DIFFERENTIAL DIAGNOSIS of OBSTRUCTIVE JAUNDICE 1.malignant obstructive jaundice Calculous Obstructive Jaundice -female/40 years. Biliary dyspepsia.

Course: longintermittent. Pain: colicky- in Rt hypochondriumradiating to back & shoulder. Malignant Obstructive Jaundice -male/old (60 years) Pancreatic dyspepsia. Course: shortprogressive. Pain: absent at 1st then constant &progressivedullaching- in epigastriumradiating to backrelieved by lying on his belly & exaggerated by lying on back. -ve Charcot's triad Jaundice deeppersistent Moderate state Late (cirrhosis) Loss of weight (gall bladder) (abdominal mass) (ascitis) Usually not enlarged --Due to: -secondaries (hard, nodular) -hydrohepatosis (firm, smooth)

Type of the patient History

+ve Charcot's triad. Examination -General -Abdominal (hepatomegaly) Jaundice light intermittent

Investigations 1.laboratory Bilirubin SGOT, SGPT Alk.phosphatase 2.others Barium meal

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Enlarged Maybe felt ,late In late cases

High Very high with cholangitis High

Higher Slighty disturbed Higher

-widening C shape of dudenoum (pad sign) Smooth cresentric filling defect ERCP -inverted 3 filling defect with hypotonic dudenography (Frostberg's sign) With cancer head pancreas: -complete obstruction -huge dilatation with smooth wall Diagnostic e.g. cytology Therapeutic : passage of stents --

PTC

Cholelocoscope

Diagnostic, therapeutic e.g. papillotomy, removal of stones either operatively through CBD or postoperative through T-tube Stones in GB & upper part CBD,

U/S

CT, MRCP

enlarged CBD, intrahepatic biliary channel dilation cirrhosis

Intrahepatic biliary channel dilation, enlarged head of pancreas, secondaries in liver, LNs at porta hepatic Best to diagnose

2.Haemolytic jaundice: jaundice is caused by anything which causes an increased rate of hemolysis (breakdown of red blood cells). In tropical countries, malaria can cause jaundice in this manner. Certain genetic diseases, such as sickle cell anemia, spherocytosis, thalassemia andglucose 6-phosphate dehydrogenase deficiency can lead to increased red cell lysis and therefore hemolytic jaundice. Commonly, diseases of the kidney, such as hemolytic uremic syndrome, can also lead to coloration. Defects in bilirubin metabolism also present as jaundice, as inGilbert's syndrome (a genetic disorder of bilirubin metabolism which can result in mild jaundice, which is found in about 5% of the population)and Crigler-Najjar syndrome. In jaundice secondary to hemolysis, the increased production of bilirubin, leads to the increased production of urine-urobilinogen. Bilirubin is not usually found in the urine because unconjugated bilirubinn is not water-soluble, so, the combination of increased urine-urobilinogen with no bilirubin(since, unconjugated)in urine is suggestive of hemolytic jaundice. Laboratory findings include: .-Stool is dark. -There is no bilirubin in urine, but urinary urobilinogen is increased. (i.e., hemolytic anemia causes increased heme metabolism; exception: infants where gut flora has not developed). -The blood shows increased levels of unconjugated prehepatic bilirubin (leading to high readings on the indirect van den Bergh test). Transaminases (SGPT and SGOT) are normal, and so alkaline phosphatase. Kernicterus is associated with increased unconjugated bilirubin

3.Hepatocellular jaundice: It can be caused by acute hepatitis, hepatotoxicity, and alcoholic liver disease. Cell necrosis reduces the liver's ability to metabolize and excrete bilirubin leading to a buildup of unconjugated bilirubin in the blood. Other causes include primary biliary cirrhosis leading to an increase in plasma conjugated bilirubin. Laboratory findings: -Urine: liquorice in color. Conjugated bilirubin present, urobilinogen is decreased (except in children) -Stool is pale. -Serum bilirubin is moderately increased (mostly conjugated). -Alkaline phosphatase is usually only moderately increased, but if cholestasis is a prominent feature it can rise to levels seen in obstructive jaundice. Transaminases are increased. Kernicterus is not associated with increased conjugated bilirubin Ultrasound is very useful. An intravenous cholangiogram is not helpful in the presence of jaundice. The ducts will not be outlined. 4.Carcinoma of the head of pancreas vague epigastric pain radiates to back 25% cases relieved by leaning forwards or sitting up & increase by lying supine , and weight loss. Jaundice is progressive , persistent & deep +pruiritis . This usually occurs with melena. Jaundice may occur due to: -obstruction of terminal part of CBD by the tumor. -LN in the porta hepatis. -liver metastasis. 5. congenital anomalies of bile duct e.g. biliary atresia & choledochus cyst.

Atresia means that the common bile duct between the liver and the small intestine is blocked or absent. the symptoms are indistinguishable from neonatal jaundice. Symptoms are usually evident between one and six weeks after birth. Besides jaundice, other symptoms include clay colored stools, dark urine, swollen abdominal region and large hardened liver. liver enzymes tend to be grossly deranged, hyperbilirubinaemia is conjugated & does not lead to kernicterus. Ultrasound can confirm the diagnosis. Further testing includes radioactive scans of the liver and a liver biopsy. Choledochus cyst is a congenital weakness in the wall of CBD resulting in dilatation. Presented by recurrent abdominal pain, obstructive jaundice & palpable abdominal mass (commonest). Diagnosed by Ultrasound. 6.Stenosis of bile-ducts, either malignant or benign a tender, enlarged liver. His gall-bladder may or may not be palpable. 7.Carcinoma of the gall-bladder Rare condition. Obstructive jaundice in half of patients with palpable mass in Rt hypochondrium. the patient is a woman with an enlarged liver and a hard, irregular mass in her right hypochondrium. 8.Secondary deposits in liver. 9.Hepatoma. a large, hard, irregular liver. A bruit is often present, ascites is common, and is often bloodstained. 10.carcinoma of his stomach with secondaries in porta hepatic. pain, anorexia, vomiting, an upper abdominal mass, and the visible peristalsis of pyloric stenosis. Anaemia is common.