Obstructive jaundice:A physician's trap!

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Obstructive jaundice is a dangerous form of disease. It is invariably treated medically leading to a delay in diagnosing the surgical cause. Prompt multipronged approach is therefore essential for early diagnosis.

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Obstructive jaundice:A physician's trap!

  1. 1. Obstructive Jaundice Dr.Ketan Vagholkar MS,DNB,MRCS,FACS Professor of Surgery & Consultant General Surgeon
  2. 2. Surgical Anatomy of Extrahepatic Biliary Tract
  3. 3. Bilirubin Metabolism <ul><li>Fragile RBC </li></ul><ul><li>Cell Membrane Rupture </li></ul><ul><li>Hb released </li></ul><ul><li>Phagocytosed by REcells(macrophages) </li></ul><ul><li>Heme +Globin </li></ul><ul><li>Free iron combines with ferritin+Straight chains of 4pyrole nuclei forms the substrate from which bile pigments are formed </li></ul><ul><li>Biliverdin </li></ul><ul><li>Bilirubin(released into plasma) </li></ul><ul><li>Bound to albumin and trasportedto the liver. Then absorbed thru the hepatic cell membrane </li></ul><ul><li>.During this processit is released from albumin but remains attached to one of the proteins Y and Z inside the hepatic cells. </li></ul><ul><li>Bilirubin is detached from these proteins as well and is conjugated. </li></ul><ul><li>80%bilirubin glucoronide </li></ul><ul><li>10%bilirubin sulphate </li></ul><ul><li>10%other substances </li></ul><ul><li>Biirubin is then excreted by an active process into the bile cacaliculi </li></ul><ul><li>Small amount of conjugated bilirubin enters plasma </li></ul><ul><li>Rest enters the intestine </li></ul><ul><li>In intestine </li></ul><ul><li>Conjugated bilirubin </li></ul><ul><li>Urobilinogen (bacterial action) </li></ul><ul><li>Enters kidney urobilinogen-urobilin </li></ul><ul><li>Rest enters gut-stercobilinogen-stercobilin </li></ul>
  4. 4. Types of jaundice <ul><li>Hemolytic </li></ul><ul><li>Obstructive </li></ul><ul><li>Hepatocellular </li></ul>
  5. 5. Differences between individual types
  6. 6. Classification of Obstructive Jaundice <ul><li>Complete obstruction </li></ul><ul><li>Intermittent obstruction </li></ul><ul><li>Chronic incomplete obstuction </li></ul><ul><li>Segmental obstruction </li></ul>
  7. 7. Classification of Jaundice <ul><li>Complete obstuction </li></ul><ul><li>Tumors </li></ul><ul><li>Ligation of cbd </li></ul><ul><li>Cholangiocarcinoma </li></ul><ul><li>Tumors </li></ul><ul><li>Intermittent obstuction </li></ul><ul><li>Stones </li></ul><ul><li>Periampullary tumors </li></ul><ul><li>Choledochal cyst </li></ul><ul><li>Parasites </li></ul><ul><li>Duodenal diverticula </li></ul>
  8. 8. Classification of Jaundice <ul><li>Chronic incomplete obstruction </li></ul><ul><li>Strictures of cbd </li></ul><ul><li>Stenosed biliary enteric anastomosis </li></ul><ul><li>Chronic pancreatitis </li></ul><ul><li>Cystic fibrosis </li></ul><ul><li>Segmental obstruction </li></ul><ul><li>Traumatic </li></ul><ul><li>Sclerosing cholangitis </li></ul><ul><li>Cholangiocarcinoma </li></ul><ul><li>Hepatodocholithiasis </li></ul>
  9. 9. Etiology(common causes) <ul><li>Calculi </li></ul><ul><li>Strictures </li></ul><ul><li>Periampullary carcinoma </li></ul><ul><li>Chronic pancreatitis </li></ul>
  10. 10. Clinical features <ul><li>Jaundice </li></ul><ul><li>Odp,treatment taken,blood transfusions,pruritus,high colored urine,claycolored stools,waxing and wanning,sudden decrease in jaundice,therapeutic interventions. </li></ul><ul><li>Weight loss/anorexia/vomiting/distention of abdomen </li></ul><ul><li>Previous operations </li></ul><ul><li>Attacks of pain-pancreatitis </li></ul>
  11. 11. Physical Examination (general examination) <ul><li>Level of consciousness </li></ul><ul><li>Signs of hepatocellular failure </li></ul><ul><li>Vital parameters </li></ul>
  12. 12. Per abdomen <ul><li>Lump in rhc </li></ul><ul><li>Courvoisier’s law </li></ul><ul><li>Hepatosplenomegaly </li></ul><ul><li>Ascites </li></ul><ul><li>Pr/proctoscopy </li></ul>
  13. 13. Investigations hematology <ul><li>CBC </li></ul><ul><li>LFT </li></ul><ul><li>VIRAL MARKERS </li></ul><ul><li>COAGULATION PROFILE </li></ul><ul><li>RENAL PROFILE </li></ul>
  14. 14. Investigations radiology <ul><li>USG </li></ul><ul><li>ERCP </li></ul><ul><li>PTC </li></ul><ul><li>MRCP </li></ul>
  15. 15. PREPARATION <ul><li>Nutritional </li></ul><ul><li>Coagulation deficiency </li></ul><ul><li>Prevention of hepatorenal syndrome </li></ul><ul><li>Bowel preparation </li></ul>
  16. 16. Therapeutic options <ul><li>Benign causes </li></ul><ul><li>Stone disease </li></ul><ul><li>Strictures </li></ul><ul><li>Malignant cause </li></ul><ul><li>Periampullary growths </li></ul>
  17. 17. Thank you

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