awesome

1. -DEBALINA MAJUMDER and MANOJIT SARKAR
FINAL PROF
MALDA MEDICAL COLLEGE

2. introduction
 Jaundiceisthe yellowishdiscolouration of the
sclera,skinandthe mucusmembranesdue to
riseinserumbillirubin.
 Theprevalencevarieswithageandsex.
 Obstructivejaundiceis the causeof severe
jaundice inone thirdpatients.

3.  Cases of obstructive jaundice whichare dueto
malignancycarrypoorprognosiswith2 year
mortalityrate95%.
 It wasoncecalled“morbusregium”or theregal
diseaseinthebeliefthatonlythetouchofa king
couldcureit.

4. anatomy
The hepatobiliary system
 Thehepatobiliarysystemconsistsof the
liver,gallbladderandthebiliarytree.
 Theyarisefromthe ventralbudfromthemost
caudalpartoftheforegutandivideinto2
parts:
a) Pars hepatica- whichisthe primordium
ofliver.
b) Parscystica-fromwherearisethegall
bladder.
 Thestalkbecomesthecysticduct.
 Thebiliarysystemcanbedividedinto
extrahepaticandintrahepatic

5. LIVER
 Liveris locatedin theright
hypochondrin,extendinginto
epigastriumandlefthypochondrium.
 Hepatic lobulesis thefunctionalunit
Eachlobuleconsistof livercells,venous
channels andportalveins.
 Hilumof liver:Consistsof hepatic
artery,bileductanteriorlyandportalvein
posteriorly.
 Bloodsupply:Rt branchof hepatic
arterysuppliesrightlobe
andLeftbranchsuppliesleftlobe

6.  Venousdrainagethrough
the3 hepaticveinsright
middleandleftdraining
intoIVC.
 Lymphatics: Portahepatis,
alongthesuspensory
ligament orpost
mediastinum

7. The gall bladder
 Pearshapedorgan locatedin
theinferiorsurfaceofliverina
fossaorhangswitha
mesentery.
 length: 7.5 to 12 cm
 Capacity: 25-30ml
 It is dividedintofundus,body
andneck terminatingina
narrowinfundibulum.

8. It drainstotheCysticductintoCommon Hepatic
ducttoformtheCommonBileduct.
It is suppliedby the Cysticarterywhichis the
branchofRightHepaticArtery.

9. Common bile duct
 Length:7.5cm
 Diameter: 6-8mm
 Formedbyjunctionof
cysticandcommon
hepaticduct.
 Dividedinto4 parts:
I. Supraduodenal
II. Retroduodenal
III. Infraduodenal
IV. Intraduodenal

10.  Theintraduodenal partpassesthroughthewall of
2nd part of duodenum,surroundedby the Sphincter
of Oddi, & terminate byopeningonthesummit of
theAmpullaof Vater.
 Bloodsupply: Gastroduodenal,Retroduodenal,
Posterosuperiopancreaticoduodenal.

11. Calot’s triangle
 Describedby Jean
Francois Calot in1891.
 Bounded :
 inferiorlyby Cystic
duct
Mediallyby
CommonHepatic
duct
Superiorly byCystic
Artery

12. TheCysticarteryentersthetriangleafterpassing
behindCommonHepaticArtery
It containsthelymphnodesofLund or
Mascagni’snode.
It is a sentinel lymphnode.

13. Functions of gall bladder
It is the reservoirofbile.
It alsohelpsinconcentrationof bile atleast 5-10
timeswithincreaseinbile
pigments,salts,cholesterol,etc.
Thethirdfunctionis thesecretionofmucus
approximately20ml producedperday.

14. bile
 Dailyupto1000mlof bileis producedbytheliver
andstoredin thegallbladder fromwhichit is
released to Duodenum.
 Therateof secretionof bileestimated to be
approximately40ml/hour.
 About 95%of bilesalts arereabsorbedin terminal
Ileumin the enterohepaticcirculation.

