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"We reported here a rare case of a 62 year old male patient with obstructive jaundice due to bile duct tumor. The main clinical features were yellowish eye and skin, followed by pruritus and clay-colored stool. Ultrasonography showed common bile duct dilatation and without evidence of stones. Computed Tomography Scan of upper abdomen showed a mass which were thought of head of pancreas origin. Endoscopic Retrograde Cholangio Pancreatograph revealed tight narrowing of the distal bile duct to a malignant tumor. A stent was inserted to allow biliary drainage, A surgical plan for billio digestive anastomosis was rejected by the patient and family."

"Obstructive: jaundice represents the most common complication of biliary tract Malignancy. Obstructive jaundice causes releases of proinflammatory cytokine. There has been controversy about effect of biliary drainage on the change in proinflammatory cytokine level in pancreatobiliary cancer patients. The present study was designed to determine levels of tumor necrosis factor alpha (TNF-alfa) and interleukin 6 (IL-6) in preprocedure of either endoscopic retrograde cholangio pancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) and postprocedure of them in obstructive jaundice patient caused by pancreatobiliary cancer.Method: The study method was before-and-after case study design with consecutive sampling. Blood was collected five days prior to either endoscopic retrograde cholangio pancreatography (ERCP) procedure or percutaneus transhepatic biliary drainage (PTBD) procedure and five days after either of them. Enzyme linked immunosorbed assay (ELISA) was used to determine TNF-alfa and IL-6.Results: Forty subjects were included in this study which consisted of 22 men and 18 women. The age was 55.3 (SD 13.7) years old. According to the results of imaging and endoscopy procedure, twenty-two people were diagnosed cholangicarcinoma, ten people were diagnosed ampulla vateri and eigth people were diagnosed pancreatic tumor. In preprocedure, the TNF-alfa concentration was 4.81 (SD 2.91) pg/mL, the IL-6 concentration was 7.79 (SD 1.57) pg/mL and the bilirubin concentration was 15.5 (SD 6,9) mg%. In postprocedure, the TNF-alfa concentration was 8.05 (SD 6.7) pg/mL, there was a significant increase in TNF-alfa concentration (p = 0.02). However, IL-6 concentration was 7.75 (SD 1.76) pg/mL, there was not any significant chance in IL-6 concentration (p = 0.52). The bilirubin concentration was 11.3 (SD 6,5) mg%.Conclusion: There was a significant increase in mean concentration value of TNF-alfa after biliary drainage procedure. On the other hand there was not any significant decrease in the mean concentration value of IL-6 after biliary drainage procedure"

"Pembedahan mayor abdomen yang berhubungan dengan kanker Cholangiocarcinoma (CCA) seringkali dikaitkan dengan kejadian perawatan ICU pasca pembedahan dan mengakibatkan intensitas nyeri yang tinggi pasca operasi. Penatalaksanaan nyeri yang tidak optimal dapat berkontribusi pada komplikasi dan memiliki efek buruk pada kesembuhan pasien. Oleh karena itu, diperlukan terapi komplementer yang berfokus pada kenyamanan dan preferensi pasien sebagai bentuk optimalisasi penatalaksanaan nyeri pasien CCA pasca pembedahan abdomen di ICU. Karya Ilmiah Akhir ini bertujuan untuk memaparkan hasil praktik berupa asuhan keperawatan medikal bedah pada pasien tumor distal Common Bile Duct (CBD) post laparatomy double bypass dengan penerapan manajemen nyeri menggunakan aromaterapi lavender di ICU Rumah Sakit. Intervensi ini dilakukan pada pasien usia 25 tahun dengan ikterik obstruktif et causa tumor distal Common Bile Duct (CBD) suspek ganas kesan unresectable. Setelah dilakukan intervensi selama tiga hari, didapatkan kesimpulan bahwa aromaterapi lavender dapat digunakan sebagai intervensi manajemen nyeri non-farmakologi yang menyempurnakan terapi farmakologi dalam menurunkan nyeri pada pasien sadar pasca operasi laparatomy double bypass di ICU.

