This document discusses surgical jaundice, including:
1. It defines jaundice and surgical jaundice, and classifies jaundice into pre-hepatic, hepatic, and post-hepatic types.
2. It describes the anatomy and physiology of the biliary tract and bilirubin metabolism.
3. Common causes of obstructive jaundice include gallstones, cancer, strictures, and inflammation. A thorough history and physical exam can help identify the cause.
4. Investigations include blood tests, imaging like ultrasound and MRCP, and procedures like ERCP. The goal is to determine the specific cause and level of obstruction.
5. Treatment depends on the
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
OBSTRUCTIVE JAUNDICE: UNDERSTANDING THE PATHOPHYSIOLOGYKETAN VAGHOLKAR
Jaundice is one of the most prevalent symptom in hepatobiliary disorders. The nature of jaundice may varyfrom hepatocellular to obstructive pattern. In a few cases, it may be haemolytic in nature. Identifying and ascertainingthe type is pivotal for further investigation. A combination of haematological and radiological investigations will notonly provide information on the severity and the impact of obstructive jaundice on various organ systems of the bodybut also help in determining the prognosis. Endoscopy can also provide diagnostic as well as a therapeutic benefit inobstructive jaundice. The pathophysiology, clinical evaluation and investigations in a case of obstructive jaundice isdiscussed in this paper.
Hemostasis, Coagulation, Intrinsic, Extrinsic & common Pathways of Clotting, Common bleeding disorders & their investigations, BT, CT, PT, APTT, TT, Blood & its products, Blood transfusion & its complication.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
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- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
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The prostate is an exocrine gland of the male mammalian reproductive system
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A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. SURGICAL JAUNDICE
By
Dr. Abdul Qadeer
MBBS; FCPS; FICS
Assistant Professor in General Surgery
King Faisal University College of Medicine
Kingdom of Saudi Arabia
2.
3. OBJECTIVES
1. Surgical anatomy & physiology of biliary
tract
2. Definition of jaundice
3. Bilirubin metabolism
4. Classification of jaundice
5. Important points in the history &
examination of jaundice
6. Investigations of biliary tract with indications
7. Treatment of surgical jaundice
5. 2. DEFINITION OF JAUNDICE
Jaundice is the yellowish pigmentation of the
skin, the conjunctival membranes over the
sclerae, and other mucous membranes
caused by hyperbilirubinemia
Icterus is the clinical manifestation due to
jaundice
Total serum bilirubin values are normally 0.2-
1.2 mg/dL. Jaundice may not be clinically
recognizable until levels are at least 3 mg/dL.
6. Surgical jaundice is any jaundice amenable
to surgical treatment.
Majority are due to extra-hepatic biliary
obstruction
Jaundice is not a diagnosis.
7. 3. BILIRUBIN METABOLISM
Bile is produced by hepatocytes
500-1000 ml/day
An exocrine secretion
Contains bilirubin (a pigment) + bile salts
Bile goes from liver to duodenum and also
stored within gallbladder
8. From gallbladder, it is released in response
to acid, fat & amino acids / CCK from
duodenal mucosa
CCK relaxes the sphincter of Oddi
VIP & Somatostatin inhibit the contraction of
gallbladder
9. BILIRUBIN
Bilirubin may be unconjugated (Indirect) or
conjugated (Direct)
Produced from heme portion of hemoglobin
as biliverdin which converts to bilirubin
Bilirubin conjugates in liver with glucronic
acid by glucronyl transferase enzyme, which
makes it water-soluble
10. Within intestine (colon), the bilirubin is
metabolized by bacteria to stercobilinogen
Minor quantity of stercobilinogen is
reabsorbed to reach the liver and then to
kidneys and excreted in urine as urobilinogen
Major portion is excreted into feces as
stercobilinogen
11.
