2. DR FAIZ NAEEM
HOUSE OFFICER
SURGICAL UNIT-II AFH

3.  Jaundice is a yellow discoloration of skin,sclera and
mucous membrane.
 Jaundice is usually detectable clinically when the
plasma bilirubin exceeds 2.5mg/dl.

5. 1. Pre-Hepatic Jaundice
2. Hepatocellular Jaundice
3. Obstructive Jaundice

6. INTRAHEPATIC
• Primary Biliary Cholangitis
• Primary Sclerosing Cholangitis
• Alcohol
• Drugs
• Cystic Fibrosis
• Hepatic Infiltrations
• Pregnancy
• Bacterial Infections
• Rotor syndrome
• Dubin johnson syndrome
EXTRAHEPATIC
• Carcinoma
• Choledocholithiasis
• Parasitic Infection
• Traumatic Biliary Strictures
• Chronic Pancreatitis
• Mirizzi’s Syndrome

7. INTRA-MURAL TRANS-MURAL EXTRA-MURAL
• CBD Stones
• Parasite(Ascariasis)
• Cholangiocarcinoma
• Choledochal Cyst
• Strictures
• Ca Head of Pancreas
• Peri Ampullary Tumor
• Mirizzi’s Syndrome

8. TYPE I
(Complete
Obstruction)
TYPE II
(Intermittent
Obstruction)
TYPE III
(Chronic
Incomplete
Obstruction)
TYPE IV
(Segmental
Obstruction)
• CA Head of
pancreas
• Ligation of CBD
• Cholangiocarci
noma
• Parenchymal
Liver Disease
• Choledocholith
iasis
• Periampullary
Tumor
• Duodenal
Diverticula
• Choledochal
Cyst
• Intra biliary
parasite
• Sticture of CBD
• Cystic fibrosis
• Chronic
pancreatitis
• Stenosed Biliary
enteric
anastmosis
• Traumatic
• Sclerosing
Cholangitis
• Intra Hepatic
Stones
• Cholangiocarci
noma

9.  Itching
 Abdominal Pain
 Dark urine
 Pale stools
 Weight loss
 Fever
 Dry eyes
 Jaundice
 Fatigue

10.  Complains of yellow skin , eyes ,pale stools ,dark urine
,jaundice and pruritis
 Patient’s Age
 Presence or Absence of pain
 Location of pain
 Systemic symptoms (fever, anorexia , weight loss)
 History of Anemia
 Previous malignancy
 Known gall stone disease
 Hepatitis
 Previous biliary surgery
 Use of Alcohol , drugs , medications

12. SITE FINDINGS
FACE Jaundice
xanthelasma
HANDS Clubbing
Leukonychia
CHEST Spider navi
Left supraclavicular lymph nodes
Abdomen inspection Scars
Distension
Caput medusae
Abdomen palpation/percussion Hepatomegaly
Splenomegaly
Ascites
Palpable gallbladder
LEGS Edema

13.  This law states that a painless palpably enlarged
gallbladder accompanied with mild jaundice is
unlikely to be caused by gallstones.

14. TEST HEPATOCELLULAR OBSTRUCTIVE
Conjugated bilirubin Mild elevation Marked increased
Urine urobilinogen Normal Absent
AST Marked elevation Mild elevation
ALT Marked elevation Mild elevation
ALP Mild elevation Marked elevation
GGT Mild elevation Marked elevation

15.  CBC
 Hepatitis serology
 Antimitochondrial antibodies
 Prothrombin time

16.  PLAIN ABDOMINAL XRAY
 ABDOMINAL USG
 ENDOSCOPIC USG
 CT SCAN
 MRCP

17. PATHOLOGY FINDING
Cholelithiasis Radio oapaque stones
Radiolucent gas in stone Mercedes-Benz sign
Porcelain gallbladder Calcification of GB
Emphysematous cholecystitis Gas in wall of GB
Speckled(spotty) calcification Chronic pancreatitis