15. Bilirubin metabolism

16.  Totalbileflowis 600ml/day(500-1000ml/day).
 Hepatocytecomponent is 450ml/day.
 Cholangiocyte component150ml/day.
 Totalserumbilirubin-0.3-1.2mg/dl.
 Conjugatedbilirubinis less than15%

17. jaundice
It is theyellowish
discolourationof thesclera
,skin,andmucusmembranes
asa resultof raisedserum
bilirubinandis usually
detectableclinicallywhenit is
greaterthan2mg/dl.
• Derivedfromthefrench
word“Jaune”meaning
yellow

18.  Yellowingofscleraoccursat 3mg%
 Yellowingofskin& mucusmembranesat 6mg%
 Bilirubinlevelsriseupto3 weeksthenstabilise.

19. Types of jaundice

20. DIFFERENCE( From history)
OBSTRUCTIVE JAUNDICE MEDICAL JAUNDICE
Fever with chills and
rigor,pain,malaise comes later
Fever with chills and
rigor,pain,malaise comes earlier
Yellowish discolouration comes first Yellowish discolouration comes later
Whitish discolouration of stool No discolouration of stool
Pruritus is intense Pruritus is absent or very less.
Palpable Gall Bladder found in case
of malignancy
Gall bladder is not palpable
Tender Hepatomegaly is a late
manifestations.
Tender Hepatomegaly occurs early

21. LABORATORY DIFFERENCE

22. Causes of obstructive jaundice
Congenital: Biliaryatresia,Choledochal Cyst,
Caroli’s disease,alpha1 antitrypsindefiency
Inflammatory: Ascendingcholangitis,Sclerosing
cholangitis.
Obstructive: Commonbileductstones,gall
bladderstones,biliarystricture,parasiticinfestations.

23. Neoplastic: Periampullarycarcinoma,
cholangiocarcinoma,Klatskintumor.
Extrinsic: CompressionofCBD bylymph
nodesortumors

24. COURVOISIER’SLAW
Ina patientwithjaundice,ifthereis palpable
gallbladderit isnotduetostones.
 Rulemaynotbeusefulin:
a. Absenceofgallbladder
b. Intrahepatic gall bladder
c. Previouscholecystectomy

25.  Exceptionstothelaw:
a. Doubleimpactedstones
b. LargestoneinHartmann’spouch
c. Empyemagallbladderwithcommonbileduct
stones.

26. Clinical features
Symptoms
• Generalisedmanifestationsof
jaundice.
• Yellowishdiscolourationofeyes
andskin.
• Passageofclaycoloredstools.
• Passageofdarkcoloured
urine.
• Presenceof billiousvomiting.

27. • Pruritus
• Pain(biliarycolic)
• Patient maycomplainof anorexiaandweightloss.
• Theremaybecomplaintsof fever.
• Theremaybe presenceof lumpreportedby the
patient.
• Malaenamaybe present(blackishdiscolourationof
stool).

28. Signs
General survey
 Patient is alert ,conscious,cooperative.
 Nutritionis poor
 Patientis deeplyjaundiced.
 Scratchmarksonskindueto itching.
 Mildpalloris present.
 No cervicallymphadenopathy.

30. Local examination
Inspection
 Shapeandcontouroftheabdomenis normal
 Umbilicusis normal.
 A masscanbe seenin righthypochondriac
region.
 Scratchmarkscanbeseenontheskinof
abdomen.

31. Palpation
 Superficialpalpationrevealsnormalto mildlyraised
temperature.
 Tendernessmayormaynotbepresentat Gallbladder
point.
 Deeppalpation mayreveallumpin right
hypochondriac extendingto theepigastriumandright
lumbarregion.
 Livermaybepalpable 2cm below therightcostal
marginif thejaundiceis due to choledocholithiasis
whichis firm,smooth,nontender.
 Spleenis notpalpable.

32. complications
Biliarycirrhosis
Acutecholangitis
Septicshock
Visual problems
Osteomalacia
Peripheral neuropathy
Cerebellar ataxia
Bleedingtendencies