12. NORMAL BLOOD VALUES OF BILIRUBIN
μmol/L
mg/dL
Total bilirubin <21 <2.1
Direct bilirubin 1.0–5.1 0.1–0.4
13. BILE SALTS
Bile salts help to absorb fats after converting
these to micelles
Bile salts are re-absorbed through terminal
ileum, hence maintain the enterohepatic
circulation
15. PREHEPATIC (HEMOLYTIC) JAUNDICE
Occurs in case of hemolytic anemia.
Total bilirubin level is increased due to increased
blood indirect bilirubin level.
The color of urine remains normal, because
indirect bilirubin is bind to albumin, and
subsequently unable to pass the glomerular
filter.
Higher level of blood indirect bilirubin, results in
higher bilirubin uptake by the liver and increases
the rate of formation of direct bilirubin, and
increases the direct bilirubin that passes to the
small intestine. This results in dark brown color
16. PREHEPATIC (HEMOLYTIC) JAUNDICE CONTD:
The increased stercobilinogen level in the
small intestine results in increased formation
of urobilinogen, which is excreted in urine.
The most important changes in pre-hepatic
jaundice are increased total and indirect
bilirubin in blood, dark brown feces and
increased urobilinogen in urine.
17. HEPATIC JAUNDICE
Occurs in case of hepatitis.
Total bilirubin level increased due to increase
of both direct and indirect bilirubin.
18. POST-HEPATIC (OBSTRUCTIVE) JAUNDICE
Occurs in case of obstruction of main bile
duct.
Total bilirubin increased due to increase
blood direct bilirubin level.
Dark brown color of urine.
Clay color of feces
Absence of urobilinogn from urine.
19. Biliary obstruction refers to the blockage of
any duct that carries bile from the liver to the
gallbladder(intrahepatic) or from the
gallbladder to the small intestine
(extrahepatic).
This can occur at various levels within the
biliary system.
The major signs and symptoms of biliary
obstruction result directly from the failure of
bile to reach its proper destination.
20. Extrahepatic obstruction to the flow of bile
may occur within the ducts or secondary to
external compression.
Overall, gallstones are the most common
cause of biliary obstruction.
Other causes of blockage within the ducts
include malignancy, infection, and biliary
cirrhosis.
21. External compression of the ducts may occur
secondary to inflammation (eg, pancreatitis)
and malignancy.
Regardless of the cause, the physical
obstruction causes a predominantly
conjugated hyperbilirubinemia
22. The lack of bilirubin in the intestinal tract is
responsible for the pale stools typically
associated with biliary obstruction.
The cause of itching (pruritus) associated
with biliary obstruction is not clear.
It is that it may be related to the
accumulation of bile acids in the skin.
23.
24. CAUSES OF OBSTRUCTIVE JAUNDICE
1. Gallstones
2. Ca head pancreas
3. Biliary strictures
4. Liver abscess
5. Pseudopancreatic cyst
6. Cholangiocarcinoma
7. Peri-ampulary carcinoma
8. Choledochal cyst
25. Stone disease is the most common cause of
obstructive jaundice.
Ascaris lumbricoides
Clonorchis sinensis, Fasciola hepatica
Common in Asian countries
26. MIRIZZI SYNDROME
It is the presence of a
stone impacted in the
cystic duct or the
gallbladder neck,
causing inflammation
and external
compression of the
common hepatic duct
and thus biliary
obstruction.
27. Of biliary strictures, 95% are due to surgical
trauma and 5% are due to external injury to
the abdomen or pancreatitis or erosion of
the duct by a gallstone.
A tear in the duct causes bile leakage and
predisposes the patient to a localized
infection. In turn, this accentuates scar
formation and the ultimate development of
a fibrous stricture.
28. PSC is most common in men aged 20-40
years, and the cause is unknown.
PSC is characterized by diffuse
inflammation of the biliary tract, causing
fibrosis and stricture of the biliary system.
diagnosis based on findings from
endoscopic retrograde
cholangiopancreatography (ERCP).
