The differential diagnosis for yellowing of the skin is limited. In addition to jaundice, it includes
Carotenoderma
The use of the drug Quinacrine
Excessive exposure to phenols
It is yellowish discoloration of
Skin, mucous membranes, sclera
Due to excess plasma bilirubin
JAUNDICE in carotenoderma the pigment is concentrated on the palms, soles, forehead, and nasolabial folds. Carotenoderma can be distinguished from jaundice by the sparing of the sclerae
Is not a disease but rather a sign that can occur in many different diseases
Normal range
5-17 m mol/l
Clinically obvious
50 mmol/l
(2.5mg/dl)

Liver, Spleen &
Bone marrow
Phagocytosis & Lysis
Hemoglobin
Globin
Amino acids www.drsarma.in
Amino acid pool
Heme Bilirubin
Fe 2+
Through Liver
Excreted
3

About 70 to 80% of the 250 to 300 mg of bilirubin produced each day is derived from the breakdown of hemoglobin in senescent red blood cells
The remainder comes from prematurely destroyed erythroid cells in bone marrow and from the turnover of hemoproteins such as myoglobin and cytochromes found in tissues throughout the body.
Excretion

Direct Hyperbilirubiemia

Medical Causes
1-Alcoholic hepatitis
2-Drugs-Intravenously administered tetracycline, chlorpromazine
Hydrochloride, oral contraceptives, methyl testosterone, halothane, azathioprine
3-Lymphomas
4-Primary biliary cirrhosis
5-Cholestasis of pregnancy (3 rd trimester)
6-Benign, recurrent intrahepatic cholestasise
7-Post-operative jaundice (anoxia, transfusions, etc.)
8-Sclerosing cholangitis
9-Pericholangitis

Surgical Causes
Very common (25 to 35 percent)
Choledocholithiasis
Carcinoma of head of pancreas
Common (5 to 10 percent)
Carcinoma of common duct
Stricture of common duct
Ampullary carcinoma
Uncommon (I to 5 percent)
Chronic pancreatitis
Sclerosing cholangitis
Lymphoma
Metastatic carcinoma
Primary liver cell carcinoma
Rare (less than I percent)
Post-bulbar ulcer
Hepatic artery aneurysm
Choledochal cyst
Biliary atresia
Duodenal diverticulum hemobilia
Medical Causes

Gallstones are also associated with certain medical conditions including:
1-Diabetes
2-Liver disease
3-Crohn's disease
4-Blood disorders like sickle-cell anaemia
5-Stomach surgery - gallstones are more common if you have had surgery to remove part of your stomach

The majority of cases
(approximately 80%)are asymptomatic (silent) gall stones , discovered accidentally by abdominal sonar .
A gall stone may impact in the neck of gall bladder or in the cystic duct giving biliary pain or cholecystitis
Biliary pain usually occurs in the epigastrium and right hypochondrium
Gall stones increase risk of carcinoma of the gall bladder
Obstruction of common bile duct leading to pain & jaundice
Pancreatitis.

Charcot’s Triad:
1-Pain
2-Jaundice
3-Fever
Obstruction of common bile duct leading to pain & jaundice
May Complicate to
Abdominal Ex:
1-Gall Bladder: in 80%Not Distended
When gall bladder be distended??
Murphy’s sign +ve
2-Liver:Enlarged?????
Reynold’s Pentad:
1-Pain
2-Jaundice
3-Fever
4-Altered Mental State
5-Shock

Preoperative Preparation:
Correct Clotting Dysfunction
Guard vs LCF
Guard vs RF
Definitive Treatment:
Remove Source of Obstruction (stone)
Remove Source of Stone (Gall bladder)
Chronic cholecystitis Obstructive Jaundice Charcot’s Triad
ERCP
Reynold’s Pentad ttt
Of
Shock
Treatment

Symptoms Signs
Cachecxia
Criteria of obstructive jaundice
Pain which is common, characterized by starting as vague
(Lower abdomen or back)
Usually worsen in supine position & relived by lining forward
It may be caused by:
A) Tumor invasion of splanchnic plexuses & retroperitoneum
B) Obstruction of pancreatic duct
Digestive symptoms
Jaundice
Palpable liver
Palpable gall bladder
Tenderness
Ascites
Abdominal mass
In advanced cases:
Nodular liver
Enlarged supraclavicular lymph node
Periumblical adenopathy