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Major abdominal surgery related to Cholangiocarcinoma (CCA) cancer is often associated with post-surgical ICU admission and results in high pain intensity post-surgery. Suboptimal pain management can contribute to complications and have an adverse effect on patient recovery. Therefore, complementary therapy is needed that focuses on patient comfort and preferences as a form of optimizing pain management for CCA patients after abdominal surgery in the ICU. This Final Scientific Work aims to present practical results in the form of medical surgical nursing care for patients with distal Common Bile Duct (CBD) tumors post double bypass laparotomy with the application of pain management using lavender aromatherapy in the ICU Hospital. This intervention was carried out on a 25-year-old patient with obstructive jaundice caused by a distal Common Bile Duct (CBD) tumor, which was suspected to be malignant and unresectable. After three days of intervention, it was concluded that lavender aromatherapy could be used as a non-pharmacological pain management intervention that complements pharmacological therapy in reducing pain in conscious patients after double bypass laparotomy surgery in the ICU."

"Excessive hepatocyte apoptosis induced by bile acid accumulation occurred in severe obstructive jaundice, and impair the liver secretion function. The objective of this study is to determine whether the inhibition of bile acid accumulation through bile duct decompression affect the excessive hepatocyte apoptosis and caused improvement the liver secretion functions on human model. In this study we use a before and after study on severe obstructive jaundice patients due to extra hepatic bile duct tumor was decompressed. Bile duct decompression was performed as a model of the role ofinhibition of bile acid accumulation inhibition bile acid accumulation and excessive hepatocyte apoptosis. Bile acid and marker of liver secretion functions were serially measured. Liver biopsy pre and post decompression was performed for Hepatocyte apoptosis pathologic examination by TUNEL fluorescing, which measured by 2 people in double blinded system. Total bile acid, and liver secretion functions were measured by automated chemistry analyzer. The result ofthis study shows that twenty one severe obstructive jaundice patients were included. After decompression the hepatocyte apoptosis index decreased from an average of 53.1 (SD 105) to 11.7 (SD 13.6) (p < 0.05). Average of bile acid serum decreased from 96.4 (SD 53.8) to 19.9 (SD 39.5) until 13.0 (SD 12.6) μmol/L (p < 0.05) Total bilirubin decreased from 20.0 (SD 8.9) to 13.3 (SD 5.0) until 6.2 (SD 4.0) mg/dL (p < 0.05), while the phosphates alkaline (ALP) and γ-glutamil transpeptidase (γ-GT) activities also decreased significantly. In conclusion, bile acids accumulation and excessive hepatocyte apoptosis through bile duct decompression improve the liver secretion functions by inhibition mechanism."

"Pancreatic carcinoma commonly occur in patients over 60 years. It is usually manifested as abdominal pain, jaundice, and pancreatic mass. In this report, a pancreatic carcinoma occured in young woman is presented. A surgical drainage was done and followed by Whipple resection. However the patient passed away three month after the diagnosis.

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Karsinoma pankreas umumnya terjadi pada pasien berusia di atas 60 tahun. Biasanya bermanifestasi sebagai perut nyeri, penyakit kuning, dan massa pankreas. Dalam laporan ini, karsinoma pankreas yang terjadi pada wanita muda adalah disajikan. Drainase bedah dilakukan dan diikuti dengan reseksi Whipple. Namun pasien tersebut meninggal hilang tiga bulan setelah diagnosis."

