OBSTRUCTIVE JAUNDICE

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OBSTRUCTIVE JAUNDICE

• DR.JAMIL SAWAKED

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DEFITION OF JAUNDICE

• YELLOW DISCOLOURATION OF SKIN AND MUCOUS
  MEMBRANE

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TYPES
HAEMOLYSIS

• A

PREHEPATIC
HEPATIC
POSTHEPATIC
OBSTRUCTIVE OR SURGICAL
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ANATOMY
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ANATOMY

• A

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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

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BILIRUBIN CYCLE CONTINUE

• HAEM SPLITS INTO IRON
  BILIRUBIN pigments
• IRON STORED AS FERRITIN FOR
• REUSE

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• 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
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HAEMOGLOBIN
IRON
RBC WALL PROTEIN
FERRITIN TO BE REUSED
BILIRUBIN WATER INSOLUBLE
AMINOACIDS
AMINOACID POOL
GOES TO THE LIVER FOR CONGUGATION WITH
GLUCOURINIC A.TO BECOME
WATER SOLUBLE
BLOOD
URINE
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URINE IN OBSTRUCTIVE JAUNDICE
TEA COLOUR
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BILIRUBIN CYCLE
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DEEP JAUNDICE OBSTRUCTIVE
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CAUSES OF OBSTRUCTIVE JAUNDICE

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

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CAUSES IN THE LUNEN
ASCARIS
PARASITES
CLONORCHIASIS
HYDATID
PAPILLOMATOSIS
CHOLANGIOCARCINOMA
STONE IS THE COMMONEST
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IN THE WALLSTRICTURES
BENIGN STRICTURES
MALIGNANT STRICTURES
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OUTSIDE THE WALL
L.N.
ANY MASS OUTSIDE
Stone in cystic duct
MIRIZZI SYND
HARTMANNS POUCH stone
HEAD OF THE PANCREASE
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MIRRIZIs syndrome
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BENIGN STRICTURES

• 1-BILIARY ATRESIA
• 2-IATROGENIC
• BILIARY SURGERY
• GASTRECTOMY
• HEPATIC RESECTION
• LIVER TRANSPLANT
• 3-INFLAMMATORYCHOLANGITIS , PANCREATITIS,
  SCLEROSING CHOLANANGITIS.
• 4-TRAUMA
• 5-IDIOPATHIC
• 6-RADIOTHERAPY

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BILIARY ATRESIA
BILIARY ATRESIA
NORMAL
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CAUSES
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THE COMMONEST CAUSE

• STONE SLIPPING INTO THE BILIARY TREE

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IMPACTED STONE AT THE LOWER END OF C.B.D.
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ASSENDING CHOLANGITIS WITH LIVER ABSESSES
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CA. HEAD OF THE PANCREASE
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ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR
ORIGIN 1-DEUDENAL MUCOSA OR
2-C.B.D. OR 3-PANCREATIC DUCT
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CHOLANGICARCINOMA
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CHOLANGIOCARCINOMA
LIVER METASTASIS
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C.B.D.STRICTURE
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SCLEROSING CHOLANGITIS

• Associated with U.Colitis in 70 of cases
• May lead to malignancy
• Unknown aetiology
• Symptoms of cholangitis
• TreatmentAntibiotics
• Or liver transplant

??? ???????
Rosary beads
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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

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SIGNS

• LOSS OF Wt. IN MALIGNANCY
• TOXIC IN CHOLANGITIS,
• CHARCOTS TRIAD,PAIN, FEVER ,JAUNDICE
• YELLOW DISCOLOURATION OF SKIN,M.M.
• TROISIERS SIGN. VIRCHOWS NODE
• TENDER R.U.Q.IN CHOLANGITIS
• COURVOISIER LAWIN CA.HEAD OF PAN.
• ABDOMINL MASS
• ASCITESIN MAIGNANCY

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DEEP JAUNDICE GREEN OBSTRUCTIVE

• VIRCHOWS NODE

OR
TROISIERS SIGN
BRUISING VIT.K DEF.
2,4,7,9,10.DEPEND ON IT
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COURVOISIER LAW
DISTENDED GALL BLADDER IN CA,HEAD OF PANCREASE
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ASCITES IN ADVANCED CA. HEAD OF
PANCREASE
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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.

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INVESTIGATIONS

• U.S.

STONE
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DILATED CBD STONE US
Should be more than 6 mm
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C.T. DOUBLE BURRLE SIGN
DISTENDED G.
PERIAMPULLARY TUMOUR
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ERCP
SPHINCTEROTOMY
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STONE EXTRACTION BY BASKET
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STONE EXTRACTION BY BALLON
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ERCP
C.B.D.STONE
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C.B.D. BIG STONE
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STENT
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STONE REMOVED
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C.B.D. STRICTURE
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C.B.D.STENT WITH GOOD FLOW
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CHOLANGICARCINOMA
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CHOLANGIOCARCINOMA
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E.R.C.P.FOR EXTRAHEPATIC CHOLANGIOCARCINOMA
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ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR
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M.R.C.P
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P.T.C.

• PERCUTANOUS TRANSHEPATIC
• CHOLANGIOGRAM

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PEROPERATIVE
CHOLANGIOGRAM
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T.TUBE CHOLANGIOGRAM
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DRAIN CHOLANGIOGRAM
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MANAGEMENT-1

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

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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-WHIPPLES OPERATIONPANCREATICO-DUODENE
  CTOMY.
• LATE-BYPASS SURGERYCHOLECYSTO-JUJENOSTOMY

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STENT FOR Ca. head of pancrease
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WHIPPLES OPERATION
Pancreatico-duodenoctomy
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