1. Mechanical jaundice

2. ETIOLOGY OF THE MECHANICAL JAUNDICE
MJ (obturative, obstructive, subhepatic) is the pathologic state, conducting with the jaundice of the skin, skleras, mucous shells as a result of increasing of bilerubin in blood, developing because of different pathologic processes, induct the obturation of the bile ducts

3. Main reasons of the mechanical jaundice
Concrement
Diseases of ducts
External compression
Parasite invasion
Innate (cysts, atresias)
Choledocholithyasis
Tumors (of pancreas, liver, gall bladder, big duodenal teat,
metastases)
Not tumorous (sclerosing, festering cholangitis, strictures, cholangiopathies)
Round worms, suckers,
Ribbon worms
Mirizzi’s syndrome

4. Choledocholithyasis
Choledocholithyasis – is the localization of the concrements in extra- and intrahepatic bile ducts, appears more frequently as a result of migration of the concrements from the gall bladder at the calculous cholecystitis

5. Mirizzi’s syndrome
1 type– the concrement, wedging to the neck of gall bladder, Hartman’s pocket or bladder’s duct, compresses the common bile duct from the outside
2 type- development of the bedsore with the formation of the cholecystocholedochial fistula

6. Atresia of the extrahepatic ducts
Atresy of the extrahepatic ducts – is characterized with the full defeat of the bile’s evacuation as a result of full obliteration of the extrahepatic ducts

7. Cysts of the bile ducts
Cysts of the bile ducts – is the extension of the intra- and extrahepatic bile ducts

8. Posttraumatic strictures of the bile ducts
Posttraumatic strictures of the bile ducts – it is the strictures of the bile ducts as a result of their defeat
Classification of the posttraumatic strictures of the bile ducts
By the level of defeat
High
Low
By the degree of stricture
Full
Not full
By the duration of defeat
Limited (to 1 sm)
Spreaded (1-3 sm)
Subtotal (over 3 sm)
Total
By the clinic currency
With the jaundice
With the cholangitis
With the external bile fistula
With the biliar cirrhosis of liver

9. Primary sclerosing cholangitis
Primary sclerosing cholangitis – idiopathic disease, characterised with the diffuse inflammation and fibrosis of the bile ducts
1. PSC, not connected with other additional diseases
2. PSC, developing on the background of inflammatory diseases of intestines (ulcer colitis, Crone’s disease)
3. PSC, connected with the system fibrous changes (retroperitoneal fibrosis, Veber-Crengen’s disease, Ridel’s thyreoditis, mediastinal fibrosis)
4. PSC, connected with other autoimmune diseases (lupus, RA, diabetes 1 type, Shegren’s disease)
5. At some cases the development of the PSC connect with the development of immune deficit, as innate, so obtained (AIDS and other)

10. Secondary sclerosing cholangitis
Secondary sclerosing cholangitis unites the group of cholangitis with the directly stated etiologic factor
The reasons of the secondary sclerosing cholangitis
1. Choledocholithyasis
2. Postoperative scare strictures
3. Fungous infection
4. Parasite invasion
5. Pancreatitis
6. Intraductal and intraarterial introducing of some medicines
7. Ischemia as a result of trauma of the vessels
8. Cholangiocarcinoma or limphoma

11. Recidivate festering cholangitis
– develops after passed cholangitis as a result of not adequate sanation of the bile ducts
Clinic picture
Pain in the right under-rib, high temperature with the shiverings, slow progressive jaundice
Incitants of the RFC
Gram negative, conditionally pathogeneous flora, less – anaerobe infection

12. Tumorous defeats of the bile ducts
1. Tumors of the pancreas’s head
2. Tumors of the big duodenal teat
3. Tumors of the liver’s gates
4. Tumors of the gall bladder
5. Secondary (metastatic) defeat of the perycholedochial lymph nodes

13. External compression of the bile ducts
Tumorous defeat of the hepatobiliar zone
Tumors of the pancreas’s head, tumors of the big duodenal teat, tumors of the liver’s gates, gall bladder, secondary (metastatic) defeat of the perycholedochial lymph nodes
Inflammatory diseases
Pancreatitis, cysts of the pancreas, papillitis, diverticulitis, perycholedochial lymphadenitis, postbulbar ulcer of the duodenum, parapapillar or perypapillar divrticulitis
Diseases of the vessels Aneurisms of the hepatic artery, abdominal aorta, cavernous transformation of the portal vein

14. Parasite invasion of the bile ducts
Round worms
(ascarides, hair-head)
Suckers
(two-moustaches of cats, hepatic)
Ribbon worms
(bull cepen, pig cepen, echinococc)

15. The main clinic symptoms at the mechanical jaundice
Jaundice of the skin, scleras;
Skin scratching;
Discoloration of the excrements;
Darkening of urine.