"Tujuan: mendapatkan kesintasan dan faktor-faktor yang berhubungan dengan mortalitas pada pasien ikterus obstruktif dengan etiologi maligna. Metode: penelitian kohort retrospektif dan prospektif dilakukan dengan data sekunder pasien ikterus obstruktif yang dirawat di RS. Cipto Mangunkusumo, Jakarta antara Januari 2010-Desember 2013. Faktor-faktor yang dinilai meliputi umur, jenis kelamin, sepsis, hipoalbumin, tingkat bilirubin serum, tingkat CA 19-9 serum, drainase bilier, keganasan non ca ampula Vater, dan komorbid dengan hasil keluaran berupa mortalitas pasien.Hasil: sebanyak 181 dari 402 pasien ikterus obstruktif dengan etiologi maligna memenuhi kriteria penelitian dengan proporsi laki-laki sebesar 58,6 % dengan pasien berumur ≥50 tahun sebesar 57,5%. Analisis multivariat menunjukkan bahwa sepsis, riwayat drainase bilier sebelumnya dan skor komorbid Charlson ≥4 merupakan prediktor independen terhadap mortalitas. Median kesintasan pasien dengan faktor prognosis bermakna adalah 14 hari sedangkan median kesintasan keseluruhan 26 hari. Ambang skor prognostik terbaik didapatkan pada skor ≥2 dengan sensitivitas 68% dan spesifisitas 75%. AUC pada kurva ROC 0.769.Kesimpulan: kesintasan pasien dengan faktor prognosis sepsis, drainase bilier tidak berhasil/tidak ada, dan skor indeks komorbid Charlson ≥4 lebih pendek dibandingkan kesintasan keseluruhan pasien. Skor prognostik ≥2 termasuk dalam risiko tinggi kematian dan kemampuan prediksi mortalitas dari faktor prognosis bermakna adalah 76.9%.

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Aim: to obtain survival rate and mortality-related factors of malignant obstructive jaundice patients.Methods: all medical records of obstructive jaundice inpatient at Cipto Mangunkusumo Hospital, Jakarta from January 2010 to December 2013 were reviewed retrospectively. The following factors were analyzed in terms of mortality: age, gender, sepsis, hypoalbumin, serum bilirubin level, serum CA 19-9 level, billiary drainage, non-ampulla Vateri carcinoma, and comorbid factors.Results: total 181 out of 402 patients were enrolled in this study with male proportion was 58.6%, and patients aged 50 years or above was 57.5%. Multivariate analysis showed that only sepsis, unsuccessful or no prior biliary drainage and Charlson comorbid score ≥4 were independent predictors of mortality. Patients with significant prognostic factors had median survival 14 days compared with overall median survival 26 days. Score ≥2 identified as the highest prognostic score threshold with sensitivity 68%, specificity 75%, and AUC on ROC curve 0.769.Conclusion: sepsis, unsuccessful or no prior bilirary drainage, and Charlson comorbid score ≥4 are factors significantly associated with shortened survival in malignant obstructive jaundice patients. Prognostic score ≥2 was determined to classify patients into high risk mortality group. Mortality of patients with those significant prognostic factors can be predicted in 76.9%."

"Latar Belakang: Ikterus obstruktif merupakan salah satu komplikasi tersering keganasan sistem bilier. Keadaan ini akan memicu pelepasan sitokin proinflamasi. Terdapat kontroversi mengenai pengaruh drainase bilier terhadap perubahan kadar sitokin proinflamasi pada penderita kanker pankreatobilier.Tujuan: Untuk mengetahui kadar Tumor Necrosis Faktor alfa (TNF-alfa) dan Interleukin 6 (IL6) sebelum dan sesudah Endoscopic Retrograde Cholangio Pancreatography (ERCP) atau Percutaneus Transhepatic Biliary Drainage (PTBD) pada penderita ikterus obstruksi etiologi kanker pankreatobilier.Metode: Desain penelitian adalah one group before after study. Pemilihan sampel secara consecutive sampling. Sampel darah diambil sebelum dan lima hari sesudah ERCP atau PTBD. Pengukuran kadar TNF-alfa dan IL-6 dengan cara Enzyme Linked Immunosorbed Assay (ELISA).Hasil: Terdapat 40 orang responden yang diikutsertakan dalam penelitian ini, 22 laki laki dan 18 perempuan dengan usia rata rata 55,3 tahun. Berdasarkan imaging dan endoskopi, ditegakkan diagnosis kolangiokarsinoma sebanyak 22 orang, tumor ampula Vateri 10 orang, dan tumor pankreas 8 orang. Kadar rata-rata TNF- alfa sebelum tindakan 4,81 (2,91) pg/ml dan sesudah tindakan 8,05 (6,7) pg/ml, terdapat peningkatan yang bermakna setelah tindakan drainase bilier (p:0,02). Kadar rata-rata IL-6 sebelum tindakan 7,79 (1,57) pg/ml dan sesudah tindakan 7,75 (1,76) pg/ml, tidak terdapat perbedaan yang bermakna setelah tindakan drainase bilier (p:0.52). Kadar rata-rata bilirubin sebelum tindakan 15,5 mg% dan sesudah tindakan 11,3 mg%.Simpulan: Terjadi peningkatan kadar rata-rata TNF-alfa secara bermakna setelah drainase. Tidak ada penurunan yang bermakna kadar rata-rata IL-6.

