Post hepatic jaundice Jaundice : warna kekuningan pada kulit, sclera, mukosa, karena deposisi bilirubin dalam plasma.

( > 2mg/dl) klasifikasi jaundice : Category Hepatic Definition The pathology is located within the liver.

Pre-hepatic The pathology is occurring prior to the liver. Post-Hepatic The pathology is located after the conjugation of bilirubin in the liver.

Hallmark posthepatic jaundice jaundice Dark urine Pale stools Generalized pruritus (bile salt in circulation) Penyakit tersering yang mengakibatkan jaundice : 1. 2. 3. 4. 5. Choledocholithiasis cholelithiasis cholecystitis Cholangiocarcinoma Ampullary cancer Ca of pancreas Billiary strictures

1. STONES Choledocholithiasis Common bile duct stones (primary, secondary) Clinical manifestation Silent Present with o Biliary colic o Cholangitis o Gallstone pancreatitis o Obstructive jaundice Diagnosis US MRC ERCP

2. MALIGNANCY Pancreatic Cancer Etiology Smokers Fat, Protein, Caffeine, Alcohol diets Genetic Pathophysiology Arise from epithelial cells of pancreatic ducts Tumour in late stage spread throughout pancreas Can be result of metastasis disease from Lung Breast Thyroid Kidney Skin Rapid growing with spread to surrounding tissue Head of pancreas (most common site) Thromboplastic factors Necrotic pancreatic tumours Results in thrombophlebitis

Clinical Management (Prevent spread of tumour) Chemotherapy, radiation Pain control Total resection Head of pancreas removal Whipple procedure Nutritional support TPN, tube feeding Fluid, electrolyte replacement Glucose monitoring

Cholangiocarcinoma Slow growing malignancy Biliary tract Infiltrate locally, metastasize late Extra-hepatic (90%) 60-70 y/o, M=F ( Incidence Japan, Israel, Native Americans)

Etiology Ulcerative colitis Sclerosing cholangitis Choledochal cysts Hepatolithiasis Liver flukes Papillomatosis of bile ducts Thorotrast exposure Typhoid carrier Adult polycystic kidney disease

Pathology Adenocarcinoma Types Papillary Nodular Sclerosing Best prognosis papillary distal tumours

Cancer of Common Bile Duct (CBD) Bifurcation Periampullary Carcinoma Pathology Adenocarcinoma Arises from 4 different tissues of origin Head of pancreas Distal bile duct Ampulla of Vater Periampullary duodenum Treatment

Standard Whipple pancreaticoduodenectomy

3. BILLIARY STRICTURES Stenosis of Sphincter of Oddi Inflammation, fibrosis, muscular hypertrophy Episodic biliary pain Abnormal LFT Dilated common bile duct (difficult to cannulate, delayed emptying of contrast) Causes (Bile duct strictures) Operative injury Fibrosis (due to chronic pancreatitis) Common bile duct stones Acute cholangitis Biliary obstruction (due to cholecystolithiasis) (Mirizzis syndrome) Sclerosing cholangitis Cholangiohepatitis Strictures of a biliary-enteric anastomosis Bile Duct Strictures Recurrent cholangitis, 2 biliary cirrhosis, portal hypertension Present with cholangitis, jaundice US, CT, MRC, PTC, ERCP Treatment Endoscopic dilatation Stent placement Roux-en-Y choledochojejunostomy Hepaticojejunostomy Choledochoduodenostomy