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Obstructive jaundice

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Abdallah Badaha

on 7 June 2013

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Transcript of Obstructive jaundice

Obstructive jaundice Supervisor: MR. Nadir Case presentation (Problem + Questions) 65 years old male, from Aldroshab North, presented to Khartoum North Teaching Hospital, complaining of constipation and yellowish discoloration of the sclera. The condition started 2 weeks with yellowish discoloration of the sclera of gradual onset, not associated with headache or joint pain. No vomiting, or diarrhea. No cough, or other respiratory, cardiovascular, symptoms. There is history of marked weight loss, and loss of appetite,There are itching and pale color of stool and no history of similar conditions. The patient is not known hypertensive, diabetic or allergic to any drugs. There is no history of blood transfusion and no history of previous operation. No family history of similar condition, and no family history of diabetes, hypertension, no history of hepatitis and no recent history of contact of patient with hepatitis
The patient is not known allergic to any drugs, not on long term medications, no recent history of drug injection
Patient is not educated, he is a farmer , and he is a previous alcoholic but he stopped 20 years ago. On examination: patient looks ill, pale and deeply jaundiced.Vital signs are normal. No parotid gland enlargement, no gynaecomastia, normal
hair distribution, no testicular atrophy and no left supraclavicular lymph
nodes enlargement. ON Abdominal Examination: Abdomen is not distended, umbilicus inverted, no dilated veins and no surgical scars, and there is hypopigmentation all over the skin. The Abdomen is not tender, soft, normal temp., and no superficial masses, no organomegaly, no ascites, liver is shrunken (6cm) and there is palpable gall bladder.
Examination of the other systems was normal. It is the yellowish discolouration of the body tissues and fluids. Result from accumulation of bilirubin in blood. That is occurs when serum bilirubin exceeds 2.5 mg/dl. 1-Haemolytic jaundice:

In this type the RBCs are excessively distructed.
The unconjugated bilirubin elevate in blood. Types of jaundice: 3-obstructive jaundice:

This type is due to an obstruction in the biliary pathway.
The bilirubin reabsorped to the blood and the bile salt accumilate. 2-Hepatocellular jaundice:

In this type the defect is in the liver.
The both conjugated and unconjugated bilirubin elevate in the blood. jaundice Osman Ahmed Applied anatomy of the biliary system Biliary system 1) Left & right hepatic duct. 4) Common bile duct. 3) Cystic duct. 2) Common hepatic duct. The gallbladder Blood supply of the biliary system Basic Physiology of the biliary system Sara Ahmed PATHOPHYSIOLOGY
At any level between the liver &the duodenum The obstruction can be: Types of gallstones:
O.J more common caused by pigmented stone.. Partial or complete This can be in the:
Lumen-Intramural-Outside the wall Osman Merghani Ca-Head of Pancreas 75% of the pancreatic carcinoma affects it’s head.

The intra-pancreatic part of the CBD passes through the head
obstructing the bile flow . Biliary stricture Bengin Malignant recurrent
1) Iatrogenic
2) Trauma to abdomen 1) Pancreatitis
2) Bile duct stone Mechanism of Benign biliary stricture injury fibrosis narrowing Primary bile ducts cancer Neoplasm in adjacent organ Cholangiocarcinoma Ca-Head of Pancreas Single acute event BLIARY ATRESIA Congenital Aquired CBD –blocked or abscent Usually After autoimmune disease Liver flukes liver Other sites 1) Feed blood.
2) Produce eggs
pass into intestine 1) Bile ducts
2) Gall bladder Pancreatic pseudocyst Circumscribe collection of fluid rich in:

1) Pancreatic enzymes
2) Blood.
3) Necrotic tissues

It is usually
a complication of pancreatitis or
abdominal trauma. Mechanism of formation: Disruption of pancreatic parenchyma Ductal system Extravasation of pancreatic enzymes Digest the adjoining tissues Suzan Abd-Almoniem Causes of obstructive jaundice
1} Inside the lumen:

Most common:
Stones: which are divide into three types:

1) Cholesterol stone: which is white in coluor, big and radiolucent.
2) Pigment stones: which is small/black irregular & radiolucent.
3) Mixed stones: contain calcium, pigment & cholesterol.
2} Outside the wall:

Carcinoma of the head of the pancreas which is adenocarcinoma.
*Age group 40-60years.
*Local invasive or lymph metastases before it has been detected.
3- In the wall:

1) Congital biliary atresia.
2) Inflamatory stricture secondary to an impacted stone.
3) Bile duct injury due to surgery like cholecystectomy & gastrectomy.
4) Malignancy of C.H.D\C.H.D.
5) Ca of Ampulla of vater. Other causes:
1) Pericholecystic abscess.
2) Compression from lymph nodes. It divides into three main types: Other causes:
1) Food particles like tomato peels.
2) Worms (ascaris).
3) Foreign body. Mohammed Adam
Suhaib Khaleel Al-Rahman Clinical features 1– Jaundice.
2– Dark urine.
3– Pale stool.
4– Pruritis. Signs and symptoms: Dark urine/ tea color yellow discoloration Clinically/ types of obstruction: In jaundice patient with palpable gall bladder the cause of jaundice is unlikely gall stone.

Exceptions Courvoisier's law We have pt. with obstructive jaundice.

The consequence:
The first signs and symptoms are :

•Pale stools.
•Dark urine.
•Fever, if due to infectious cholangitis.
•Sudden abdominal pain, if due to gallstones.