16. Clinic forms of the mechanical jaundice
Jaundice-painful form
Jaundice-pancreatic form
Jaundice-cholecystitis form
Jaundice-septic form
Jaundice-not painful form

17. Physical data at the mechanical jaundice
Jaundice of the skin, scleras, mucous shells;
High temperature;
Light (acholic) excrement;
Urine with a color of beer or strong tea;
Increased sizes of liver and gall bladder;
Pain in the right under-rib; 
Formation in the abdominal cavity at the palpation;
Curvuaz’e’s syndrome.

18. Laboratory data at the mechanical jaundice
Hyperbilerubinemia because of direct fraction;
Increased level of the hepatic fraction of alkaline phosphatas of blood;
High level of bile acids;
Hypercholesterinemia;
Absence of the stercobilin in the excrement, urobilinogen in the urine;
Increased content of the bile pigments in urine.

19. Hepatic insufficiency
It is the complex of symptoms, characterized with the defeat of one or many functions of the liver as a result of acute or chronic defeat of its parenchima, at which there is no correspondence between requirements of the organism and possibilities of the liver in satisfaction of these requirements.

20. Clinic stages of the hepatic insufficiency
I stage of the hepatic insufficiency
II stage of the hepatic insufficiency
III stage of the hepatic insufficiency

21. Clinic picture at the I stage of the heepatic insufficiency
The state is satisfactory, asthenovegetative, dyspeptic, painful syndromes. Cholestatic syndrome. Jaundice of the scleras, skin, increasing of the liver; hypoalbuminemia. Cytolitic syndrome. Subicterous scleras, the liver is increased, compact concentration, its border is sharp, sometimes the spleen is increased; Субиктеричность склер, печень умеренно увеличена, плотной консистенции, край её заострен, иногда увеличена селезенка; hypoalbuminemia with dysproteinemia.

22. Biochemical factors of blood at the first stage of hepatic insufficiency
Bilirubin
Alkaline phosphatase
AST
ALT
Cholestatic syndrome
Cytolitic syndrome

23. Clinic picture at the II stage of hepatic insufficiency
the state is middle: asthenovegetative, dyspeptic syndromes, insomnia, sleepiness in a day, apathy, fever Cholestatic syndrome. Jaundice of the scleras, skin with the grey tone, scratching, pain in joints and bones, balloned abdomen, hemorrhages, significant increasing of the liver; its surface is smooth, compact, the border is rounded or sharp, hypoalbuminemia. Cytolitic syndrome. Icterous scleras, skin, vessel’s stars on the skin, the liver is significantly increased, compact concentration, not smooth surface, spleenomegaly with the hyperspleenism; ascitis, varicous extended veins of the esophagus, different hemorrhages, nasal, gastral, uterus bleedings; hypoalbuminemia with dysproteinemia.

24. Biochemical factors of blood at the first stage of hepatic insufficiency
Bilirubin
Alkaline phosphatase
AST
ALT
Cholestatic syndrome
Cytolitic syndrome

25. Clinic picture at the III stage of the heepatic insufficiency
The state is hard or very hard, jaundice of the skin, fever, sometimes the “hepatic” smell from the mouth, hemorrhagic diathesis, significant increasing of liver or its reduction. А – deceleration of the thinking, defeat of sleeping, disorientation, depression or euphoria, sometimes appearance of the tremor of hands. Hypoalbuminemia with dysproteinemia. B – defeat of the consciousness, enxiety with the delirium, sleepiness, disorientation, significant tremor of hands (pre-coma). C – absence of the consciousness, rigid muscles of the head, pathologic reflexes (coma).

26. Biochemical factors of blood at the third stage of hepatic insufficiency
Bilirubin
AST
ALT

27. Stages of the diagnostic
careful gathering of the anamnesis, physician examination, using of the screening laboratory researches.
wording of the preliminary diagnosis (suspicion to the obstructive genesis of the jaundice).
choose and indication of the sequence of using of the special instrumental methods of the research for topic diagnostic.