Courvoisier’s sign = painless, palpable/distended gallbladder on exam (think of CA)

Diagnosis & management of pancreatic cancer:
It depends on results of
Spiral CT
1 ) Resectable: ask yourself if operative candidate or not a)YES :Explore for resection b) NO: =NONOPERATIVE: Palliation, Biliary stent & Chemo/Radiotherapy
2) Unresectable: is it only Biliary or associated with duodenal obstruction a)only Biliary:Endobiliary stent b)Both: Operative palliation(Biliary bypass)
Gastrojejunostomy
Celiac plexus block

Magnetic resonance cholangiopancreatography (MRCP)
– Advantage
• Detects choledocholithiasis, neoplasms, strictures, biliary dilations
• Sensitivity of 81-100%, specificity of 92-100% of choledocholithiasis
• Minimally invasiveavoid invasive procedure in 50% of patients
– Disadvantage:
• cannot sample bile, test cytology, remove stone
• Contraindications: pacemaker, implants, prosthetic valves
– Indications
• If cholangitis not severe, and risk of ERCP high, MRCP useful
• If Charcot’s triad present, therapeutic ERCP with drainage should not be delayed.
Endoscopic retrograde cholangiopancreatography
(ERCP)
-Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction
-Advantage
•Therapeutic option when CBD stone identified
•Stone retrieval and sphincterotomy
-Disadvantage
•Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding
•Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

MRCP
• purely diagnostic .
• rapid, accurate and noninvasive
• Safe : no contrast material administration no radiation.
• alternative to diagnostic
ERCP.
• MRCP avoids the complications of ERCP

•

• Endoscopic biliary drainage
– Endoscopic sphincterotomy with stone extraction and stent insertion
• CBD stones removed in 90-95% of cases
• Therapeutic mortality 4.7% and morbidity
10%, lower than surgical decompression
• Surgery
– Emergency surgery replaced by non-operative biliary drainage
– Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal
– Elective surgery: low M & M compared with emergency survey
– If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

ERCP

• Choledocholithiasis develops in
10-20% of patients with gallbladder disease
• At least 3-10% of patients undergoing cholecystectomy will have CBD stones
– Pre-op
– Intra-op
– Post-op

– Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP
• High risk (>50%) of choledocholithiasis:
– clinical jaundice, cholangitis,
– CBD dilation or choledocholithiasis on ultrasound
– Tbili > 3 mg/dL correlates to 50-70% of CBD stone
• Moderate risk (10-50%):
– h/o pancreatitis, jaundice correlates to CBD stone in 15%
– elevated preop bili and AP,
– multiple small gallstones on U/S
• Low risk (<5%):
– large gallstones on U/S
– no h/o jaundice or pancreatitis,
– normal LFTs
-Treatment:
•ERCP
•Surgery

• Diagnosis: intraoperative cholangiography (IOC)
– Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects.
– Detect CBD stones
– Potentially identify bile duct abnormalities, including iatrogenic injuries
– Sensitivity 98%, specificity 94%
– Morbidity and mortality low
• Treatment
-Open CBD exploration
Most surgeons prefer less invasive techniques
-Laparoscopic CBD exploration
•
• via via choledochotomy: CBD dilatation > 6mm cystic duct (66-82.5%)
•CBD clearance rate 97%
•Morbidity rate 9.5%
•Stones impacted at Sphincter of Oddi most difficult to extract
-Intraoperative ERCP

• 1889 , 1 st CBD exploration by Ludwig
Courvoisier, a Swiss surgeon
– Kocherization of duodenum and short longitudinal choledochotomy
– Stones removed with palpation, irrigation with flexible catheters, forceps,
– Completion with T-tube drainage
– For many years, this was the standard treatment for cholecystocholedocholithiasis
• 1970s , endoscopic sphincterotomy (ES)
-Gained wide acceptance as good, less invasive, effective alternative
-In patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choice

PTC
• Diagnostic and theraputic
• Performed with 22G
Chiba Needle
• Complication:
-Bacteremia
-Haemorrhage
-Contrast reaction
-Pneumothorax
-Intrahepatic arterioportal fistula
-Bile leakage

Percutaneous access to the biliary tree, through the
CBD, if possible, and into the duodenum.
Downsides:
External drainage
Procedural risks:
– Coagulopathy
– ascites