OBSTRUCTIVE JAUNDICE

DR.JAMIL SAWAKED

DEFITION OF JAUNDICE

YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE

TYPES

A PREHEPATIC

HEPATIC

POSTHEPATIC

HAEMOLYSIS

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

+RBC WALL PROTEIN

AMINOACIDS

AMINOACID

POOL

IRON

BILIRUBIN

WATER INSOLUBLE

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

WATER SOLUBLE

FERRITIN

TO BE REUSED

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

STONE IS THE COMMONEST

CHOLANGIOCARCINOMA

PAPILLOMATOSIS

HYDATID

ASCARIS

CLONORCHIASIS PARASITES

IN THE WALL:STRICTURES

BENIGN STRICTURES

MALIGNANT STRICTURES

OUTSIDE THE WALL

L.N.

HEAD OF THE PANCREASE

MIRIZZI SYND

ANY MASS OUTSIDE

HARTMANN`S POUCH stone

Stone in cystic duct

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

شكل المسبحة

Rosary beads

SYMPTOMS

PAIN YELLOW DISCOLOURATION SKIN &M.M. DARK URINE [TEA COLOUR] CLAY COLOUR STOOL الطحينية لون 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

]TROISIER`S SIGN[

BRUISING

VIT.K DEF.

OR

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

ERCPSPHINCTEROTOMY

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[CHOLECYSTO-

JUJENOSTOMY

STENT FOR Ca. head of pancrease

WHIPPLE`S OPERATIONPancreatico-duodenoctomy