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OBSTRUCTIVE JAUNDICE. DR.JAMIL SAWAKED. DEFITION OF JAUNDICE. YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE. TYPES. HAEMOLYSIS. PREHEPATIC. A. HEPATIC . POSTHEPATIC. OBSTRUCTIVE OR SURGICAL. ANATOMY. ANATOMY. A. BILIRUBIN CYCLE. BROKEN DOWN RED CELLS ARE

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Obstructive jaundice

OBSTRUCTIVE JAUNDICE

DR.JAMIL SAWAKED


Defition of jaundice
DEFITION OF JAUNDICE

  • YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE


Types
TYPES

HAEMOLYSIS

PREHEPATIC

A

HEPATIC

POSTHEPATIC

OBSTRUCTIVEOR SURGICAL




Bilirubin cycle
BILIRUBIN CYCLE

  • BROKEN DOWN RED CELLSARE

    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
BILIRUBIN CYCLE CONTINUE

HAEM SPLITS INTO IRON & BILIRUBIN [pigments]

IRON STORED AS FERRITINFOR

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 WALLPROTEIN

FERRITIN

TO BE REUSED

BILIRUBIN

WATER INSOLUBLE

AMINOACIDS

AMINOACID

POOL

GOES TO THE LIVER FOR CONGUGATIONWITH GLUCOURINIC A.TO BECOME WATER SOLUBLE

BLOOD

URINE





Causes of obstructive jaundice
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
CAUSES IN THE LUNEN

ASCARIS

PARASITES

CLONORCHIASIS

HYDATID

PAPILLOMATOSIS

CHOLANGIOCARCINOMA

STONE IS THE COMMONEST


In the wall strictures
IN THE WALL:STRICTURES

BENIGN STRICTURES

MALIGNANT STRICTURES


Outside the wall
OUTSIDE THE WALL

L.N.

ANY MASS OUTSIDE

Stone in cystic duct

MIRIZZI SYND

HARTMANN`S POUCH stone

HEAD OF THE PANCREASE



Benign strictures
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
BILIARY ATRESIA

BILIARY ATRESIA

NORMAL



The commonest cause
THE COMMONEST CAUSE

  • STONE SLIPPING INTO THE BILIARY TREE





Endoscopic view of periampullary tumour
ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR

ORIGIN

1-DEUDENAL MUCOSA OR

2-C.B.D. OR

3-PANCREATIC DUCT



Cholangiocarcinoma
CHOLANGIOCARCINOMA

LIVER METASTASIS



Sclerosing cholangitis
SCLEROSING CHOLANGITIS

  • Associated with U.Colitis in 70% of cases

  • May lead to malignancy

  • Unknown aetiology

  • Symptoms of cholangitis

  • Treatment;Antibiotics

  • Orliver transplant

Rosary beads

شكل المسبحة


Symptoms
SYMPTOMS

  • PAIN

  • YELLOW DISCOLOURATION SKIN &M.M.

  • DARK URINE [TEA COLOUR]

  • CLAY COLOUR STOOL لون الطحينية

  • ITCHING

  • FEVER IF CHOLANGITIS SUPERVENE

  • LOSS OF APPETITE

  • LOSS OF WEIGHT IN MALIGNACY


Signs
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
DEEP JAUNDICE [GREEN] [OBSTRUCTIVE]

  • VIRCHOW`SNODE

OR

[TROISIER`S SIGN]

BRUISING

VIT.K DEF.

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


Courvoisier law
COURVOISIER` LAW

DISTENDED GALL BLADDER

IN CA,HEAD OF PANCREASE



Investigations
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.


Investigations1
INVESTIGATIONS

  • U.S.

STONE


Dilated cbd stone us
DILATED CBD & STONE [US]

Should be more than 6 mm



ERCP

SPHINCTEROTOMY




ERCP

C.B.D.STONE












P t c
P.T.C.

  • PERCUTANOUS TRANSHEPATIC

    CHOLANGIOGRAM





Management 1
MANAGEMENT-1

  • CORRECTION OF THE DERENGED PARAMETRES

  • ADMINISTRATION OF VITAMIN K

  • ANTIBIOTICS

  • MANNITOL PRE, INTRA and POSTOPERATIVELY TO PREVENT

    HEPATO-RENAL SHUTDOWN


Management 2
MANAGEMENT-2

  • 1. STONE-SPHINCTEROTOMY

  • 2.STONE-EXPLORATION OF C.B.D.

  • 3.STRICTURE-RESECTION ANASTOMOSIS FORSHORT 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



Whipple s operation
WHIPPLE`S OPERATION

Pancreatico-duodenoctomy


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