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Background: Obstructive jaundice represents the most common complication of biliary tract malignancy. Obstructive jaundice causes releases of proinflammatory cytokine. There has been controversy about effect of biliary drainage on the change in proinflammatory cytokine level in pancreatobiliary cancer patients.Objective: The present study was designed to determine levels of Tumor Necrosis Factor Alpha (TNF-Alpha) and Interleukin 6 (IL-6) in preprocedure of either Endoscopic Retrograde Cholangio Pancreatography (ERCP) or Percutaneus Transhepatic Biliary Drainage (PTBD) and postprocedure of them in obstructive jaundice patient caused by pancreatobiliary cancer.Methods : The study method is before- and- after case study design with consecutive sampling. Blood was collected five days prior to either Endoscopic Retrograde Cholangio Pancreatography (ERCP) procedure or Percutaneus Transhepatic Biliary Drainage (PTBD) procedure and five days after either of them. Enzyme Linked Immunosorbed Assay (ELISA) was used to determine TNF-Alpha and IL-6.Results: Forty subjects were included in this study which consisted of 22 men and 18 women. The mean age was 55.3 years old. According to the results of imaging and endoscopy procedure, twenty two (22) people were diagnosed cholangi carcinoma, ten (10) people were diagnosed ampulla varteri and eigth (8) people were diagnosed pancreatic tumor. In preprocedure, the mean of TNF-Alpha concentration was 4.81 (2.91) pg/mL, the mean of IL-6 concentration was 7.79 (1.57) pg/mL and the mean of bilirubin concentration was 15.5 mg%. In postprocedure, the mean of TNF-Alpha concentration was 8.05 (6.7) pg/mL, there was significant increase in TNF-Alpha concentration (p:0.02). However, the mean of IL-6 concentration was 7.75 (1.76) pg/mL, there was not any significant chance in IL-6 concentration (p:0.52). The mean of bilirubin concentration was 11.3 mg%.Conclusions: On one hand, there was significant increase in mean concentration value of TNF-Alpha after biliary drainage procedure. On the other hand there was not any significant decrease in mean concentration value of IL-6 after biliary drainage procedure."

"Chalangiocarcinoma is the second most common primary liver malignancy with global increase of incidence and mortality. The mean age at presentation is 50 years. Patients with cholangiocarcinoma usually will have symptoms of obstructive jaundice followed with supporting laboratory and imaging findings. The predominant clinical feature of extrahepatic cholangiocarcinoma is biliary obstruction resulting in Jaundice; while intrahepatic cholangiocarcinoma causes symptoms of intrahepatic mass including abdominal pain in right upper quadrant and other tumor-related symptoms such as cachexia and malaise. The diagnosis and staging of cholangiocarcinoma require multidisciplinary approaches including laboratory, radiological, endoscopic approaches and analysis on pathology. This case report describes a patient with a cholangiocarcinoma based on result of endoscopic retrograde cholangiopancreatography (ERCP) imaging. In addition to a diagnosis tool, ERCP can also be a therapeutic modality for placing stent to reduce symptoms of cholestasis. There were supporting laboratory findings such as increased bilirubin level, alkaline phosphates (ALP) and gamma glutamyltransferase (GGT) levels as well as increased level of tumor markers such as carcinoembryonic antigen (CEA), carbohydrate antigen (CA 19-9 and cytological examination."

