Obstructive jaundice
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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

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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


Anatomy

ANATOMY


Anatomy1

ANATOMY

A


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


Obstructive jaundice

  • 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]


Obstructive jaundice

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


Urine in obstructive jaundice tea colour

URINE IN OBSTRUCTIVE JAUNDICE TEA COLOUR


Bilirubin cycle1

BILIRUBIN CYCLE


Deep jaundice obstructive

DEEP JAUNDICE [OBSTRUCTIVE]


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


Mirrizi s syndrome

MIRRIZI`s syndrome


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


Causes

CAUSES


The commonest cause

THE COMMONEST CAUSE

  • STONE SLIPPING INTO THE BILIARY TREE


Impacted stone at the lower end of c b d

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


Assending cholangitis with liver absesses

ASSENDING CHOLANGITIS WITH LIVER ABSESSES


Ca head of the pancrease

CA. HEAD OF THE PANCREASE


Endoscopic view of periampullary tumour

ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR

ORIGIN

1-DEUDENAL MUCOSA OR

2-C.B.D. OR

3-PANCREATIC DUCT


Cholangicarcinoma

CHOLANGICARCINOMA


Cholangiocarcinoma

CHOLANGIOCARCINOMA

LIVER METASTASIS


C b d stricture

C.B.D.STRICTURE


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


Ascites in advanced ca head of pancrease

ASCITES IN ADVANCED 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


C t double burrle sign distended g

C.T. DOUBLE BURRLE SIGN &DISTENDED G.

PERIAMPULLARY TUMOUR


Obstructive jaundice

ERCP

SPHINCTEROTOMY


Stone extraction by basket

STONE EXTRACTION BY BASKET


Stone extraction by ballon

STONE EXTRACTION BY BALLON


Obstructive jaundice

ERCP

C.B.D.STONE


C b d big stone

C.B.D. BIG STONE


Stent

STENT


Stone removed

STONE REMOVED


C b d stricture1

C.B.D. STRICTURE


C b d stent with good flow

C.B.D.STENT WITH GOOD FLOW


Cholangicarcinoma1

CHOLANGICARCINOMA


Cholangiocarcinoma1

CHOLANGIOCARCINOMA


E r c p for extrahepatic cholangiocarcinoma

E.R.C.P.FOR EXTRAHEPATIC CHOLANGIOCARCINOMA


Endoscopic view of periampullary tumour1

ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR


M r c p

M.R.C.P


P t c

P.T.C.

  • PERCUTANOUS TRANSHEPATIC

    CHOLANGIOGRAM


Peroperative cholangiogram

PEROPERATIVE CHOLANGIOGRAM


T tube cholangiogram

T.TUBE CHOLANGIOGRAM


Drain cholangiogram

DRAIN 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


Stent for ca head of pancrease

STENT FOR Ca. head of pancrease


Whipple s operation

WHIPPLE`S OPERATION

Pancreatico-duodenoctomy


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