1. Mechanical jaundice

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

3. Mirizzi’s syndrome 1 type 2 type

4. Atresia of the extrahepatic ducts

5. 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 By the degree of stricture Full Not full Classification of the posttraumatic strictures of the bile ducts 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 By the level of defeat High Low

6. Parasitic infestation of biliary tract roundworms (roundworm, whipworm) flukes (dvuuska cat, liver) tapeworms (tapeworm bovine, pork tapeworm, echinococcus) Neoplastic lesions of the biliary tract 1.Tumors of the head of the pancreas 2.Tumors of the major duodenal papilla 3.Tumors of the porta hepatis 4.Tumors of the gallbladder 5.Secondary (metastatic) SHOCK- periholedohialnyh of lymph nodes

7. Clinical forms of jaundice Icteric-painful form Icteric form of pancreatic- Icteric-holetsistitnaya form Yellowness of septic-form Icteric, painless form The main clinical symptoms Yellowing of the skin, sclera pruritus discoloration of feces dark-colored urine

8. Physical examination of obstructive jaundice -Yellowing of the skin, sclera, mucous membranes; -High fever; -Bright (aholic) excrement; -Urine "colored beer" or "strong tea"; -Increasing the size of the liver and gallbladder; -Tenderness in the right upper quadrant; -Palpable abdominal mass; -Courvoisier syndrome. Laboratory data in obstructive jaundice Hyperbilirubinemia, mainly due to the direct fraction; The increase in hepatic alkaline phosphatase blood; High blood levels of bile acids; hypercholesterolemia; Absence sterkobilina in the feces urobilinogen in the urine; The increase of bile pigments in the urine

9. Increasing the pressure in the bile ducts biliary hypertension Violation of the blood and lymph circulation in the liver Change of organ microcirculation Inappropriate secretion of hepatocyte Degenerative changes in hepatocytes biliary cirrhosis The pathogenesis of hepatic failure

10. Stages of the diagnostic search A careful history, physical examination, the use of search (screening) laboratory tests. The wording of the preliminary diagnosis (suspected obstructive jaundice genesis). Selecting and sequencing using special instrumental methods for topical diagnosis. Methods of instrumental diagnostics 1 Noninvasive methods: ultrasound Computed tomography 2 Invasive methods: ERCP TTChG

11. Ultrasound examination Sensitivity - 70-90%, specificity - 80-85%. Computed tomography Sensitivity - 70-90%, specificity - 80-85%.

12. Endoscopic retrograde cholangiopancreatography Percutaneous transhepatic cholangiography Sensitivity - 90-98%, specificity - 90-100% Sensitivity and 100% specificity - 90%

13. Diagnostic algorithm at obstructive jaundice JAUNDICEJAUNDICE History, physical examination, routine laboratory tests ultrasound Increased alkaline phosphatase or transaminases Chance of biliary obstruction RPHG, TTHG, CT Therapeutic measures (traditional or minimally invasive surgery)

14. Differential diagnostic of the jaundices by the clinic signs Clinic signType of the jaundice mechanicalparenchimatoushemolytuc Weakness, adynamy Yes Absence Gall bladderIncreased at the low obstruction Not increased PulseBradicardy Normal or tachycardia LiverIncreased Not very increased СелезенкаNot increasedSometimes increased Often increased Повышенная кровоточивость Yes

15. Algorithm for the management of patients with obstructive jaundice Stage I Drainage Dosage decompression Elimination of multiple organ failure Lack of effect open surgery Stage II Restoration of normal passage of bile into the intestine Endoscopic retrograde intervention Percutaneous transhepatic endobiliary intervention

16. Indications for endoscopic retrograde endobiliary interventions Extension of the common bile duct by ultrasound than 8 mm Identifying the causes of breast and localization of the pathological process in the biliary tract Hyperbilirubinemia with poor visualization of the extrahepatic bile passages by ultrasound Indications for endoscopic papillosphincterotomy choledocholithiasis stenosing papillitis Stenosis of the terminal part of the common bile duct and major duodenal papilla of up to 1.5 cm Jaundice with liver failure in the I and II Contraindications CAD – AMI; Stroke; AHI; ABI