"Latar Belakang. Keganasan merupakan etiologi utama ikterus obstruktif selain batu. EUS memiliki nilai diagnostik yang lebih baik dibandingkan MRCP dalam mendeteksi batu saluran empedu. Di Indonesia, belum ada penelitian yang membandingkan EUS dan MRCP pada kasus keganasan saluran bilier dan pankreas. Nilai diagnostik ini penting untuk meningkatkan kecepatan dan ketepatan diagnostik sehingga dapat diambil tatalaksana yang paling sesuai.Tujuan. Mengetahui nilai sensitivitas dan spesifisitas EUS dibandingkan MRCP pada pasien ikterus obstruktif karena keganasan.Metode. Studi observasional analitik dengan mengumpulkan data rekam medik pasien usia > 18 tahun di RSCM yang terdiagnosis ikterus obstruktif diduga karena keganasan tahun 2014-2018 dan telah dilakukan pemeriksaan EUS dan atau MRCP sebelum dilakukan ERCP (baku emas). Dilakukan identifikasi hasil EUS, MRCP, dan ERCP, kemudian dilakukan analisis dengan IBM SPSS Statistic 20 untuk uji diagnostik.Hasil Utama. Terdapat 54 subyek yang memenuhi kriteria inklusi dan eksklusi, dimana 53,7% di antaranya adalah laki-laki dengan rerata usia 56,48 ± 11,37 tahun. Tumor kaput pankreas merupakan jenis keganasan yang paling banyak dijumpai (50%) berdasarkan pemeriksaan ERCP. Nilai sensitivitas, spesifistas, NDP, NDN, RKP, RKN, dan akurasi untuk EUS masing-masing adalah 96%, 60%, 96%, 60%, 2.40, 0.07, dan 93%. Untuk MRCP, nilai masing-masing adalah 90%, 40%, 94%, 29%, 1.50, 0.26, 85%. Sedangkan nilai AUC dari EUS adalah 78% (IK95% 51%-100%), p = 0,041. Untuk MRCP, nilai AUC yang diperoleh adalah 64,9% (IK95% 36,2%-93,6%), p = 0,276.Simpulan. EUS memiliki nilai sensitivitas dan spesifisitas yang lebih baik dibandingkan MRCP pada pasien ikterus obstuktif karena keganasan.

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Background Malignancy is the main etiology of obstructive jaundice besides stones. EUS has a better diagnostic value than MRCP in detecting bile duct stones. In Indonesia, there are no studies comparing EUS and MRCP in cases of biliary and pancreatic malignancies. This diagnostic value is important to improve the speed and accuracy of the diagnostic so that the most appropriate treatment can be taken.Methods Analytic observational study by collecting medical records of patients aged> 18 years in RSCM diagnosed with obstructive jaundice suspected due to malignancy in 2014-2018 and EUS and / or MRCP examination before the ERCP (gold standard) was performed. EUS, MRCP, and ERCP results were identified, then an analysis was performed with IBM SPSS Statistics 20 for diagnostic tests.Results There were 54 subjects who met the inclusion and exclusion criteria, of which 53.7% were men with an average age of 56.48 ± 11.37 years. Pancreatic head tumor is the most common type of malignancy (50%) based on ERCP examination. The sensitivity, specificity, PPV, NPV, LR+, LR-, and accuracy values for EUS are 96%, 60%, 96%, 60%, 2.40, 0.07, and 93%, respectively. For MRCP, the values are 90%, 40%, 94%, 29%, 1.50, 0.26, 85%, respectively. AUC value for EUS is 78% (CI95% 51%-100%), p = 0.041. Meanwhile, AUC value for MRCP is 64,9% (CI95% 36,2%-93,6%), p = 0.276.Conclusion: EUS has better sensitivity and specificity values than MRCP in obstructive jaundice patients due to malignancy."