical aspects of jaundice. Surgery, 39: 1016, 1956. 2. WERTHER, J. L. and KORELITZ, B. I. Chtorpromazine jaundice, an analysis of twenty-two cases. Am. J. tied., 22: 351, 1957. 3. WxLIAh%s, R. D. and ZOLLINGER, R. M. Principles of surgica1 nutrition. Am. J. Clin. Nutrition, 3: 449.
471
1955.
M.D.,
ATIENT
Clinic Columbus, Obio
negative; blood volume (radioactive iodinated albumin method), 1,400 cc. deficit. Problems. DifferentiaI diagnosis, preoperative preparation, postoperative complication. Diflerential diagnosis: The cIear history of painIess, progressive jaundice with severe pruritus and weight loss strongly suggested extrahepatic biliary obstruction. Although pain is common with maIignancy, carcinoma of the pancreas is the most common cause of painless jaundice with significant weight 10~s. Absence of pain is rare with icterus due to common duct stone. There was no history of previous surgery or bIood transfusions, and any injections given at another hospitat two months earlier following the cataract Surgery were considered given with needIes adequate1.y sterilized against hepatitis virus. The physica findings also corroborated to some degree obstructive jaundice, aIthough the gaIIbIadder was not felt. An enIarged, non-tender gaIlbladder is palpated, however, in only about one-third of patients with jaundice due to extrahepatic malignant) (positive Courvoisier’s law). The liver was not greatly enIarged or tender; the icterus was a deep yeIIow-green and the patient was malnourished; spIenomegaIy and skin angiomas were absent. Therefore, both the history ant1 physical findings weighed heaviIy for the diagnosis of surgica1 jaundice. results corroborated this The laboratory initiai impression of obstructive (surgica1 j jaundice. In the presence of progressive, severe icterus the aIkaIine phosphatase had remained eIevated y-et onI>- minima1 liver parenchyma1 injury had developed. The cephaIin fIoccuIation and th>-mo1 turbidity were normal. The cholesterol and cholesterol esters were low; however, the prothrombin remained normal. In the face of these findings, interpretation of the upper intestinal x-ray studies led to a preoperative diagnosis of obstructive jaundice due to maIignancy in the pancreas or hiIe ducts.
B. MC., a seventy-three year old man, was admitted with the history of pruritus, a 40 pound weight loss and progressive severe icterus of two months’ duration. Pruritus began just prior to his discharge from another hospital where he had uneventfully undergone bilatera1 cataract extractions. He had had no pain, nausea, vomiting or intoIerante to fatty foods. There had been no previous abdomina1 surgery and no transfusions were given during his previous hospitalization for eye surgery. He did have several injections while in the hospita1. Physical Examination. Physical examination showed a somewhat emaciated, elderly, severely icteric man with blood pressure of 100/:8o mm. Hg and otherwise normal vital signs. There were superficia1 excoriations of the skin but no spider angiomas. The Iiver was felt 3 cm. below the costal margin on inspiration; it was firm, smooth and non-tender. The spIeen and gaIIbIadder were not feIt. The remainder of the phvsica1 examination was negative for abnormaIi”ties. Laboratory Data. Upper gastrointestinai x-ray films showed a constant indentation along the medial aspect of the duodenum in the region of the ampulla without change in the mucosal pattern. This was interpreted as indicative of a pancreatic tumor. The urine had an acid reaction (pH 5.4) and specific gravity of 1.015; otherwise it was normal. The hemogIobin was 10.8 gm. per cent, the red bIood ceI1 count 3.89 million per cu. mm. and the white blood cell count 7,000 per cu. mm. The blood urea nitrogen was 15 mg. per cent. Icterus index, zoo; cephaIin flocculation test, trace; thymo1 turbidity test, 20 units; alkaline phosphatase, 22.8 Bodansky units; prothrombin, 90 per cent. The total protein was 7.1 gm. per cent, atbumin 3.9 gm. per cent and gIobuIin 3.2 gm. per cent. The choIestero1 was 150 mg. per cent, esters 21 per cent. Stool guaiac was
P white
469
American
Journal
of Surper~,,
Volume
96, September,
1058
Williams Preoperative preparation: A high protein, 3,000 caIorie diet was encouraged, nearIy threefourths of which the patient was able to eat daiIy. Since both pancreatic and biIe ducts were considered obstructed, pancreatic extract and biIe saIts were given to aid the absorption of ora food. WhoIe bIood, 1,500 cc., was given to restore bIood volume to normaI. Vitamin K, therapeutic muItivitamins were 10 mg., and given daiIy. The day before surgery tetracycline, IOO mg. every six hours, was begun to obtain preoperative bIood and biIe IeveIs in order to prevent postsurgical choIangitis. Surgery: Through a right paramedian incision carried high into the xiphocosta1 angIe the Iiver was found to be onIy sIightIy enIarged. The gaIIbIadder was thin-waIIed and contained only a few smaI1 stones. The common biIe duct was of normaI size. The gaIIbIadder was removed and the common duct explored. No obstruction was noted either in the dista1 portion of the common duct or the hepatic ducts. In order to visuaIize the hepatic ducts further, as we11 as the