28. Anamnesis Presence of the GSD in the anamnesis Attacks of the pain
Fever, shivering
Operations on the bile ducts in the anamnesis
Firm skin scratching
Loss of the weight
Elder age

29. Methods of the instrumental diagnostic
1. Not invasive methods: US
computer tomography
2. Invasive methods :
ERPChG
TTHG

30. Ultra sonic research

31. Computer tomography

32. Endoscopic retrograd pancreatocholagiography

33. Transcutaneus transhepatic cholangiography

34. Types of jaundice
Hemolytic
Parenchimatous
Mechanical

35. Hemolytic jaundice
Hemolytic jaundice is conditioned by the increased defeat of the erytocytes or their not developed predecessors. As a result of this the increased formation of the bilerubin begins, that the liver cannot evacuate it fully.

36. Parenchimatous jaundice
is conditioned by the defeat of the hepatocytes and bile capillaries, with the increasing of the not direct bilerubin in blood.

37. Mechanical jaundice
Mechanical jaundice develops at the obstacle to the passage of bile from the bile ducts to the duodenum

38. Differential diagnostic of the jaundice by the clinic signs
Type of the jaundice
mechanical
parenchimatous
hemolytuc
Color of skin
Green-yellow with the bronze tone
Red-yellow with the orange tone
Lemon-yellow
Skin scretching
Very expressed
Expressed
Absence
Color of excrement
decolorized, grey-white
At the top of the disease decolorized
Intensive colorized
Color of urine
Dark
Ordinary
Appetite
Defeated at the long lasting jaundice
Reduced or absence
Not defeated
Dyspeptic phenomena
Yes
Pain in the abdomen
May be
No or not strong No

39. Differential diagnostic of the jaundices by the clinic signs
Type of the jaundice
mechanical
parenchimatous
hemolytuc
Weakness, adynamy
Yes
Absence
Gall bladder
Increased at the low obstruction
Not increased
Pulse
Bradicardy
Normal or tachycardia
Liver
Increased
Not very increased
Селезенка
Sometimes increased
Often increased
Повышенная кровоточивость

40. When the mechanical character of jaundice is defined it is necessary to carry out the differential diagnostic between the benignus and malignus jaundice to the right choose of the treatment tactic

41. Differential diagnostic of the mechanical jaundices by the clinic signs
Benignus jaundice
Malignus jaundice
External look of the patient
The patients are thick
The patients are cachectic
anamnesis
Calculous cholecystitis in the anamnesis, the pain connects with the feeding.
No particularities
Complaints
Pain in the right under-rib
Repulsion to the feeding, general weakness, loss of weight.
Gall bladder
Gall bladder may be not palpated
Positive Curvuas’e’s symptom

42. Need of two-stage treatment
On the background of the hepatic and renal insufficiency, long lasting at the state of jaundice inducts such changes in the organs and systems that the reconstruction of the normal passage of bile by the one-stage operative way may cause the progressing of the hepatic insufficiency

43. Liquidation of the polyorgan insufficiency
I stage
Drainage
Dosed decompression
Liquidation of the polyorgan insufficiency

44. Reconstruction of the normal passage of the bile into the intestine
II stage
Reconstruction of the normal passage of the bile into the intestine
Endoscopic retrograd interventions
Transcutaneus transhepatic endobiliar interventions
Absence of the effect
Open operations

45. Indications to the endoscopic retrograd interventions
extension of the choledoch by the US data over 8 mm
discovery of the reasons of the MJ and localization of the pathologic process in the bile ducts
hyperbilerubinemia with the bad visualization of the extrahepatic bile ducts by the US data

46. Contraindications to the endoscopic retrograd endobiliar interventions
Acute infarct
acute breaches of the blood circulation
hard not corrective manifestations of the heart-vassels and breathing insufficiency

47. Endoscopic retrograd pancreatocholangiography Nasobiliar drainage
Types of the endoscopic retrograd endobiliar interventions
Endoscopic retrograd pancreatocholangiography
Nasobiliar drainage

48. Indications to the endoscopic papillosphincterotomy
choledocholithyasis
stenosing papillitis
stenosis of the terminal department of the choledoch and big duodenal teat with the duration to 1,5 sm
mechanical jaundice with the hepatic insufficiency of I and II degree

