Aetiology and Management of Benign Conditions Causing Surgical Jaundice ; It includes Biliary atresia , Choledochal cyst , Sclerosing Cholangitis , Gall stones , Biliary strictures

1. BENIGN CONDITIONS
AMARAN.M
FINAL YEAR MBBS , S2
PROF.P.RAGUMANI UNIT

2. JAUNDICE
 JANEU ( FRENCH ) ; ICTERUS ( LATIN )
 DEFINITION
 “REGAL” DISEASE

3. BENIGN CONDITIONS
CONGENITAL : BILIARY ATRESIA ; CHOLEDOCHAL CYST.
INFLAMMATORY : SCLEROSING CHOLANGITIS.
OBSTRUCTIVE : GALLSTONES ; BILIARY STRICTURES.

4. BILIARY ATRESIA

5. BILIARY ATRESIA
 DEFINITION
 INCIDENCE 1 : 10,000
 ASSOCIATED WITH
CONGENITAL
ANAMOLIES
 TYPES

6. TYPES OF BILIARY ATRESIA

7. PATHOGENESIS
CAUSES
 INFECTIONS : CMV, HPV,
REOVIRUS,
ROTAVIRUS.
 AUTOIMMUNE
 ABNORMAL DEVELOPMENT
 TOXINS
 VASCULAR DEFECTS

8. TREATMENT
 HEPATICO-PORTO-
JEJUNOSTOMY
 PRESENTLY KASAI
PORTO-ENTEROSTOMY
 8 WEEKS OF AGE

9. CHOLEDOCHAL CYST

10. CHOLEDOCHAL CYST
 CYSTIC DIALTATIONS OF
BILE DUCT
 MORE COMMON IN ASIA
 1 :1000
 TYPES
 CAROLI’S DISEASE
( TYPE 5 )
 CAUSE IS EXPLAINED BY
BABBIT THEORY

11. COMPLICATIONS OF CYSTS
 PANCREATITIS MAINLY IN TYPE 3
 GALLSTONE AND CBD STONE FORMATION
 BILIARY CIRRHOSIS
 MALIGNANCY ( CHOLANGIOCARCINOMA ; COMMON IN POST.
WALL )

12. TREATMENT OF CYSTS
TYPE 1
 COMPLETE EXCISION OF
CYST
 RECONSTRUCTION BY
HEAPTICO-
JEJUNOSTOMY

13. TREATMENT OF CYSTS
TYPE 2
 EXCISION OF
DIVERTICULUM
 SUTURING THE CBD
WALL

14. TREATMENT OF INTRADUODENAL PART
TYPE 3
 ENDOSCOPIC
SPHINCTEROTOMY
( FOR LESIONS < 3cm )
 TRANSDUODENAL
APPROACH
( FOR LESIONS > 3cm )

15. TREATMENT OF CYSTS
TYPE 4
 EXTRAHEAPTIC PART IS
EXCISED AND
RECONSTRUCTION
PROCEDURE
 INTRAHEPATIC PART
ARE RESECTED ONLY
WHEN THERE IS
STRICTURES OR LIVER
ABSCESS
 LILY’S OPERATION

16. TREATMENT OF CAROLI’S DISEASE
TYPE 5
 LEFT LOBAR DUCTS ARE
USUALLY AFFECTED
 LOBAR RESECTION IS
DONE.
 BILOBAR INVOLVEMENT
: TRANSPLANTATION

17. SCLEROSING CHOLANGITIS

18. SCLEROSING CHOLANGITIS
 INFLAMMATION AND SUBSEQUENT OBSTRUCTION OF BILE DUCTS
AT BOTH INTRAHEPATIC & EXTRAHEPATIC LEVELS +
DILATATION OF PRESERVED SEGMENTS
 HIGH RISK FOR CHOLANGIOCARCINOMA
 TYPES
 1. PRIMARY ( NO CAUSE IS FOUND )
 2. SECONDARY TO OTHER DISEASES
(CHEMOTHERAPY 5-FU)

19. PATHOGENESIS OF PSC
AUTOIMMUNE ; HLA-B8/DR3
T CELL MEDIATED INFLAMMATION ; FIBROSIS &
STRICTURES
PROGRESSIVE DESTRUCTION OF SMALL & MEDIUM SIZED
DUCTS WITHIN LIVER & LARGE DUCTS OUTSIDE LIVER
OBSTRUCTION TO BILE FLOW (CHOLESTASIS)
CHRONIC
INFLAMMATION
CHRONIC
INFLAMMATION MAY
PROGRESS TO :
 CHOLANGIOCARCINOMA
 CIRRHOSIS OF LIVER

