1. OBSTRUCTIVE JAUNDICE
DR.JAMIL SAWAKED

2. DEFITION OF JAUNDICE
YELLOW DISCOLOURATION OF SKIN AND MUCOUS MEMBRANE

3. TYPES A HEPATIC POSTHEPATIC PREHEPATIC OBSTRUCTIVE OR SURGICAL
HAEMOLYSIS A
PREHEPATIC
HEPATIC
POSTHEPATIC
OBSTRUCTIVE OR SURGICAL

4. ANATOMY

5. ANATOMY A

7. BILIRUBIN CYCLE BROKEN DOWN RED CELLS ARE REMOVED BY R.E.S.
HAEMOGLOBIN SPLITS INTO HAEM &GLOBIN
GLOBIN & CELL WALL PROTEIN GO DOWN
TO AMINOACIDS
THEY ENTER THE AMINO ACID POOL

8. BILIRUBIN CYCLE CONTINUE
HAEM SPLITS INTO IRON & BILIRUBIN [pigments]
IRON STORED AS FERRITIN FOR
REUSE

9. Van den Bergh reaction [DIRECT]
BILIRUBIN IS NOT REUSED
[GOES TO THE LIVER]
COMBINE WITH GLUCOURINC ACID
TO FORM THE CONJUGATED [ DIRECT ]
BILIRUBIN [ WATER SOLUBLE ]
Van den Bergh reaction [DIRECT]
Alcohol added after van den Gergh [INDIRECT]

10. HAEMOGLOBIN IRON +RBC WALL PROTEIN FERRITIN BILIRUBIN TO BE REUSED
WATER INSOLUBLE
AMINOACIDS
AMINOACID
POOL
GOES TO THE LIVER FOR CONGUGATION WITH GLUCOURINIC A.TO BECOME WATER SOLUBLE
BLOOD
URINE

11. URINE IN OBSTRUCTIVE JAUNDICE TEA COLOUR

12. BILIRUBIN CYCLE

13. DEEP JAUNDICE [OBSTRUCTIVE]

14. CAUSES OF OBSTRUCTIVE JAUNDICE
1-STONES
2-STRICTURES; [BENIGN]
3-CA. HEAD OF THE PANCREASE
4-CHOLANGIOCARCINOMA
5-PERIAMPULLARY TUMOUR
6-PRESSURE FROM OUTSIDE;L.N.,M.SYN.
7-CHOLEDOCHAL CYST
8-PARASITES; FILLING THE LUMEN

15. CAUSES IN THE LUNEN STONE IS THE COMMONEST HYDATID ASCARIS PARASITES
CLONORCHIASIS
HYDATID
PAPILLOMATOSIS
CHOLANGIOCARCINOMA
STONE IS THE COMMONEST

16. IN THE WALL:STRICTURES
BENIGN STRICTURES
MALIGNANT STRICTURES

17. OUTSIDE THE WALL L.N. ANY MASS OUTSIDE MIRIZZI SYND
Stone in cystic duct
MIRIZZI SYND
HARTMANN`S POUCH stone
HEAD OF THE PANCREASE

18. MIRRIZI`s syndrome

19. BENIGN STRICTURES 1-BILIARY ATRESIA 2-IATROGENIC BILIARY SURGERY
GASTRECTOMY
HEPATIC RESECTION
LIVER TRANSPLANT
3-INFLAMMATORY;CHOLANGITIS , PANCREATITIS, SCLEROSING CHOLANANGITIS.
4-TRAUMA
5-IDIOPATHIC
6-RADIOTHERAPY

20. BILIARY ATRESIA
BILIARY ATRESIA
NORMAL

21. CAUSES

22. THE COMMONEST CAUSE
STONE SLIPPING INTO THE BILIARY TREE

23. IMPACTED STONE AT THE LOWER END OF C.B.D.

24. ASSENDING CHOLANGITIS WITH LIVER ABSESSES

25. CA. HEAD OF THE PANCREASE

26. ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR
ORIGIN
1-DEUDENAL MUCOSA OR
2-C.B.D OR
3-PANCREATIC DUCT

27. CHOLANGICARCINOMA

28. CHOLANGIOCARCINOMA
LIVER METASTASIS

29. C.B.D.STRICTURE

30. SCLEROSING CHOLANGITIS
Associated with U.Colitis in 70% of cases
May lead to malignancy
Unknown aetiology
Symptoms of cholangitis
Treatment;Antibiotics
Or liver transplant
Rosary beads
شكل المسبحة

