2. Obstructive jaundice Etiology :
1_obstruction within the lumen : gall stones
2_pathology in the wall.
a_ congenital atresia of common bile duct (CBD).
b_ traumatic stricture.
c_ chronic cholangitis.
d_ tumuor of bile duct.
3_External compression
a_ pancreatitis.
b_ tumour of head pancereas
c_ tumour of ampulla of vater

3. Bile duct stones (choledocholithiasis)
Maybe single or multiple .
1_most CBD stones are formed within the gall bladder and migrate down the cystic duct into the CBD
2_ infection of the biliary tree due to stasis due to distal stricture or obstruction (inflammatory or malignant)
3_ infection by ascaris lumbricoids or clonorchis sinenses.
What are the consequence of duct stones :
1_obstruction to bile flow
2_ infection _ cholongitis

4. Clinical manifestation
Maybe asymptomatic, more often there are attacks of biliary colic accompainedby obstructive jaundice with cray _ coloured stools and dark urine.
The attacks lasting for hours or several days .
The attack ceases either when a small stone passed through the sphincter of oddi or when it disimpacts fall back into the dilated CBD.
Occasionally the jaundice is progressive or rarely it in pains
_If obstruction is not relieved either spontaneously or by operation ,the back pressure in the biliary system results in the 2nd biliary cirrhosis and liver failure .

5. If infection of CBD super venes , the jaundice and pain are accompanied by rigor , high intermittent ferver and toxaemmia here the treatment is urgent biliary drainage
In contract to patient with neoplastic obstruction of the CBD or ampulla of vater
Liver function test demonstrate pattern of obstructive jaundice especialy the S.Alkaline phosphatase prothrombin time is prolonged because the absorptionof Vit.k is dependend upon bile entering the intestine but a normal level can usually be achieved with parental Vit.k ,urine showed urobilinogen

6. Is by ultrasonorgrphy to show :
The diagnosis:
Is by ultrasonorgrphy to show :
1_intra hepatic bile duct dilatatoin .
2_liver tumour or cyst
3_stone in CBD .
4_bile duct tumour.
5_ pancreatic heat + periampullary tumour
Liver biopsy if the duct is not dilated .
//_MAR and ERCP will demonstrate the nature of obstruction.
/_ERCP can be used in removing stones from CBD and stenting stricture.
Management:
it is essential to determine whether the jaundice is due liver disease within the duct such as sclerosing cholang it is or obstruction.

7. Preoperative preparation of ajauridiced patient full supportive measures are required :
1_with rehydration by I.V fluid .
2_attention to clotting disorder .
3_proper anti biotic administration .
4_exclusion of diabetes .
Treat ment :-
A_ broad spectrum anti biotic given before , during and after surgery .
B_ parentral VIT.K 10 mg /dl / day for 5 days fresh frozen plasma.

8. After medical preparation of the patient to good condition , surgery include opening the CBD usually above the duodenum and extract the stones , that are liable for missing them , so added drianage procedure called
1_trans duodenal sphincteriotomy .
2_choledocho duodenostomy operation .
Other way to relieve obstruction by endoscopic sphincteriotomy using dorwia basket .

9. Stricture of the bile duct
Post operative 80%
Benign
Stricture
Inflammatary 20%
Malignant

10. Post operative stricture
During the procetureof cholecystectomy
Clinical manifeitation
_ bile leakage
_ jaundice
Treatment
If stricture is high Roux _ eny choledocho_jejunostomy
If stricture is low choledochoduodenostomy

11. Cholangio carcinoma Either intrahepalic extrahepalic
it is associated with:
inflammatery bowel disease
choledochal cust .
Clinical features:
Painless proqressive jaundice
Dark urine , pale stool , steatorrhea ,loss of wt . , maybe hepatomegaly with palpable G.B
Treatment :
If possible pancreaticodeodenectomy
Advandeced tumour stenting

12. Biliary fistula 1_ external biliary fistula
Most important may follow operation of cholecystectomy with injury to CBD.
Diagnoses by fistulogram
Maybe by ERCP, MRCP,PTC
2_ internal biliary fistula.
Repeated attack of acute cholecystitis
tract
With duodenum or colon
Stone may
Gall stone ileus