29. Biliary obstruction associated with
pancreatitis is observed most commonly in
patients with dilated pancreatic ducts due to
either inflammation with fibrosis of the
pancreas or a pseudocyst.
Intravenous feedings (TPN) predispose
patients to bile stasis and a clinical picture of
obstructive jaundice
30. 5. HISTORY & EXAMINATION OF JAUNDICE
Clinical Evaluation:
History
Examination
Investigations
Treatment
31. HISTORY OF OBSTRUCTIVE JAUNDICE
Patients commonly complain of pale stools,
dark urine, yellowness of the eye, and
pruritus.
The following considerations are important:
Patients' age
Jaundice (duration ,onset, progression)
32. HISTORY
the presence of abdominal pain( location and
characteristics of the pain)
The presence of systemic symptoms (e.g. fever, weight
loss)
Symptoms of gastric stasis (e.g. early satiety, vomiting,
belching)
Change in bowel habit
History of anemia
Previous malignancy
Known gallstone disease
Gastrointestinal bleeding
Hepatitis
Previous biliary surgery
Diabetes or diarrhea of recent onset
Also, explore the use of alcohol, drugs, and medications
33. PHYSICAL EXAMINATION
Upon physical examination, the patient may
display signs of jaundice (sclera icterus).
When the abdomen is examined, the
gallbladder may be palpable (Courvoisier
law). This may be associated with underlying
pancreatic malignancy.
Also, look for signs of weight loss, occult
blood in the stool, suggesting a neoplastic
lesion.
34. PHYSICAL EXAMINATION
Note the presence or absence of ascites and
collateral circulation associated with
cirrhosis.
A high fever and chills suggest a coexisting
cholangitis.
35. PHYSICAL EXAMINATION
Abdominal pain may be misleading; some
patients with CBD calculi have painless
jaundice, whereas some patients with
hepatitis have distressing pain in the right
upper quadrant.
Malignancy is more commonly associated
with the absence of pain and tenderness
during the physical examination.
37. LAB STUDIES
Basic
FBC+ Blood film: aneamia,
infection,Hgbpathy
Serum E/U/Cr
Urinalysis : bilirubin present, urobilinogen
absent
Stool for ocult blood: ca ampula
Stool mucus for ova and parasites
Clotting profile: PT deranged
Hepatitis serology: HbsAg, HCV
38.
39. IMAGING
Plain radiographs are
of limited utility to help
detect abnormalities in
the biliary system
Ultrasonography
(US):US is the
procedure of choice for
the initial evaluation
40. Traditional computed tomography (CT) scan
is usually considered more accurate than
US for helping determine the specific cause
and level of obstruction.
Percutaneous transhepatic cholangiogram
(PTC): done esp if the intrahepatic duct is
dilated, outline the biliary tree, locates
stones.
41. ENDOSCOPIC RETROGRADE CHOLANGIO-
PANCREATOGRAPHY (ERCP)
It is an outpatient procedure that combines
endoscopic and radiologic modalities to
visualize both the biliary and pancreatic duct
systems.
42. ENDOSCOPIC ULTRASOUND (EUS)
It combines endoscopy and US to provide
remarkably detailed images of the pancreas
and biliary tree. It allows diagnostic tissue
sampling via EUS-guided fine-needle
aspiration (EUS-FNA)
43. MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY
(MRCP)
It is a noninvasive way to visualize the
hepatobiliary tree.
MRCP provides a sensitive noninvasive
method of detecting biliary and pancreatic
duct stones, strictures, or dilatations within
the biliary system. It is also sensitive for
helping detect cancer.
45. TREATMENT
Medical care: Treatment of the underlying
cause is the objective of the medical
treatment of biliary obstruction.
Do not subject patients to surgery until the
diagnosis is clear.
In cases of cholelithiasis in which either the
patient refuses surgery or surgical
intervention is not appropriate give
46. Ursodeoxycholic acid (10 mg/kg/d) works
to reduce biliary secretion of cholesterol. In
turn, this decreases the cholesterol
saturation of bile.