31. SYMPTOMS PAIN YELLOW DISCOLOURATION SKIN &M.M. DARK URINE [TEA COLOUR]
CLAY COLOUR STOOL لون الطحينية
ITCHING
FEVER IF CHOLANGITIS SUPERVENE
LOSS OF APPETITE
LOSS OF WEIGHT IN MALIGNACY

32. SIGNS LOSS OF Wt. IN MALIGNANCY TOXIC IN CHOLANGITIS,
[CHARCOT`S TRIAD,;PAIN, FEVER ,JAUNDICE]
YELLOW DISCOLOURATION OF SKIN,M.M.
TROISIER`S SIGN. VIRCHOW`S NODE
TENDER R.U.Q.[IN CHOLANGITIS]
COURVOISIER` LAW[IN CA.HEAD OF PAN.]
ABDOMINL MASS
ASCITES[IN MAIGNANCY]

33. DEEP JAUNDICE [GREEN] [OBSTRUCTIVE]
VIRCHOW`S NODE OR
[TROISIER`S SIGN]
BRUISING
VIT.K DEF.
2,4,7,9,10.DEPEND ON IT

34. COURVOISIER` LAW
DISTENDED GALL BLADDER
IN CA,HEAD OF PANCREASE

35. ASCITES IN ADVANCED CA. HEAD OF PANCREASE

36. INVESTIGATIONS C.B.C. DIFF., ESR. L.FT. *S.ALK.P.* PROTHROMBIN TIME
S. AMYLASE
K.F.T. ELECTRLYTES
URINE ANALSIS * BILIRUBIN *
STOOL ANALYSIS,;FAT,BLOOD.

37. INVESTIGATIONS
U.S.
STONE

38. DILATED CBD & STONE [US]
Should be more than 6 mm

39. C.T. DOUBLE BURRLE SIGN &DISTENDED G.
PERIAMPULLARY TUMOUR

40. ERCP
SPHINCTEROTOMY

41. STONE EXTRACTION BY BASKET

42. STONE EXTRACTION BY BALLON

43. ERCP
C.B.D.STONE

44. C.B.D. BIG STONE

45. STENT

46. STONE REMOVED

47. C.B.D. STRICTURE

48. C.B.D.STENT WITH GOOD FLOW

49. CHOLANGICARCINOMA

50. CHOLANGIOCARCINOMA

51. E.R.C.P.FOR EXTRAHEPATIC CHOLANGIOCARCINOMA

52. ENDOSCOPIC VIEW OF PERIAMPULLARY TUMOUR

53. M.R.C.P

54. P.T.C.
PERCUTANOUS TRANSHEPATIC
CHOLANGIOGRAM

55. PEROPERATIVE CHOLANGIOGRAM

56. T.TUBE CHOLANGIOGRAM

57. DRAIN CHOLANGIOGRAM

58. MANAGEMENT-1 CORRECTION OF THE DERENGED PARAMETRES
ADMINISTRATION OF VITAMIN K
ANTIBIOTICS
MANNITOL PRE, INTRA and POSTOPERATIVELY TO PREVENT
HEPATO-RENAL SHUTDOWN

59. MANAGEMENT-2 1. STONE-SPHINCTEROTOMY 2.STONE-EXPLORATION OF C.B.D.
3.STRICTURE-RESECTION ANASTOMOSIS FOR SHORT STRICTURES
4.STRICTURE-STENT FOR SHORT AND LONG
5.CA.HEAD OF THE PANCREASE
=EARLY-WHIPPLE`S OPERATION[PANCREATICO-DUODENECTOMY.
=LATE-BYPASS SURGERY[CHOLECYSTO-JUJENOSTOMY

60. STENT FOR Ca. head of pancrease

61. Pancreatico-duodenoctomy
WHIPPLE`S OPERATION
Pancreatico-duodenoctomy