17. In the stage of compensation Improvement of bioenergetic processes in the liver (rr glucose with insulin, vitamin C and kokarboksilaza) Correction of acid-base balance (with acidosis aq sodium hydrogen carbonate, with alkalosis aq hydrochloric to-you) Correction of electrolyte abnormalities is preferably carried out with the help of diet and fruit juices. In the presence of hepatic cytolysis, prescribe medications that have membranostabi-lysing action (legalon, essentiale, geptral). Under subcompensation Detoxification therapy (gemodez, neokompensan) Correction of electrolyte disorders Correction of protein malnutrition (albumin, plasma, etc..) Correction of coagulation disorders (menadione, aminocaproic to-one Dicynone, platelets) Drug treatment In decompensated stage Treatment in an intensive care unit and intensive care Inclusion in the complex of the above activities or lymph hemosorption systematic cleansing the gastrointestinal tract (gastric lavage, siphon enema) Appointment of large doses of corticosteroids (prednisone, hydrocortisone) Suppress the activity of proteolytic enzymes (trasilol, contrycal, gordox)

18. Operation to establish a permanent passage of bile 1.EPST 2.Removing gallstones with a probe Dormia 3.Removing gallstones with flexible forceps 4.Removing gallstones with a probe Fogarty 5.Dilatation technique in secondary terminal part of the common bile duct strictures 6.Removal of stones double latex balloon 7.Mechanical lithotripsy and aspiration method 8.Loop-trap extraction of stones

19. Endoscopic retrograde sphincterotomy

20. ERPChG before EPST ERPChG after EPST

21. Removing the gallstones with a probe Dormia

22. Removing gallstones with flexible forceps Removing gallstones with a probe Fogarty

23. Dilatation of the terminal part of the common bile duct stricture at Removal of stones double latex balloon

24. Mechanical lithotripsy and aspiration method Loop-trap extraction of stones

25. Indications to TTChG  Inability to perform endoscopic retrograde vmeschatelstv-tion, their inefficiency, the presence of anti-testimony to them.  Tumors гепатикопанкреатодуоденальной zone, creating a block of biliary tract. Contraindications to TTChG  The presence of space-occupying lesions in the projection of the proposed puncture  Reduction of PTI to 50% or lower  Decrease in platelet count to 100 thousand. Below and  Colon interposition between the abdominal wall and the liver  Suppurative diseases of soft tissues in the area of ​​ the proposed puncture  Allergic reactions to iodine in history

26. Percutaneous transhepatic cholangiography

27. Open surgery in the treatment of obstructive jaundice Internal transduodenalnym choledochoduodenostomy Transduodenalnym papillosphincterotomy and papillosfinkteroplastika

28. choledochoduodenostomy HDA by YurashHDA on FlerkenuHDA by Finsterer

29. Operations performed when the common bile duct strictures Plastic bile duct by Geyneke- Mikelichu Resection of the common bile duct with the anastomosis "end to end" Terminolateralny gepatikoenteroanastomoz with V-shaped mezhkishechnye fistula after Roux Terminolateralny gepatikoenteroanastomoz with intestinal anastomosis "side to side"

30. New in the diagnosis and treatment of obstructive jaundice Adenometionin in complex therapy of liver failure in patients with obstructive jaundiceAdenometionin in complex therapy of liver failure in patients with obstructive jaundice Molecular adsorbent recirculating system in the treatment of obstructive jaundice (MARS)Molecular adsorbent recirculating system in the treatment of obstructive jaundice (MARS) Application erythrocyte farmakotsitov in treatment of acute liver failure in obstructive jaundiceApplication erythrocyte farmakotsitov in treatment of acute liver failure in obstructive jaundice Controlled laser therapy in complex treatment of patients with cholelithiasis complicated by cholangitis and obstructive jaundiceControlled laser therapy in complex treatment of patients with cholelithiasis complicated by cholangitis and obstructive jaundice Application sporobacterin for the prevention and treatment of cholangitis in patients with obstructive jaundiceApplication sporobacterin for the prevention and treatment of cholangitis in patients with obstructive jaundice Peritoneal detoxification in the treatment of obstructive jaundicePeritoneal detoxification in the treatment of obstructive jaundice The drug Hepa-Merz in treatment of hepatic failure with jaundiceThe drug Hepa-Merz in treatment of hepatic failure with jaundice