Extracorporeal shock-wave lithotripsy
may be used as an adjunct to oral
dissolution therapy.
Contraindications include complications of
gallstone disease (eg, cholecystitis,
choledocholelithiasis, biliary pancreatitis),
pregnancy, and coagulopathy or
anticoagulant medications (i.e. because of
the risk of hematoma formation).
47. Bile acid–binding resins, cholestyramine (4
g) or colestipol (5 g), dissolved in water or
juice 3 times a day may be useful in the
symptomatic treatment of pruritus associated
with biliary obstruction.
Vitamins A,D,E,K supplements
Antihistamines may be used for the
symptomatic treatment of pruritus,
particularly as a sedative at night.
48. SURGERY (PRE-OPERATIVE CARE)
The following are problems of a jaundiced
pt and all must be taken care of before
surgery
Infection due to biliary stasis
Uncontrolled bleeding due to vitamin K
deficiency
Liver glycogen depletion
Dehydration
Hepatorenal syndrome
49. THEREFORE;
Fluid resuscitation using dextrose alternate with
Saline. Encourage oral rehydration as well
Give broad spectrum antibiotics at induction of
anaesthesia to cover for G+,G- and anaerobes
Bowel prep
IM Vit. K 10mg daily until PT/APTT normalizes
(start 5 days pre-op)
Monitor UO, catheterize night before surgery
You may consider given Mannitol pre-op, intra-
op and post-op for diuresis to prevent
hepatorenal syndrome
50. SURGERY
The need for surgical intervention depends
on the cause of biliary obstruction.
Cholecystectomy is the recommended
treatment in cases of choledocholithiasis
.(open or lap)
Open / Laparoscopic cholecystectomy is
relatively safe, with a mortality rate of 0.1-0.5
%.
51. SURGERY
Ca head of pancres
Early stage: Whipple’s operation, pancreatoduodenectomy+
pancreticojejunostomy+ gastrojejunostomy+ cholecystojejunostomy
Late surgery: bypass surgery
Cholangiocarcinoma:
hepatodochojejunostomy
Cancer ampulla of vater: whipples operation
Chronic pancreatitis: subduodenal
exploration, sphincterectomy, insertion of
stent
Liver transplantation may be considered in
52.
53. PREVENTION
In patients with risk factors for developing
any of the conditions that lead to biliary
obstruction, awareness of the signs and
symptoms can improve chances for early
diagnosis and improved outcome.
Diet: Reduce intake of saturated fats, High
intake of fiber has been linked to a lower risk
for gallstones.
Gradual and modest weight reduction may
be of value in patients who are at risk.
54. Activity: Regular exercise may reduce the
risk of gallstones and gallstone complications
Estrogens cause an increase in the risk for
formation of gallstones and may need to be
avoided in patients with known gallstones or
a strong family history of stone disease.
55. COMPLICATIONS
The complications of cholestasis are
proportional to the duration and intensity of
the jaundice.
High-grade biliary obstruction begins to
cause cell damage after approximately 1
month and, if unrelieved, may lead to
secondary biliary cirrhosis.
56. Acute cholangitis is another complication
associated with obstruction of the biliary tract
and is the most common complication of a
stricture, most often at the level of the CBD.
Bile normally is sterile. In the presence of
obstruction to flow, stasis favors colonization
and multiplication of bacteria within the bile.
Concomitant increased intraductal pressure
can lead to the reflux of biliary contents and
bacteremia, which can cause septic shock
and death.
57. Biliary colic that recurs at any point after a
cholecystectomy should prompt evaluation
for possible choledocholithiasis.
Failure of bile salts to reach the intestine
results in fat malabsorption with steatorrhea.
In addition, the fat-soluble vitamins A, D, E,
and K are not absorbed, resulting in vitamin
deficiencies.
Disordered hemostasis with an abnormally
prolonged PT may further complicate the
course of these patients.