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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

DR.JAMIL SAWAKED


DEFITION OF JAUNDICE

  • YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE


TYPES

HAEMOLYSIS

PREHEPATIC

A

HEPATIC

POSTHEPATIC

OBSTRUCTIVEOR SURGICAL


ANATOMY


ANATOMY

A


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

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


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

PARASITES

CLONORCHIASIS

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

BILIARY ATRESIA

NORMAL


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

  • Orliver transplant

Rosary beads

شكل المسبحة


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

  • 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`SNODE

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 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


WHIPPLE`S OPERATION

Pancreatico-duodenoctomy


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