2. in carotenoderma the pigment
is concentrated on the palms, soles, forehead, and nasolabial
folds. Carotenoderma can be distinguished from jaundice by the sparing of the sclerae
The differential diagnosis for yellowing of the skin is limited. In
addition to jaundice, it includes Carotenoderma
The use of the drug Quinacrine
Excessive exposure to phenols
Is not a disease but rather a sign that can
occur in many different diseases
JAUNDICE
It is yellowish discoloration of
Skin, mucous membranes, sclera
Due to excess plasma bilirubin
Normal range
5-17 m mol/l
Clinically obvious   
50 mmol/l (2.5mg/dl)

3. E V Pathway for RBC Scavanging
Liver, Spleen &
Bone marrow
Phagocytosis & Lysis
Hemoglobin
Globin
Heme
Bilirubin
Amino acids
Fe2+
Through Liver
Amino acid pool
Excreted

4. Bilirubin Production & Metabolism:
About 70 to 80% of the 250 to 300 mg of bilirubin
produced each day is derived from the breakdown of
hemoglobin in senescent red blood cells
Formation of Bilirubin Mainly in RES (Spleen)
Conjugation of bilirubin in Hepatocyte
Excretion
The remainder comes from
prematurely destroyed erythroid cells in bone marrow and from the
turnover of hemoproteins such as myoglobin and cytochromes found
in tissues throughout the body.

5. Increase of production
Etiology Of Jaundice:
Increase of production
Impaired of
Clearance

7. Direct Hyperbilirubiemia

8. 2-Drugs-Intravenously administered tetracycline, chlorpromazine
1-Alcoholic hepatitis
2-Drugs-Intravenously administered tetracycline, chlorpromazine
Hydrochloride, oral contraceptives,
methyl testosterone, halothane, azathioprine
3-Lymphomas
4-Primary biliary cirrhosis
5-Cholestasis of pregnancy (3rd trimester)
6-Benign, recurrent intrahepatic cholestasise
7-Post-operative jaundice (anoxia, transfusions, etc.)
8-Sclerosing cholangitis
9-Pericholangitis
Medical Causes

9. Surgical Causes Medical Causes Choledocholithiasis
Very common (25 to 35 percent)
Choledocholithiasis
Carcinoma of head of pancreas
Common (5 to 10 percent)
Carcinoma of common duct
Stricture of common duct
Ampullary carcinoma
Uncommon (I to 5 percent)
Chronic pancreatitis
Sclerosing cholangitis
Lymphoma
Metastatic carcinoma
Primary liver cell carcinoma
Rare (less than I percent)
Post-bulbar ulcer
Hepatic artery aneurysm
Choledochal cyst
Biliary atresia
Duodenal diverticulum
hemobilia
Medical Causes

10. Anatomy of biliary system

11. Risk Factors Gall bladder Stone
Gallstones are also associated with certain medical conditions including:
1-Diabetes
2-Liver disease
3-Crohn's disease
4-Blood disorders like sickle-cell anaemia
5-Stomach surgery - gallstones are more common if you have had surgery to remove part of your stomach

12. Gall bladder Stone
The majority of cases (approximately 80%)are asymptomatic (silent) gall stones , discovered accidentally by abdominal sonar .
Other symptoms are related to site of movement of stone
A gall stone may impact in the neck of gall bladder or in the cystic duct giving biliary pain or cholecystitis
Biliary pain usually occurs in the epigastrium and right hypochondrium
Obstruction of common bile duct leading to pain & jaundice
Gall stones increase risk of carcinoma of the gall bladder
Pancreatitis.

13. 1-Gall Bladder: in 80%Not Distended When gall bladder be distended??
Charcot’s Triad:
1-Pain
2-Jaundice
3-Fever
Obstruction of common bile duct leading to pain & jaundice
May Complicate to
Reynold’s Pentad:
1-Pain
2-Jaundice
3-Fever
4-Altered Mental State
5-Shock
Abdominal Ex:
1-Gall Bladder: in 80%Not Distended
When gall bladder be distended??
Murphy’s sign +ve
2-Liver:Enlarged?????

14. Treatment of Choledocholithiasis:
Preoperative Preparation:
Correct Clotting Dysfunction
Guard vs LCF
Guard vs RF
Definitive Treatment:
Remove Source of Obstruction (stone)
Remove Source of Stone (Gall bladder)
Reynold’s Pentad
Chronic cholecystitis
Obstructive Jaundice
Charcot’s Triad
ttt Of
Shock
Cholecystectomy
ERCP
Cephalosporin
Generation
3rd
Treatment

15. Carcinoma of head of pancreas
Symptoms
Signs
Cachecxia
Criteria of obstructive jaundice
Pain which is common, characterized by starting as vague
(Lower abdomen or back)
Usually worsen in supine position & relived by lining
forward
It may be caused by:
A) Tumor invasion of splanchnic plexuses &
retroperitoneum
B) Obstruction of pancreatic duct
Digestive symptoms
Jaundice
Palpable liver
Palpable gall bladder
Tenderness
Ascites
Abdominal mass
In advanced cases:
Nodular liver
Enlarged supraclavicular
lymph node
Periumblical adenopathy

