OBSTRUCTIVE
JAUNDICE
DR.JAMIL SAWAKED
DEFITION OF JAUNDICE
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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
TYPES
A
PREHEPATIC
HEPATIC
POSTHEPATIC
OBSTRUCTIVE
OR SURGICAL
HAEMOLYSIS
ANATOMY
ANATOMY
A
BILIRUBIN CYCLE
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BROKEN DOWN RED CELLS ARE
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 FERRITIN FOR
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 WALL
PROTEIN
FERRITIN
BILIRUBIN
TO BE
REUSED
WATER
INSOLUBLE
GOES TO THE LIVER
FOR CONGUGATION
WITH GLUCOURINIC
A.TO BECOME
WATER SOLUBLE
BLOOD
URINE
AMINOACIDS
AMINOACID
POOL
URINE IN OBSTRUCTIVE JAUNDICE
TEA COLOUR
BILIRUBIN CYCLE
DEEP JAUNDICE
[OBSTRUCTIVE]
CAUSES OF OBSTRUCTIVE
JAUNDICE
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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
CLONORCHIASIS
PARASITES
HYDATID
PAPILLOMATOSIS
CHOLANGIOCARCINOMA
STONE IS THE
COMMONEST
IN THE WALL:STRICTURES
BENIGN STRICTURES
MALIGNANT STRICTURES
OUTSIDE THE WALL
L.N.
Stone in
cystic duct
MIRIZZI SYND
HARTMANN`S POUCH stone
HEAD OF THE
PANCREASE
ANY MASS
OUTSIDE
MIRRIZI`s syndrome
BENIGN STRICTURES
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1-BILIARY ATRESIA
2-IATROGENIC
BILIARY SURGERY[commonest]
GASTRECTOMY
HEPATIC RESECTION
LIVER TRANSPLANT
3-INFLAMMATORY;CHOLANGITIS , PANCREATITIS,
SCLEROSINGCHOLANANGITIS.
4-TRAUMA
5-IDIOPATHIC
6-RADIOTHERAPY
BILIARY ATRESIA
NORMAL
BILIARY ATRESIA
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
• Or liver transplant
Rosary beads ‫شكل المسبحة‬
SYMPTOMS
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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
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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`S
NODE
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
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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
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CORRECTION OF THE DERENGED
PARAMETRES
ADMINISTRATION OF VITAMIN K
ANTIBIOTICS
MANNITOL PRE, INTRA and
POSTOPERATIVELY TO PREVENT
HEPATO-RENAL SHUTDOWN
MANAGEMENT-2
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1. STONE-SPHINCTEROTOMY
2.STONE-EXPLORATION OF C.B.D.
3.STRICTURE-RESECTION ANASTOMOSIS FOR
SHORT STRICTURES
4.STRICTURE-STENT FOR SHORT AND LONG
5.CA.HEAD OF THE PANCREASE
=EARLY-WHIPPLE`S
OPERATION[PANCREATICO-DUODENECTOMY.
=LATE-BYPASS SURGERY[CHOLECYSTOJUJENOSTOMY
STENT FOR Ca. head of
pancrease
WHIPPLE`S OPERATION
Pancreatico-duodenoctomy