1. Ultrasound Obstructive Hepatocellular
JAUNDICE
Ultrasound
Obstructive Hepatocellular

2. Obstructive Jaundice Gallstones Pancreatic Cancer Cholangiocarcinoma
Ampullary tumour
Benign Biliary stricture
Metastatic-Liver, Portal
Primary sclerosing cholangitis
IgG 4 disease
Surgical trauma

3. ERCP or PTC ERCP is preferable- less traumatic, better tolerated.
Failed ERCP- why?- Patient tolerance, Anatomical, Pathology, Post-surgical, Unable to cross obstruction.
Repeat ERCP- with or without Combined, GA.
PTC- with or without combined.

5. Ductal Stones
Be sure of the diagnosis- ERCP should rarely be used as a diagnostic test.
Adequate Esx.
Balloon clearance, Basket, Lithotripter, Plastic Stent.
Always achieve drainage.

6. Benign Stricture
Be sure of the diagnosis- CT, MRCP, Bx, Cytology, EUS.
Sphincterotomy
Balloon sphincteroplasty
Plastic Stent
Covered Metal Stent
Surgical reconstruction

7. Malignant Stricture Be sure of the diagnosis.
Plastic stent, simple, rarely fails, cheap, removable, Bridge to Surgery, short prognosis.
Expanding Metal Stent- Uncovered, Covered.
Multiple stents, Stent within Stent.
Surgical Resection, Palliative bypass.

15. NHS TRUST CEO COUNCILLING