OBSTRUCTIVE

JAUNDICE
DR.JAMIL SAWAKED

DEFITION OF JAUNDICE
YELLOW

DISCOLOURATION OF SKIN AND

MUCOUS MEMBRANE

TYPES
A

PREHEPATIC

HEPATIC

POSTHEPATIC
OBSTRUCTIVE
OR SURGICAL

HAEMOLYSIS

ANATOMY

ANATOMY
A

BILIRUBIN CYCLE
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
BROKEN

BILIRUBIN CYCLE CONTINUE

HAEM

IRON &
BILIRUBIN

SPLITS INTO

[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 +

FERRITIN

BILIRUBIN

TO BE
REUSED

WATER
INSOLUBLE
GOES TO THE LIVER
FOR CONGUGATION
WITH GLUCOURINIC
A.TO BECOME

WATER SOLUBLE
BLOOD
URINE

PROTEIN

AMINOACIDS

AMINOACID
POOL

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

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

1-BILIARY ATRESIA
2-IATROGENIC
BILIARY SURGERY
GASTRECTOMY
HEPATIC RESECTION
LIVER TRANSPLANT
3-INFLAMMATORY;CHOLANGITIS , PANCREATITIS,
SCLEROSING 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
DEUDENAL MUCOSA-1
OR
C.B.D.

OR-2

PANCREATIC DUCT-3

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

SYMPTOMS
PAIN
YELLOW

DISCOLOURATION SKIN &M.M.

DARK URINE [TEA COLOUR]
CLAY COLOUR STOOL

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

DEPEND ON IT.2,4,7,9,10

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[CHOLECYSTOJUJENOSTOMY

STENT FOR Ca. head of

pancrease

WHIPPLE`S OPERATION
Pancreatico-duodenoctomy