OBSTRUCTIVE JAUNDICE

1. OBSTRUCTIVE JAUNDICE DR.JAMIL SAWAKED

2. DEFITION OF JAUNDICE • YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE • Clinically evident when bilirubin is more than 2.5 mg/dl • Normal bilirubin 0.2-1.2 mg /dl

3. TYPES HAEMOLYSIS PREHEPATIC A HEPATIC POSTHEPATIC OBSTRUCTIVEOR SURGICAL

4. ANATOMY

5. ANATOMY A

7. 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

8. BILIRUBIN CYCLE CONTINUE HAEM SPLITS INTO IRON & BILIRUBIN [pigments] IRON STORED AS FERRITINFOR REUSE

9. 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]

10. 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

11. URINE IN OBSTRUCTIVE JAUNDICE TEA COLOUR

12. BILIRUBIN CYCLE

13. DEEP JAUNDICE [OBSTRUCTIVE]

14. 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

15. CAUSES IN THE LUNEN ASCARIS PARASITES CLONORCHIASIS HYDATID PAPILLOMATOSIS CHOLANGIOCARCINOMA STONE IS THE COMMONEST

16. IN THE WALL:STRICTURES BENIGN STRICTURES MALIGNANT STRICTURES

17. OUTSIDE THE WALL L.N. ANY MASS OUTSIDE Stone in cystic duct MIRIZZI SYND HARTMANN`S POUCH stone HEAD OF THE PANCREASE

18. MIRRIZI`s syndrome

19. BENIGN STRICTURES • 1-BILIARY ATRESIA • 2-IATROGENIC BILIARY SURGERY[commonest] GASTRECTOMY HEPATIC RESECTION LIVER TRANSPLANT • 3-INFLAMMATORY;CHOLANGITIS , PANCREATITIS, SCLEROSINGCHOLANANGITIS. • 4-TRAUMA • 5-IDIOPATHIC • 6-RADIOTHERAPY

20. BILIARY ATRESIA BILIARY ATRESIA NORMAL

21. CAUSES

22. THE COMMONEST CAUSE • STONE SLIPPING INTO THE BILIARY TREE

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

24. ASSENDING CHOLANGITIS WITH LIVER ABSESSES

25. CA. HEAD OF THE PANCREASE

26. ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR ORIGIN 1-DEUDENAL MUCOSA OR 2-C.B.D. OR 3-PANCREATIC DUCT

27. CHOLANGICARCINOMA

28. CHOLANGIOCARCINOMA LIVER METASTASIS

29. C.B.D.STRICTURE

30. 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

31. 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

32. 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]

33. DEEP JAUNDICE [GREEN] [OBSTRUCTIVE] • VIRCHOW`SNODE OR [TROISIER`S SIGN] BRUISING VIT.K DEF. 2,4,7,9,10.DEPEND ON IT

34. COURVOISIER` LAW DISTENDED GALL BLADDER IN CA,HEAD OF PANCREASE

35. ASCITES IN ADVANCED CA. HEAD OF PANCREASE

36. 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.

37. INVESTIGATIONS • U.S. STONE

38. DILATED CBD & STONE [US] Should be more than 6 mm

39. C.T. DOUBLE BURRLE SIGN &DISTENDED G. PERIAMPULLARY TUMOUR

40. ERCP SPHINCTEROTOMY

41. STONE EXTRACTION BY BASKET

42. STONE EXTRACTION BY BALLON

43. ERCP C.B.D.STONE

44. C.B.D. BIG STONE

45. STENT

46. STONE REMOVED

47. C.B.D. STRICTURE

48. C.B.D.STENT WITH GOOD FLOW

49. CHOLANGICARCINOMA

50. CHOLANGIOCARCINOMA