Obstructive Jaundice

History

·         50 yrs old male

·         Low socio-economic

·         H/O fever – 1 month

·         H/O pain and lump Right upper abdomen – 15 days

·         H/O yellowish discoloration of eyes – 10 days

·         Fever  -  Off and on – 1month, sudden onset, high grade, intermittent and associated with chills and rigors, reduced on taking oral medicines.

·         Pain over right upper abdomen – 15 days, insidious onset, dull aching, non-shifting, non-radiating and decreased on medication.

·         Patient noticed lump in right upper abdomen since past 15 days of size 6*4cms and progressively increased in size to present size.

·          Yellowish discoloration of eyes -  insidious onset and deepened since then.

·         H/O of passing clay coloured stools since 10 days.

·         H/O loss of appetite and weight loss – 5 kgs – 2 months

·         No H/O itching, vomiting, abdominal distension, obstipation, haematemesis, malena, other constitutional symptoms and urinary complaints.

·         No H/O contact, IV drug abuse, blood transfusions.

·          No H/O respiratory distress, bone pains, headache, or seizures.

·         No H/O diabetes mellitus, hypertension, Kochs

·         Alcoholic and smoker since 20 years

Prodromal symptoms	Constitutional symptoms
Eg. – infective hepatitis Short history Loss of appetite Smoker will lose taste of smoking Jaundice appearing and then receding

Is Clay coloured stool always means obstructive jaundice?

-          No

-          In some cases of infective type of hepatitis initially obstructive type of features are present due to oedema of liver cells- stools can be clay coloured, alkaline phosphatase may be raised.

-          But they (obstructive jaundice) do not progress.

Examination-

-          Elderly male, conscious, co-operative, well oriented to time, place and person

-          Performance status – 80 Kornoffosky

-          Nutritional status – poor

-          Hydration status – adequate

-          Pulse – 86/min, regular

-          BP – 124/78 mm Hg

-          RR – 18/min, abdominothoracic

-          Afebrile

-          Patient is albino with yellowish discoloration of skin

-          Icterus – present, pedal edema+

-          Pallor +, no generalised lymphadenopathy

-          Respiratory system – WNL

-          Cardiovascular – WNL

-          Central and peripheral Nervous system – WNL

-          Stigma of liver disease-

o   Hair texture – change or alopecia

o   Icterus

o   Spider naevi

o   Palmar erythema

o   Dupeytren’s contracure

o   Clubbing

o   Gynaecomastia

o   Caput medussae

o   Ascites

o   Testicular atrophy

o   Pedal  oedema

-          Liver failure (include more feature)-

o   Posterior column disorders eg. Flapping tremors

o   Fetor hepaticus

How do you look for hydration status?

-          Tongue

-          Skin turgor- over dorsum of hand.

Abdominal examination-

Inspection:

·         Visible fullness in Rt Hypochondrium

·         All the quadrants moving well with respiration

·         Umbilicus is central

·         Skin over abdomen is normal

·         No dilated veins, scars

·         No visible peristalsis or pulsations

·         Hernia orifices are normal

·         Flanks are not full

Palpation:

·         Tender hepatomegaly with span of around 17cms, palpable 7 cms below the costal margin in MCL, round borders, firm in consistency with small area of softening around 5*6cms present at the middle of swelling.

·         No other organomegaly, no free fluid+

·         Spine, Genitals and Hernial orifices are normal

·         Left supraclavicular lymph node not enlarged

·         P/R examination – WNL.

What gives the colour to stool?

·         Stercobilinogen (formed by bacteria acting upon bilirubin:  Bilirubin=Urobilinogen+Stercobilinogen

In a patient of jaundice what happens to cardiovascular system?

·         In jaundice there is rise in serum bilirubin.

·         Serum bilirubin directly acts on SA nodes.

·         It causes bradycardia or even blocks occur.

Effect of jaundice on CNS?

·         Kernicterus (in children)- kernicterus is deposition of unconjugated bilirubin on basal ganglia after crossing blood brain barrier.

·         Adult and elderly-  (posterior column affected)

o   Tremor

o   Gait of patient

Provisional diagnosis-

·         Obstructive  jaundice due to rapidly progressive malignancy with superimposed infection

Features of infective jaundice:-

·         Prodromal symptoms

·         Jaundice initially progresses and then start receding

·         Clay coloured stool intially which later on disappears

Itching in obstructive type of jaundice take more than one month time to manifest. Deposited in subcutaneous plane. Affinity for elastin.