18.  CHOLELITHIASIS
 STONES IN CBD
 Dilation of CBD at the same level as portal
vein(Dubble-Barrel sign)
 CBD dilation
 Cholangiocarcinoma
 Ca head of pancreas

19.  EUS usg have 98% acurracy in patients with
obstructive jaundice.
 It allows sampling via eus guided fine needle
aspiration.
 Dilation of CBD
 Cholangiocarcinoma
 Ca head of pancreas

20.  SPIRAL CT SCAN
 CT cholangiography by helical ct scan
 MRCP is non invasive way to visualize hepatobiliary
tree.
 It can detect biliary and pancreatic duct stone
,strictures , and dilatations in billiary tree.

22.  Endoscopy plus fluoroscopy =ERCP
 It is an invasive procedure
 Has diagnostic and therapeutical potential
 Allows biopsy or brush cytology
 Allows stenting for stricture

24.  PTC is performed by radiologist using flouroscopic
guidence.
 The liver is punctured to enter the peripheral intra
hepatic bile duct system.
 It can be used to drain biliary obstruction.

26.  Per –Operative Cholangiography
 Operative biliary endoscopy
 Laproscopic ultrasonography

27.  Cholangitis
 Septicemia
 Hepato-Renal syndrome
 Coagulopathy
 Pancreatitis

28.  It is defined as renal failure in patients with advance
cirhosis and ascites.
 DIAGNOSTIC CRITERIA
A. Cirhosis with ascites
B. Creatinine >1.5 mg/dl
C. No shock
D. No nephrotoxic drug use
E. No organic kidney disease
F. No improvement in creatinine after discontinuing
diuretics and volume expansion (1g/kg/d of albumin
for 2 days)

30. TYPE I HRS
 Rapidly progressive
 Poor prognosis
 Creatinine >2.5mg/dl
TREATMENT
 Octreotide
 Midodrine
 Albumin infusion
 Terlipressin
 Liver transplant
 Steady deterioration
 Better prognosis
TREATMENT
 TIPSS
TYPE II HRS

31.  Ursodeoxycholic acid (10mg/kg/d)
 Cholestyramine (4g in glass of water three times a day)
 Antihistamine
 Vitamin k
 5 or 10% dextrose water
 Prophylactic antibiotics to prevent cholangitis
 Keep the patient over hydrate

32.  Broad spectrum antibiotics
 Parentral vitamin k
 Antihistamine
 Nutritional support
 Hydration
 Pre operative biliary drainage

33.  It can be achieved by internal or external approach.
 Internal biliary drainage is achieved by endoscopic
placement of a biliary stent and endoscopic
sphincterotomy.
 External biliary drainage is performed via flouroscopic
guided percutaneous trans-hepatic approach.
 If the levels of bilirubin is more than 5mg/dl and
duration of jaundice is more than 3 weeks then
drainage improves liver function so that major
operation can be performed without major
complications.

34. CAUSE TREATMENT
Cholelithiasis • Open cholecystectomy
• Laproscpic
cholecystectomy
CBD stones • Pre operative removal
through ERCP followed
by lap cholecystectomy
• Mechanical lithotripsy
• Shock wave lithotripsy
• Open exploration of CBD
Choledocal cyst • Excision
• Hepaticojejunostomy
Chronic pancreatitis • Endoscopic
sphincterotomy
• Stent placement
• Pancreaticojejunostomy

35. CAUSE TREATMENT
Biliary stricture • Stent placement
Malignancy • Pre operative drainage
• Resection
• Endoscopic biliary stent
• Whipple resection
• Chemotherapy
• Radiotherapy
ESLD • Liver transplant

36.  Early cholecystectomy after ERCP within 72 hours has
better outcomes probably due to inflammatory
process.
 The longer the interval between ERCP and LC , the
higher are the chances of complications, the risk to
conversion to open technique and increased hospital
stay.

37.  Gradual reduction of weight
 High intake of fibre
 Reduce intake of saturated fats
 Reduction in sugar intake
 Regular exercise

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