OBSTRUCTIVE JAUNDICE

DR.JAMIL SAWAKED

DEFITION OF JAUNDICE

YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE

TYPES
A
PREHEPATIC

HAEMOLYSIS

HEPATIC

POSTHEPATIC
OBSTRUCTIVE OR SURGICAL

ANATOMY

ANATOMY
A

BILIRUBIN CYCLE

BROKEN DOWN RED CELLS ARE REMOVED BY R.E.S. HAEMOGLOBIN SPLITS INTO HAEM &GLOBIN GLOBIN & CELL WALL PROTEIN GO DOWN TO AMINOACIDS THEY ENTER THE AMINO ACID POOL

BILIRUBIN CYCLE CONTINUE

HAEM SPLITS INTO IRON BILIRUBIN [pigments]

&

IRON STORED AS FERRITIN FOR

REUSE

BILIRUBIN IS NOT REUSED [GOES TO THE LIVER] COMBINE WITH GLUCOURINC ACID TO FORM THE CONJUGATED [ DIRECT ] BILIRUBIN [ WATER SOLUBLE ]

Van den Bergh reaction [DIRECT] Alcohol added after van den Gergh [INDIRECT]

HAEMOGLOBIN IRON +RBC WALL BILIRUBIN WATER INSOLUBLE

GOES TO THE LIVER FOR CONGUGATION WITH GLUCOURINIC A.TO BECOME PROTEIN

FERRITIN
TO BE REUSED

AMINOACIDS

AMINOACID POOL

WATER SOLUBLE
BLOOD

URINE

URINE IN OBSTRUCTIVE JAUNDICE TEA COLOUR

BILIRUBIN CYCLE

DEEP JAUNDICE [OBSTRUCTIVE]

CAUSES OF OBSTRUCTIVE JAUNDICE

1-STONES 2-STRICTURES; [BENIGN] 3-CA. HEAD OF THE PANCREASE 4-CHOLANGIOCARCINOMA 5-PERIAMPULLARY TUMOUR 6-PRESSURE FROM OUTSIDE;L.N.,M.SYN. 7-CHOLEDOCHAL CYST 8-PARASITES; FILLING THE LUMEN

CAUSES IN THE LUNEN

ASCARIS
CLONORCHIASIS

PARASITES

HYDATID

PAPILLOMATOSIS

CHOLANGIOCARCINOMA

STONE IS THE COMMONEST

IN THE WALL:STRICTURES
BENIGN STRICTURES

MALIGNANT STRICTURES

OUTSIDE THE WALL

L.N. ANY MASS OUTSIDE

Stone in cystic duct

MIRIZZI SYND HARTMANN`S POUCH stone

HEAD OF THE PANCREASE

MIRRIZI`s syndrome

BENIGN STRICTURES

1-BILIARY ATRESIA 2-IATROGENIC BILIARY SURGERY GASTRECTOMY HEPATIC RESECTION LIVER TRANSPLANT 3-INFLAMMATORY;CHOLANGITIS , PANCREATITIS, SCLEROSING
CHOLANANGITIS.

4-TRAUMA 5-IDIOPATHIC 6-RADIOTHERAPY

BILIARY ATRESIA

NORMAL

BILIARY ATRESIA

CAUSES

THE COMMONEST CAUSE

STONE SLIPPING INTO THE BILIARY TREE

IMPACTED STONE AT THE LOWER END OF C.B.D.

ASSENDING CHOLANGITIS WITH LIVER ABSESSES

CA. HEAD OF THE PANCREASE

ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR

ORIGIN
1-DEUDENAL MUCOSA OR 2-C.B.D. OR

3-PANCREATIC DUCT

CHOLANGICARCINOMA

CHOLANGIOCARCINOMA

LIVER METASTASIS

C.B.D.STRICTURE

SCLEROSING CHOLANGITIS
Associated with U.Colitis in 70% of cases May lead to malignancy
Unknown aetiology Symptoms of cholangitis Treatment;Antibiotics Or liver transplant

Rosary beads

SYMPTOMS

PAIN YELLOW DISCOLOURATION SKIN &M.M. DARK URINE [TEA COLOUR] CLAY COLOUR STOOL ITCHING FEVER IF CHOLANGITIS SUPERVENE LOSS OF APPETITE LOSS OF WEIGHT IN MALIGNACY

SIGNS

LOSS OF Wt. IN MALIGNANCY TOXIC IN CHOLANGITIS, [CHARCOT`S TRIAD,;PAIN, FEVER ,JAUNDICE] YELLOW DISCOLOURATION OF SKIN,M.M. TROISIER`S SIGN. VIRCHOW`S NODE TENDER R.U.Q.[IN CHOLANGITIS] COURVOISIER` LAW[IN CA.HEAD OF PAN.] ABDOMINL MASS ASCITES[IN MAIGNANCY]

DEEP JAUNDICE [GREEN] [OBSTRUCTIVE]

VIRCHOW`S

NODE

OR

[TROISIER`S SIGN]

BRUISING VIT.K DEF.

2,4,7,9,10.DEPEND ON IT

COURVOISIER` LAW

DISTENDED GALL BLADDER

IN CA,HEAD OF PANCREASE

ASCITES IN ADVANCED CA. HEAD OF PANCREASE

INVESTIGATIONS

C.B.C. DIFF., ESR. L.FT. *S.ALK.P.* PROTHROMBIN TIME S. AMYLASE K.F.T. ELECTRLYTES URINE ANALSIS * BILIRUBIN * STOOL ANALYSIS,;FAT,BLOOD.

INVESTIGATIONS
U.S.

STONE

DILATED CBD & STONE [US]

Should be more than 6 mm

C.T. DOUBLE BURRLE SIGN &DISTENDED G.

PERIAMPULLARY TUMOUR

ERCP

SPHINCTEROTOMY

STONE EXTRACTION BY BASKET

STONE EXTRACTION BY BALLON

ERCP
C.B.D.STONE

C.B.D. BIG STONE

STENT

STONE REMOVED

C.B.D. STRICTURE

C.B.D.STENT WITH GOOD FLOW

CHOLANGICARCINOMA

CHOLANGIOCARCINOMA

E.R.C.P.FOR EXTRAHEPATIC CHOLANGIOCARCINOMA

ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR

M.R.C.P

P.T.C.

PERCUTANOUS TRANSHEPATIC CHOLANGIOGRAM

PEROPERATIVE CHOLANGIOGRAM

T.TUBE CHOLANGIOGRAM

DRAIN CHOLANGIOGRAM

MANAGEMENT-1

CORRECTION OF THE DERENGED PARAMETRES ADMINISTRATION OF VITAMIN K ANTIBIOTICS MANNITOL PRE, INTRA and POSTOPERATIVELY TO PREVENT HEPATO-RENAL SHUTDOWN

MANAGEMENT-2

1. STONE-SPHINCTEROTOMY 2.STONE-EXPLORATION OF C.B.D. 3.STRICTURE-RESECTION ANASTOMOSIS FOR SHORT STRICTURES 4.STRICTURE-STENT FOR SHORT AND LONG 5.CA.HEAD OF THE PANCREASE =EARLY-WHIPPLE`S OPERATION[PANCREATICO-DUODENECTOMY. =LATE-BYPASS SURGERY[CHOLECYSTOJUJENOSTOMY

STENT FOR Ca. head of pancrease

WHIPPLE`S OPERATION
Pancreatico-duodenoctomy