Then followed by ------ Pruritis (itchy skin)

Eventually -------- jaundice (yellowish skin and eye discoloration) becomes evident. Finally….. If left untreated, it will lead to malabsorption, esp.vitamins A, D, E and K.

1) Steatorrhea (‘fatty stools’) .
2) Bleeding disorder .
3) Unintentional weight loss.
4) Softening of the bones (osteomalacia).
5) Muscle pain and weakness.
6) Sensations abnormality like numbness and tingling. 1) Abdominal swelling, distension and bloating.

2) High fever (higher than 101 degrees Fahrenheit).

3) Nausea with or without vomiting.

4) Severe abdominal pain. Life-threatening
symptoms including: Investigations 1\Blood picture.
2\Urine: urobilinogen.
3\ serum bilirubin.
4\ AST and ALT.
5\ Alkaline phosphatase.
6\ prothrombin time.
7\ Faecal stercobilinogen.
8\ heptitis screening. 1\Laboratory investigations.
2\Radiological investigations CLASSIFICATION 1\Laboratory investigations. 2\Radiological investigations The gold standard investigation of biliary system is ??!! It is accurate,easy and quick to perform
it provides :

1\Detection of gall bladder stones.
2\Visualization of dilatation of extra and intrahepatic billiary ducts in patients with obstructive jaundice.
3\detection of the thickness of the wall of the G.bladder.
4\Detection of mass in the porta hepties or head of the pancreas. 1} ULTRASONOGRAPHY US show thickened GB wall ,dilated intrahepatic ducts and CBD Ibrahim Taha It is useful in detecting :

1\Hepatic and pancreatic lesions.
2\Staging of tumors of the liver, gall bladder, bile ducts, and pancreas.

It is not useful in diagnosing benign biliary diseases ,gall stones, and cholecystities. 2} Computed tomography CT scan show tumor at the head of the pancreas It is not invasive and contrast is not required.
It can demonstrate ductal obstruction, stricture and other intraductal abnormalities. 3} MRCP Normal MRCP image showing the common bile duct (curved arrow) and the pancreatic duct (arrow). Note the fluid filled duodenum. It is useful in :
1) Diagnosis of lesions involving the lower end of the CBD.
2) Detection of operative injuries of the biliary system.
3) Bile can be sent for cytological and microbiological examination . Therapeutic interventions such as stone removing or stent placement can be performed. Thus ERCP has evolved into a mainly therapeutic rather than diagnostic technique. 4} ERCP Gallstones within the common bile duct. ERCP showing distal common bile duct stricture with proximal dilation It needs normal coagulation..

1) It can visualize high obstruction of bile duct.
2) It enables placement of a catheter into bile ducts to provide external biliary drainage or insertion of indwelling stents. 5} PTC Complications:

1) Bleeding may occurs if there is hypoprothrombinaemia .
2) Biliary peritonitis . PTC demonstrating dilated ducts Image of the bile ducts, following the injection of x-ray dye, showing a large gallstone trapped in the duct The same duct, following removal of the stone through the drainage catheter Management of Obstructive Jaundice Hekma Abdo A) Initial management
B) Specific management These steps should be applied to
cases of obstructed jaundice:

1) Admission if indicated
2) Nil per mouth if indicated
3) Administration of IV fluids
4) Administration of analgesics
5) Administration of antibiotics.
6) Administration of vit K
7) Insertion of catheter A) Initial management B\ management according to the cause of obstructed jaundice: 1) Management of calcular obstructive jaundice: Aims of Surgical management:
To relive biliary obstruction- to remove the gall bladder If ERCP available: endoscopic extraction of calculi followed by:
1) Cholecystectomy
2) Sphenecterotomy by diathermy
3) Stone extraction by dormia basket or balloon catheter If ERCP not available:
Laprotomy with cholecystectomy and Exploration of CBD with T tube drainage ,, (cholecystectomy and choledocolithotomy) -NPM and IV Fluid
-Monitor the vital signs
-After subsiding of inflammation oral fluid is reinstated followed by regular diet
-Ultrasound Conservative treatment followed by Cholecystectomy -Dilatation
-Long term stenting
-Surgical reconstruction of bile duct 2)due to bile duct stricture: 1- CA head of pancreas(if it operable)
2- Cholangiocarcinoma
3- Carcinoma of Gall Bladder
4- Peri ampullary tumors 3) Management of malignant obstructive jaundice: - Endoscopic Stent use for very ill patient and this consider
a palliative rather than a curative treatment.
- In fit patient surgical resection is best mood of treatment.
- In preparation; bile salt and sugar rich food.
- Chemotherapy and Radiotherapy may be given before or after surgery. Whipples operation
(pancreaticodudenectomy) Carcinoma of head of pancreas
(inoperable) :

Palliative therapy mainly..

Triple bypass operation :
1) Gastro-jejunostomy to bypass duodenal obstruction.
2) Cholecysto-jejunostomy to bypass obstructed common bile duct.
3) Jejuno-jejunostomy
(entiroentrostomy) to divert food away from biliary tract. 1) Hepato-Renal syndrome.
2) Asacending infections(cholangitis).
3) Disordered coagulation.
4) Relative immunesuppression. Complications Any Questions !! Any Questions !! Any Questions !! Any Questions !! Any Questions !! Any Questions !! Any Questions !! 2 Designed by: 3bdallah Bada7a 3bdallah Bada7a
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