common biIe duct, an operative choIangiogram was performed. No intra- or extrahepatic obstruction was noted. In view of the absence of obstruction there was no hesitation in obtaining a biopsy specimen of the Iiver. MicroscopicaIIy the liver showed marked biIiary stasis with siight periducta1 round ceII infiItration. Postoperative complication: The biopsy of the liver suggested choIangitis. CarefuI questioning of the patient and a review of the medications given him two months earlier at another hospita1 showed that he had received chIorpromazine by injection, 100 mg. daily, for six days foIIowing his cataract surgery. This preoperative diagnosis had been considered but the patient was questioned onIy about ora medications. The pathoIogica1 findings were compatibIe with chlorpromazine jaundice. The x-ray findings Ieave the radioIogist with further expIanations to give! The patient toIerated the operative procedure weI1; however, shortIy after being returned to his room from the recovery room his bIood pressure, preoperativeIy recorded as 130/70 to 160/80 mm. Hg and hoIding above 120/70 during surgery, dropped to between go/60 and 80/50. The mechanism of this bIood pressure decline was unknown. Preoperative bIood voIume deficits were adequately rcpIaced and 500 cc. of whoIe bIood were given during sur-
gery. The surgica1 Ioss was estimated as Iess than 350 cc. and there was no indication of further intra-abdomina1 hemorrhage. Retention of carbon dioxide may have been a factor since the patient had moderate emphysema; however, his respiratory exchange was considered good. With nasa1 oxygen therapy aIone the bIood pressure returned to 128/80 after four hours. Short periods of hypotension may be of no significance in non-icteric patients; however, on the second postoperative day this patient was Iethargic. The bIood urea nitrogen had risen to 37 mg. per cent. Two days Iater the bIood urea nitrogen was 43 mg. per cent. Uremic acidosis was suspected but serum eIectroIytes showed a sodium value of 148 mEq./L. and chIoride vaIue of I IO mEq./L., vaIues which may be noted with dehydration aIone. OnIy the bIood COZ value of 34 voIumes per cent (15.2 mEq.) showed the extent of the acidosis. Uremic acidosis associated with a Iow bIood CO2 and high serum sodium and chIoride had been noted in simiIar cases with poor renaI function foIIowing hypotension in jaundice and required carefu1 ffuid and eIectroIyte management. Even when urine output is Iow, there is usuaIIy a faiIure of urine concentration to above 1.012. An attempt to determine the kidneys’ abiIity to concentrate is unnecessary and contraindicated. A high urine output must be maintained, saline withheId and the acidosis corrected with sodium bicarbonate or sodium Iactate. In this patient Auid therapy (5 per cent dextrose in water intravenousIy, pIus ora intake) was increased to produce a urinary output which ranged between 1,075 and 1,950 cc. daiIy. SmaII amounts (68 mEq.) of NaHC03 were given daiIy for three days. BIood eIectroIyte vaIues remained norma and the bIood urea nitrogen dropped to rg mg. per cent by the tweIfth postoperative day. A significant compIication was forestaIIed and the patient made a progressive recovery, his icterus index having dropping to IOO three weeks folIowing surgery. SUMMARY
This case of apparent obstructive jaundice iIIustrates three important factors in the surgica1 management of the jaundiced patient. I. Despite numerous Iaboratory determinations, a careful history remains the most important factor in the differential diagnosis of 470
Case
AnaIysis
jaundice. Certain medications in widespread use (chlorpromazine, testosterone) can produce jaundice with laboratory results suggesting surgical obstruction and these medications are given by hypodermic injection as we11 as orally. 2. A carefu1 preoperative preparation shouId include attempts to maintain if not restore nutritional deficits by the oral route and the prevention of postoperative infection of the biliary tract by antibiotics which are excreted in the bile. Oral feedings require bile and often pancreatic extract supplements to aid absorption as we11 as the regularIy prescribed vitamins A, B, C, K. Blood volume deficits wiI1 be Iarge and require adequate replacement. 3. Hypotensive episodes, minimized by adequate blood volume replacement before and during surgery, are of serious consequence. The resuIting renal tubular damage Ieads to failure
CIinic of urine concentration and dangerous electrolyte imbalance, usually a uremic acidosis. The often found elevations of serum sodium and chloride are due in part to dehydration and do not contraindicate the giving of further sodium to correct the acidosis. When this complication deveIops, the output of urine must be increased, usuaIIy to I,joo cc. or more daily; saline shouId be withheId and sodium Iactate or bicarbonate grven. REFERENCES
I. ZOLLINCER, R. M. and WILLIAMS, R. D. Surgical aspects of jaundice. Surgery, 39: 1016, 1956. 2. WERTHER, J. L. and KORELITZ, B. I. Chtorpromazine jaundice, an analysis of twenty-two cases. Am. J. tied., 22: 351, 1957. 3. WxLIAh%s, R. D. and ZOLLINGER, R. M. Principles of surgica1 nutrition. Am. J. Clin. Nutrition, 3: 449.
471
1955.