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RATIONALE
IN OBSTRUCTIVE JAUNDICE
INTRODUCTION
Intrahepatic extrahepatic
intraductal extraductal
Cirrhosis
Hepatitis
Drugs Neoplasm
Stone disease
Biliary stricture
Parasites Secondary
PSC to neoplasm
Aids related Pancreatitis
cholangiopathy Cystic duct
Biliary TB stones
drugs
Hepatocellular
necrosis
cholestasis
Acetaminophen
Anabolic steroids Acute isoniazid
chlorpromazine
gallstone cholestatic
injury
Thiazide amoxyclav
diuretics
Typically, drug-induced jaundice appears early with
associated pruritus, but the patient's well-being shows
little alteration.
Generally, symptoms subside promptly when the
offending drug is removed
Clinical classification Of Obstructive
Jaundice
(Benjamin Classification)
Type I : Complete obstruction
Choledocholithiasis
Periampullary tumor
Duodenal diverticula
Choledochal Cyst
Papillomas of the bile duct
Intra biliary parasites
Hemobilia
TYPE III : Chronic incomplete
obstruction
With or without classical symptoms but pathological
changes are present in bile duct and liver
Strictures of the CBD
Congenital
Traumatic
Sclerosing cholangitis
Post radiotherapy
Stenosed biliary enteric anastamosis
Cystic fibrosis
Chronic pancreatitis
Stenosis of the Sphincter of Oddi
TYPE IV : Segmental Obstruction
Traumatic
Sclerosing cholangitis
Intra hepatic stones
Cholangio carcinoma
INVESTIGATIONS IN OBSTRUCTIVE
JAUNDICE
LABORATORY RADIOLOGICAL
INVESTIGATIONS INVESTIGATIONS
jaundice Severity of
jaundice
Goals
of investigations
Determine Ductal
level of dilatation
obstruction Cause of
obstruction
ROUTINE INVESTIGATIONS
1. HB
2. TLC
3. DLC
5.BLOOD SUGAR
TESTS FOR ASSESSMENT OF LIVER FUNCTION
Tests for liver functioning
Based on
detoxification Enzymes Measure
& excretory indicating biosynthetic
function liver injury function
Serum Serum albumin
bilirubin Serum globulin
Urine Damage to Coagulation
bilirubin cholestasis factors
hepatocytes
Blood
ammonia Aspartate Alkaline
aminotransferase phosphatase
Alanine 5 nucleotidase
aminotransferase GGT
Bilirubin
Rise by 25-43 micromol/litre/day
Mechanism of hyperbilirubinemia
* NORMAL VALUES IN
MALES < 50 IU/L
FEMALES < 32 IU/L
ALKALINE PHOSPHATSE
GGT
5 NUCLEOTIDASE
serum albumin
normal value 3.5 5.5 gm /dl
prothrombin time
normal value 12 14 sec
URINE ANALYSIS
1 Bile salts
2 Bile pigments
3 Urobilinogen
STOOL EXAMINATION
1 Occult blood
RADIOLOGICAL EVALUATION OF BILIARY TRACT
PRE OPERATIVE METHODS INTRA OP METHODS
ERCP
PTC
BILIARY SCINTILLOGRAPHY
IMAGING GOALS
EUS has been reported to have up to a 98% diagnostic accuracy in patients with
obstructive jaundice
The sensitivity of EUS for the identification of focal mass lesions in pancreas has
been reported to be superior to that of CT scanning, both traditional and spiral,
particularly for tumors smaller than 3 cm in diameter.
Compared to MRCP for the diagnosis of biliary stricture, EUS has been reported to be
more specific (100% vs. 76%) and to have a much greater positive predictive value
(100% vs. 25%), although the two have equal sensitivity (67%).
The positive yield of eus-fna for cytology in patients with malignant obstruction has
been reported to be as high as 96%.
Endoscopic ultrasonography.
COMPLICATIONS
Pancreatitis
Cholangitis
Hemorrhage
Sepsis
CONTRAINDICATIONS
Unfavorable anatomy
Pseudo cyst
Red a/c pancreatitis
ERCP film showing Choledocholithiasis
Endoscopic retrograde cholangiopancreatography: partial
occlusion of the bile duct by a malignant stricture
Percutaneous Transhepatic Cholangiography
(PTC)