49. Types of the papillosphincterotomy
Boarded papillosphincterotomy
Subtotal or total papillosphincterotomy
Papillotomy

50. Technic of the nasobiliar drainage

51. ERPChG after EPST
ERPChG before EPST

52. Types of the REBI
Extraction of the stones with the help of flexible irons Extraction of the stones with the help of Dormia’s probe Extraction of the stones with the help of Fogarty’s probe dilatation at the strictures of the TDCh Deleting of the stones by the double latex balloon Deleting of the stones by the Fogarty-Dormia’s catheter Loop-trap for extraction of the stones

53. Complications after the retrograd interventions
1. fever, sepsis, bacteriemia
2. acute pancreatitis
3. ascending festering cholangitis and abscesses of the liver
4. hard painful reaction with the picture of acute abdomen
5. perforation of the wall of the common bile duct, peritonitis, subhepatic abscesses
6. shock state as a result of acute defeat of the passage of bile and defeat of the wall of the common bile duct
7. false ways in the tissues, appears at the introducing of different instruments

54. Indications to the TTChG
Impossibility of the performing of the endoscopic retrograd interventions, their inefficiency, presence of the contraindications to them.
Tumors of the hepaticoduodenal zone, creating the block of the bile ducts.

55. Contrandications to the TTChG
- presence of the volume formations in the projection of the possible puncture
-  reducing of the PTI to 50% and lower
-  reducing of the number of trombocytes to 100 thousands and lower
-  interposition of the intestine between the abdominal wall and liver
- festering diseases of the soft tissues in the zone of possible puncture
-  allergic reactions to the iodine preperates in the anamnesis

56. Types of drainage of the bile ducts
- External
- External-internal
- Internal

57. External drainage

58. External-internal drainage

59. Internal drainage

60. Complications of the TTEBI
Bleeding
Haemobilia
Cholangitis
Bilerhea into the abdominal cavity
Dislocation of the catheter
Pneumothorax

61. The way of dosed decompressio
to 5-6 hours decompression on mm hyd. pole.

62. Method of the double drainage of the bile ducts

63. Extractor of the stones type Dormia

64. Dilatation catheter of Gruntcig

65. Indication to the second stage of the treatment of mechanical jaundice – reconstruction of the constant passage of bile into the intestine
Reducing of the bilerubin lower than 40 mcmol/l, transaminases lower than 1,5 mmol/l, normalization of the factors of the urea, creatinin, electrolytes, coagulogramme, level of common peptid not lower than 50 g/l, normalization of the biliar pressure, reducing of the microbe contamination to 103 CFU/ml, improvement and stabilization of the general state of the patients

66. Operations, performing at the impassibility of the disatal department of the choledoch
1) Internal transduodenal choledochoduodenostomy.
2) transduodenal sphincterotomy and sphincteroplastic
3) choledochoduodenostomy by Yurash, Finsterer, Flerken
4) Pancreatoduodenal resection

67. Internal transduodenal choledochoduodenostomy

68. Transduodenal papillosphincterotomy and papillosphinteroplastic

69. Choledochoduodenostomy
ChDA by Yurash
ChDA by Flerken
ChDA by Finsterer

70. Pancreatoduodenal resection

71. Defects of the choledochoduodenostomy
1) ChDA unloads only bile system and doesn’t induct the decompression at the system of pancreatic ducts.
2) ChDA promotes the development of the bends and deformations of the duodenum after the operation.
3) At the ChDA the distal department of the choledoch forms blind bag.
4) Risk of the development of the ascending cholangitis

72. Operations, performing at the impassibility common bile duct and supraduodenal part of the choledoch
1) Choledochotony with the “deaf stitich” or different types of the drainage of the choledoch
2) Plastic of the stricture or its resection with the anastomosis of the duct “end-by-end”
3) Bileodigestive anastomosis

73. Operations, performing at the strictures of the choledoch
Plastic of the choledoch by Geyneke-Mikulich
Resection with the anastomosis “end-by-end”

74. Terminolateral hepaticoenteroanastomosis
Terminolateral hepaticojejunoanastomosis with the Y-form interintestinal mouth by Ru
Terminolateral hepaticojejunoanastomosis with the Y-form interintestinal anastomosis “side-by-side”

75. Ways of the drainage of the bile ducts
Drainage of the choledoch by Vishnevskiy
Drainage of the choledoch by Ker
Drainage of the choledoch by Certe
Drainage of the choledoch by Holsted