DR.JAMIL SAWAKED

DEFITION OF JAUNDICE
 YELLOW DISCOLOURATION OF SKIN AND
MUCOUS MEMBRANE

TYPES
A PREHEPATIC
HEPATIC
POSTHEPATIC
OBSTRUCTIVE
OR SURGICAL
HAEMOLYSIS

ANATOMY

A
ANATOMY

BILIRUBIN CYCLE




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
SPLITS INTO
IRON
&
IRON STORED AS
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]

HAEM O GLOBIN
IRON
FERRITIN
TO BE
REUSED
+ RBC WALL
PROTEIN
BILIRUBIN
WATER
INSOLUBLE
AMINOACIDS
GOES TO THE LIVER
FOR CONGUGATION
WITH GLUCOURINIC
A.TO BECOME
AMINOACID
POOL
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
CLONORCHIASIS
HYDATID
PARASITES
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
H
ARTMANN`S POUCH stone
HEAD OF THE
PANCREASE
ANY MASS
OUTSIDE

MIRRIZI`s syndrome

BENIGN STRICTURES






1-BILIARY ATRESIA
2-IATROGENIC
BILIARY SURGERY
GASTRECTOMY
HEPATIC RESECTION
LIVER TRANSPLANT
3-INFLAMMATORY; C
HOLANGITIS ,
P
ANCREATITIS
,
S
CLEROSING
CHOLANANGITIS.
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 ة حبسملا لكش

SYMPTOMS
 PAIN
 YELLOW DISCOLOURATION SKIN &M.M.


DARK URINE [ TEA COLOUR ]
CLAY COLOUR STOOL ةينيحطلا نول
 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`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
 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 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[CHOLECYSTO-
JUJENOSTOMY

STENT FOR Ca. head of pancrease

WHIPPLE`S OPERATION
Pancreatico-duodenoctomy