Supervised by Dr. Jamal Hamdi. Definition Of Jaundice yellow pigmentation of skin, mucous membrane...

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Transcript of Supervised by Dr. Jamal Hamdi. Definition Of Jaundice yellow pigmentation of skin, mucous membrane...

  • Slide 1
  • Supervised by Dr. Jamal Hamdi
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  • Definition Of Jaundice yellow pigmentation of skin, mucous membrane or sclera Jaundice clinically detected when serum bilirubin level ( 2.5 mg/dl) Normal serum bilirubin (0.2-1.0 mg/dl ) caused by an excess of bile pigments in plasma It is a symptom not a disease
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  • Bilirubin Metabolism Bilirubin is produced from the breakdown of haemoglobin in the reticuloendothelial system. 95% of the circulating bilirubin is unconjugated and bound to albumin.
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  • Bilirubin Metabolism RES Hepatic metabolism occurs in 3 phases: - Uptake - Conjugation - excretion
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  • Pathophysiology Of Hyperbilirubinemia Over production by RES Failure of hepatocellular uptake Failure of conjugation or excretion Obstruction of biliary excretion into intestine
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  • Classification Of Jaundice Posthepatic (obstructed) surgical Hepatic : Congintal ( Gilberts Syndome, Criglar-Najjar Syndrome ) Acquried ( Viral, Drugs, Alcohol, Wilsons.. Etc ) Prehepatic: RBC disorders ( Hereditary spherocytosis, SCA) Auto-immune ( Mismatched blood transfusion ) Infective ( Sepsis, Malaria )
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  • Etiology Of Obstructive Jaundice Common: Common bile duct stone. Cancer head of pancreas
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  • Etiology Of Obstructive Jaundice Less Common: Ampullary carcinoma Pancreatitis. Mirrizi syndromes. Sclorosing cholangitis. Cholangiocarcinoma
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  • Approach To Jaundice Patient History Careful History is of very important value to guide the D\D toward the cause & the type of jaundice ( PreHepatic, Hepatic, PostHepatic )
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  • Approach To Jaundice Patient History Onset Sudden ? CBD stone Hepatitis Gradual ? cirrhosis pancreatitis cancer
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  • Approach To Jaundice Patient History Pattern fluctuating ? CBD stone Ampullary carcinoma Hemolytic episodes Progressive? Pancreatic carcinoma Cholangiocarcinoma
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  • Approach To Jaundice Patient History Pain painless? Malignancy Painful? CBD stone Pancreatic diseases
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  • Approach To Jaundice Patient History Pruritis Fatty dyspepsia Steatorrhea Dark urine, pale stool Bleeding disorder Other symptoms of obstructive jaundice
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  • Approach To Jaundice Patient History RUQ pain, fever Symptoms of anemia Hx of SCD G6PD deficiency ? Food related ? Symptoms of malignancy ( weight loss & anorexia )
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  • Approach To Jaundice Patient History Blood transfusion Hx of drugs Past Hx of surgery Family Hx of jaundice & hemolytic disorders Alcohol Occupation & travel Past Medical Family Hx Past Surgical Hx
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  • Approach To Jaundice Patient Physical Examination General Appearance Cachexia Muscle Wasting Yellow Discoloration Stigmata of Chronic Liver Disease Palmar erythema clubbing. flapping tremor. duputrines contracture. Spider nevi gynecomastia caput medosa testicular atrophy General Examination Jaundice Scratch marks Pallor Vital Signs
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  • Approach To Jaundice Patient Physical Examination Abdominal Discolration, scars ( collens, Grey Tuner ) RUQ pain Murphy sign Palpaple Gallbladder ( Courvoisiers law ) Abdominal masses ( malignancy ) Hepatomegaly, splenomegaly, ascitis PR : color of stool. Abdominal Examination
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  • Obstructive Jaundice Invistigation Invasive Imaging Laboratory Exam
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  • Obstructive Jaundice Invistigation Laboratory Exam Blood LFT : Serum bilirubin (Direct / Indirect), Albumin, ALT, AST, ALP, LDH, CBC, Electrolyte, Amylase Urine Urine analysis Stool The investigations will differentiate hepatocellular and obstructive jaundice In most of the cases
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  • ObstructionHepatitisCirrhosis Bilirubin Alk phos / ALT/AST // / gGT / PT (INR) Invistigation
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  • Obstructive Jaundice Invistigation Imaging Non-invasive AXR US CT MRI/MRCP Invasive ERCP PTC Operative cholangiogram T-tube cholangiogram Angiogram Biopsy