20. MANAGEMENT
IMMUNOSUPPRESSION
• METHOTREXATE
• AZATHIOPRINE
• CYCLOSPORINE
• TACROLIOMUS
GALLSTONE
SOLUBILIZER
• URSODIOL
( suppresses
hepatic synthesis of
cholesterol )
LIPID LOWERING
AGENT
• CHOLESTYRAMINE
( forms a non
absorbable complex
with bile acids and
inhibits the
reuptake )
 STEROIDS IN LARGE DOSES
 VITAMIN SUPPLEMENTS
 STENTING
 LIVER TRANSPLANTATION is the only
proven long term treatment
GENERAL

21. GALLSTONE

22. GALLSTONE
 CHOLELITHIASIS INVOLVES THE PRESENCE OF GALLSTONES IN THE
GALLBLADDER ;
 CHOLEDOCHOLITHIASIS IS THE PRESENCE OD GALLSTONES IN COMMON
BILIARY DUCT
 FAT, FERTILE , FORTY, FLATULENT, FEMALE
 TYPES
 CHOLESTEROL STONES
 PIGMENT STONES
 MIXED ( COMMONEST 90 % )

23. CHOLESTEROL STONE PATHOGENESIS
 OBESITY
 PREGNANCY
 DRUGS
 HEREDITARY

24. PIGMENT STONES
INSOLUBLE Ca
SALTS OF
UNCONJ.
BILIRUBIN
INORGANIC
Ca SALTS
PIGMENT
STONES

25. PIGMENT STONES PATHOGENESIS
PREDISPOSING FACTORS
 CHRONIC HEMOLYTIC
SYNDROMES
 BILIARY INFECTION
 GI DISORDERS

26. MANAGEMENT
• CHENODEOXYCHOLIC ACID &
URSODEOXYCHOLIC ACID
( INHIBITS ABSORPTION OF
CHOLESTEROL FROM GUT)
DISSOLUTION
THERAPY
• OPEN CHOLECYSTECTOMY
• CHOLEDOCHOTOMY
• OPEN CHOLEDOCHODUODENOSTOMY
• OPEN CHOLEDOCHOJEJUNOSTOMY
OPEN
PROCEDURES
• LAPROSCOPIC CHOLECYSTECTOMYLAPROSCOPIC
PROCEDURES

27. OPEN CHOLECYSTECTOMY
PREOPERATIVE PREPARATION :
 DEHYDARTION CORRECTION
(IV DEXTROSE 5%)
 IV ANTIBIOTICS

29. PNEUMOPERITONEUM
WITH CO2 GAS AT
SUBUMBILICAL PORT
GRASPING THE GALL
BLADDER & CALOT’S
TRAINGLE VISUALISATION
PLACING CLIPS AROUND
CYSTIC DUCT & ATRERY
TO CUT
GALL BLADDER IS
DISSECTED OFF THE
LIVER
BLEEDING CHECK &
WASH & REMOVE THE
GAS

30. BILIARY STRICTURE

31. BILIARY STRICTURE
 CAUSES
 POST OP. ( MOST COMMON )
 INFLAMMATORY
 CBD STONES
 PARASITES
 PSC
 MALIGNANT
 TRAUMATIC

32. BISMUTH CLASSIFICATION

33. MANAGEMENT
 ERCP
 CHOLEDOCHOJEJUNOSTOMY
 CHOLEDOCHODUODENOSTOMY
 ROUX EN Y HEPATICOJEJUNOSTOMY ( IDEAL )

34. TAKE HOME MESSAGES
 CONGENITAL MALFORMATION OF BILIARY TREE MAY
BE EITHER ILEANA OR NAMITHA
 SCLEROSING CHOLANGITIS IS AUTOIMMUNE
INFLAMMATION + DESTRUCTION = OBSTRUCTION
 MIXED TYPE IS THE COMMONEST STONE
 LAPROSCOPIC > OPEN PROCEDURE
 T TUBE PALCEMENT (CHOLANGIOGRAM DONE
TWICE )

35. DON’T AFRAID OF BEING DIFFERENT!
HUMAN BEING IS ALWAYS AFRAID OF
“BEING DIFFERENT” ;
NOT BECAUSE THEY ARE DIFFERENT,
ITS BECAUSE HUMANS ARE
“WEAKER THAN” DIFFERENT !
THANK YOU