16. Courvoisier’s sign = painless, palpable/distended gallbladder on exam (think of CA)

17. Diagnosis & management of pancreatic cancer: It depends on results of
Spiral CT
1) Resectable: ask yourself if operative candidate or not
a)YES :Explore for resection
b) NO: =NONOPERATIVE: Palliation, Biliary stent & Chemo/Radiotherapy
2) Unresectable: is it only Biliary or associated with duodenal obstruction 
a)only Biliary:Endobiliary stent
b)Both: Operative palliation(Biliary bypass)
Gastrojejunostomy
Celiac plexus block

18. Whipple operation:

20. Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
Advantage
Detects choledocholithiasis, neoplasms, strictures, biliary dilations
Sensitivity of %, specificity of % of choledocholithiasis
Minimally invasive- avoid invasive procedure in 50% of patients
Disadvantage:
cannot sample bile, test cytology, remove stone
Contraindications: pacemaker, implants, prosthetic valves
Indications
If cholangitis not severe, and risk of ERCP high, MRCP useful
If Charcot’s triad present, therapeutic ERCP with drainage should not be delayed.
Endoscopic retrograde cholangiopancreatography (ERCP)
-Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction
-Advantage
Therapeutic option when CBD stone identified
Stone retrieval and sphincterotomy
-Disadvantage
Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding
Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

21. MRCP purely diagnostic . rapid, accurate and non-invasive Safe :
no contrast material administration
no radiation.
alternative to diagnostic ERCP.
MRCP avoids the complications of ERCP

22. Case 1: Normal MRCP. Note good delineation of normal caliber pancreatic and bile ducts. Fluid in stomach and duodenum also demonstrated.

23. Case 2: MRCP. Large common hepatic duct stone (asterisk) within dilated bile ducts. Note multiple gallstones

24. Surgical treatment Endoscopic biliary drainage
Endoscopic sphincterotomy with stone extraction and stent insertion
CBD stones removed in 90-95% of cases
Therapeutic mortality 4.7% and morbidity 10%, lower than surgical decompression
Surgery
Emergency surgery replaced by non-operative biliary drainage
Once acute cholangitis controlled, surgical exploration of CBD for difficult stone removal
Elective surgery: low M & M compared with emergency survey
If emergent surgery, choledochotomy carries lower M&M compared with cholecystectomy with CBD exploration

25. ERCP

27. ERCP(theraputic)

28. Choledocholithiasis
Choledocholithiasis develops in 10-20% of patients with gallbladder disease
At least 3-10% of patients undergoing cholecystectomy will have CBD stones
Pre-op
Intra-op
Post-op

29. Pre-op diagnosis & management
Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP
High risk (>50%) of choledocholithiasis:
clinical jaundice, cholangitis,
CBD dilation or choledocholithiasis on ultrasound
Tbili > 3 mg/dL correlates to 50-70% of CBD stone
Moderate risk (10-50%):
h/o pancreatitis, jaundice correlates to CBD stone in 15%
elevated preop bili and AP,
multiple small gallstones on U/S
Low risk (<5%):
large gallstones on U/S
no h/o jaundice or pancreatitis,
normal LFTs
-Treatment:
ERCP
Surgery

30. Intra-op diagnosis and management
Diagnosis: intraoperative cholangiography (IOC)
Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects.
Detect CBD stones
Potentially identify bile duct abnormalities, including iatrogenic injuries
Sensitivity 98%, specificity 94%
Morbidity and mortality low
Treatment
-Open CBD exploration
Most surgeons prefer less invasive techniques
-Laparoscopic CBD exploration
via choledochotomy: CBD dilatation > 6mm
via cystic duct ( %)
CBD clearance rate 97%
Morbidity rate 9.5%
Stones impacted at Sphincter of Oddi most difficult to extract
-Intraoperative ERCP

31. Early years: Open CBD exploration & Introduction of endoscopic sphincterotomy
1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon
Kocherization of duodenum and short longitudinal choledochotomy
Stones removed with palpation, irrigation with flexible catheters, forceps,
Completion with T-tube drainage
For many years, this was the standard treatment for cholecystocholedocholithiasis
1970s, endoscopic sphincterotomy (ES)
-Gained wide acceptance as good, less invasive, effective alternative
-In patients with CBD stones who have previously undergone cholecystectomy, ES is the method of choice

32. PTC Radiology Complication: -Bacteremia -Haemorrhage
Diagnostic and theraputic
Performed with 22G
Chiba Needle
Complication:
-Bacteremia
-Haemorrhage
-Contrast reaction
-Pneumothorax
-Intrahepatic
arterioportal fistula
-Bile leakage

33. PTC Percutaneous access to the biliary tree, through the
CBD, if possible, and into
the duodenum.
Downsides:
External drainage
Procedural risks:
Coagulopathy
ascites