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  • Obstructive Jaundice Invistigation Imaging Non-invasive 1- The presence of gall stones 2- the thickened wall of the gallbladder in acute or chronic inflammation 3- The Diameter of CBD more than 7mm is suggestive of presence of stones Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation. Ultrasounde
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  • Obstructive Jaundice Invistigation Imaging Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation. Ultrasounde
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  • Obstructive Jaundice Invistigation Imaging Non-invasive Determine the specific causes and level of obstruction CT scan can only image calcified stones CT Scan
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  • Obstructive Jaundice Invistigation Imaging CT Scan
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  • Obstructive Jaundice Invistigation Imaging Non-invasive Routine investigation-base-line & may show specked calcification in the region of pancreas. X-Ray
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  • Obstructive Jaundice Invistigation Imaging Non-invasive Magnatic resonance cholangiopancreatography (MRCP) Sensitive noninvasive method of detecting biliary and pancreatic duct stones stricture or dilatations within the biliary system MRCP
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  • Obstructive Jaundice Invistigation Imaging Invasive Useful for lesion distal to the bifurcation of the hepatic ducts (diagnostic ) ERCP has a (therapeutic) application because obstruction can potentially be relieved by the removal of stones, sphcterotomy and placement of stent and drains ERCP
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  • Obstructive Jaundice Invistigation Imaging ERCP
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  • Obstructive Jaundice Invistigation Imaging ERCP
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  • Obstructive Jaundice Invistigation Imaging Invasive Percutaneous transhepatic cholangiogram (PTC ) Useful for lesions proximal to common hepatic duct PTC
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  • Obstructive Jaundice Treatment According To The Cause
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  • Obstructive Jaundice Treatment Relief of Obstruction Prevent Complication Prevent Recurrence Goal of Treatment
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  • Obstructive Jaundice Treatment Defined as stones in the CBD intermittent obstruction of CBD Predisposes to Cholangitis & Acute Pancreatitis Elevated sr. bilirubin & Alk. Phos. Evaluation By : U\S, ERCP, CT Jaundice caused by Gallstones
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  • Obstructive Jaundice Treatment Evaluation By : ERCP Primary diagnostic and therapeutic modality Sphincterotomy and stone extraction Placement of stent if stone extraction unsuccessful Mortality rate 1.5% ERCP Jaundice caused by Gallstones
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  • Obstructive Jaundice Treatment Open CBD Exploration Indications Presence of multiple stones (more than 5) Stones > 1 cm Multiple intra hepatic stones Distal bile duct strictures Failure of ERCP Recurrence of CBD stones after sphincterotomy Jaundice caused by Gallstones
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  • Obstructive Jaundice Treatment CBD Exploration Surgical Options Common bile duct exploration with T-tube decompression Choledochoduodenostomy Transduodenal sphincterotomy and sphincterplasty Roux-en-Y Choledocho jejunostomy Jaundice caused by Gallstones
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  • Obstructive Jaundice Treatment At the time of diagnosis, 52% of all patients have distant disease 26% have regional spread. The relative 1-year survival is only 24% the overall 5-year survival rate for this disease is less than 5%. Carcinoma Head Of Pancreas
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  • Obstructive Jaundice Treatment Surgical treatment Carcinoma Head Of Pancreas Non surgical treatment (metal stents) Non Resectable Resectable
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  • Obstructive Jaundice Treatment resectability. ? Resectable, unresectable ? experience and technical skill of the surgeon And overall health of the patient Typically, extrapancreatic disease precludes curative resection, and surgical treatment may be palliative at best. Carcinoma Head Of Pancreas
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor
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  • Obstructive Jaundice Treatment Non surgical treatment Inoperable Patient :- - Endoscopic expandable metallic stent -Bypassed By Hepatojejunostomy ( Roux-en-Y) Carcinoma Head Of Pancreas
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  • Obstructive Jaundice Treatment surgical treatment Operable Patient :- Whipples Operation Pancreaticoduodenectomy Curative ? Carcinoma Head Of Pancreas
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Is It Curative ??
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipples Operation
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipples Operation
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  • Obstructive Jaundice Treatment Carcinoma Head Of Pancreas Whipples Operatio