Points in favour of malignant obstructive jaundice – painless progressive jaundice

Ca Stomach (features)-  LOADS

-          Lump

-          Obstructive features (vomiting, pain abdomen)

-          Anaemia, asthenia, anorexia

-          Dyspepsia (new onset)

-          Silent (jaundice, ascites, Krukenberg’s tumour, Sister Joseph nodules or Virchows nodules)

Investigation-(confirm the diagnosis, support the diagnosis, treat the patient)

-          USG abd-

-          LFT-

Locally Advanced Breast Cancer (LABC)

Clinical assessment in LABC-

What is LABC? & LOBC? (large operable breast cancer)

·         T3N1;  any T4, any N2, N3, M0

Inflammatory breast carcinoma-

·         T4D any N M0

Primary Tumour (T)

T3: >5cm in greatest dimension

T4: Tumour of any size with direct extension to

(a)    Chest wall or  (b) skin

T4a: Extension to chest wall, not including PM

T4b: Edema (including peau d’ orange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast

T4c: Both T4a and T4b

T4d: inflammatory carcinoma

Stage Groupings- AJCC 6^th edition

Stage 0: Tis N0 M0

I: T1 N0 M0

IIa: T0 N1 M0, T1 N1 M0, T2 N0 M0

IIb: T2 N1 M0, T3 N0 M0

IIIa: T0 N2 M0, T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N 2 M0

IIIb: T4 N0 M0, T4 N1 M0, T4 N2 M0

IIIc: any T N3 M0

IV: ant T any N M1

Peau d’ orange: fig 1

·         Sometimes elicited by pinching the skin

·         Skin is reddish

·         Multiple spots

Clinical examination (lift the arm up): fig 2

·         Nipple areola complex gone up

·         Peau d’ orange becomes more prominent

·         Going up (of lump) is due to ligament of Cooper infiltration

·         In describing lump  always start from normal side

·         Mention whether other breast and axilla is normal and if involved then describe in detail

·         This is locally advanced breast cancer

·         Retraction of nipple present-

Non-operable LABC: fig 3

·         IIIC is non-operable

·         So down staging by neo adjuvant chemotherapy

·         Operate

·         Thereafter put on adjuvant chemotherapy

LABC in male: fig 4

·         Management is same stage by stage as in female

·         Examination pattern and the staging on the same lines as their female counterpart

·         It is just that most cancers in males are locally advanced at presentation

Inflammatory breast cancer:

·         Lee & Tannenbaum 1924

·         Diagnosis is clinical: increased size of affected breast, diffuse induration, skin erythema, peau d’ orange

·         Not all these features are necessarily present

·         Breast rather than skin biopsy

·         Dermal lymphatic obstruction by tumour

Inflammation in a LABC:

·         Indolent start/ oedema not more than 1/3^rd of breast

·         Outcome same as stage matched LABC

·         Management on the same lines

Clinical assessment:

·         Mandatory for staging

·         Planning of optimum therapy

·         Before initiating the therapy (NACT)

·         Subsequent serial assessments as the therapy progresses

T size and 5 year survival rate(%)

·         <5cm                     65%

·         5-10cm                 36%

·         >10cm                   16%

For accurate T size measurement- use Calliper or measuring tape

T size and association with the axillary lymph nodes

·         <1cm                     25

·         1-2cm                    35

·         2-3cm                    50

·         >3cm                     5-65

Local examination:

·         Accurate assessment of size, fixity, to skin or underlying muscle, presence of peau d’ orange or dimpling.

·         Retraction of nipple or puckering need to be mentioned clearly in the initial assessment chart.

·         Both axillae and supraclavicular fossae examined for presence of lymph nodes and their fixity.

·         In a fungating mass these features are obvious and one may have a pictorial record of the findings for subsequent comparison.

Initial clinical assessment:

·         The routine work up like for any patient of breast cancer

·         Detailed history including family history to arrive at the initial diagnosis and staging.

·         In a LABC further effort made to exclude metastasis.

·         The management changes drastically for a metastatic breast cancer.

·         Triple assessment.

·         Assessment for performance and nutritional status as both significantly affect the outcome in these patients.

·         Local clinical assessment involves a good examination of both breasts starting with the opposite breast first in all position.

The incidence of contralateral breast cancer when a patient presents with unilateral breast cancer is 1.8% (SEER database).

Systemic examination:-

·         Abdomen for any organomegaly particulary liver and/or presence of ascites to rule out an M1 disease.

·         Examination of spine and chest along with breast mandatory.

·         P/V and DRE: mandatory to rule out peritoneal deposits (Blummer shelf) or Kruckenberg ‘s tumour (in pre-menopausal women), ovarian malignancy.

 Clinical assessment as a part of assessing response to NACT: (neo adjuvant chemotherapy)

·         The sensitivity is poor due to excessive local scarring following NACT

·         The response described as complete if the tumour size reduces by more than 50% after 3 cycles of NACT.

·         The clinical assessment may also include use of ultrasound as its natural extension.

Clinical response and outcome-

·         Role of P-glycoprotein expression in predicting response to neoadjuvant chemotherapy in breast cancer.

Clinical assessment as a dynamic phenomenon-

·         Appearance of a metastasis during the follow up after NACT would make the disease metastatic and change the intent.

·         Regular assessment mandatory and is a dynamic rather than a static affair.

Conclusion

·         LABC is a complex group of entities

·         Clinical assessment is a dynamic process

·         Serial assessments predict response and the appearance of a metastasis.

·         Inflammatory breast cancer although included in the LABC is a different entity.

·         Good clinical assessment forms the basis of subsequent assessment of tumour behaviour and response to NACT.

·         USG may serve as an extension of clinical assessment.