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ABSTRACT Jaundice is one of the most prevalent symptom in hepatobiliary disorders. The nature of jaundice may vary
from hepatocellular to obstructive pattern. In a few cases, it may be haemolytic in nature. Identifying and ascertaining
the type is pivotal for further investigation. A combination of haematological and radiological investigations will not
only provide information on the severity and the impact of obstructive jaundice on various organ systems of the body
but also help in determining the prognosis. Endoscopy can also provide diagnostic as well as a therapeutic benefit in
obstructive jaundice. The pathophysiology, clinical evaluation and investigations in a case of obstructive jaundice is
discussed in this paper.
KEYWORDS Jaundice, obstructive, causes, complications, investigations
of Luschka are small biliary ducts that lie in the gall bladder
fossa and connect the liver and gall bladder directly. The normal
Introduction thickness of the gall bladder wall is less than 4 mm. Therefore
obstruction can occur at any level. It may be intraluminal or
Obstructive jaundice is one of the most challenging types of jaun- due to extrinsic compression. Backpressure leads to dilatation
dice. It can be treated successfully once the cause is ascertained. of the passages. Identifying the level and cause for obstruction
Understanding the basic physiology of bilirubin metabolism and is, therefore, the main aim of clinical evaluation and imaging.
the structure of the extrahepatic biliary passages is essential for
the adequate diagnostic evaluation of a patient presenting with
obstructive jaundice. [1] Physiology of bilirubin metabolism
Bilirubin is of two types, direct which is water soluble and indi-
Surgical anatomy of the extrahepatic biliary passages rect, which is water insoluble. Identifying the rise of each type
is essential in the evaluation of the type of jaundice. Hence it is
The intrahepatic ducts converge to form the right and left hepatic essential to review the normal process of bilirubin formation and
ducts which exit from the liver and join to form the common hep- clearance from the gastrointestinal tract. Fragile and senescent
atic duct. The cystic duct emerges from the gall bladder and joins RBC’s are broken down in the spleen. When the RBC membrane
the common hepatic duct which then descends as the common ruptures, haemoglobin is released. The macrophages of the retic-
bile duct. The common bile duct has four parts, supraduodenal, uloendothelial system phagocytose this. Haemoglobin is further
retroduodenal, intrapancreatic and intraduodenal. The common broken down into heme and globin. The heme component is
bile duct is joined by the main pancreatic duct to open into the then further broken into free iron which combines with ferritin
ampulla of Vater situated in the second part of the duodenum. and the straight remnant chain of four pyrrole nuclei that serves
The diameter of the normal CBD is less than 8mm, and the di- as a substrate for the formation of bile pigments.
ameter of the main pancreatic duct is less than 4 mm. The ducts Biliverdin is formed which then gets converted into bilirubin.
Copyright © 2020 by the Bulgarian Association of Young Surgeons Bilirubin is released into the plasma. In the plasma, it is bound
DOI:10.5455/ijsm.2020-07-061-jaundice to albumin and transported to the liver. There it gets absorbed
First Received: July 11, 2020 across the hepatic cell membrane. During this process, it is
Accepted: July 23, 2020 released from the albumin but remains attached to two proteins
Associate Editor: Ivan Inkov (BG);
1
Annapurna Niwas, 229 Ghantali Road. Thane 400602. MS. India; E mail:
Y and Z proteins inside the hepatocytes. Soon the bilirubin
kvagholkar@yahoo.com; Mobile: 9821341290 is detached from these proteins and is conjugated. The end
8. Heiken JR, Brink JA, Vannier MW. Spiral (helical) CT. Radi- 24. Grandic L, Perko Z, Banovic J,Pogorelic Z, Ilic N, Jukic I, et
ology. 1993; 189: 647-656. al. Our experience in the treatment of obstructive jaundice.
Acta Clin Croat. 2007; 46: 157-160.
9. Guibaud I, Bret PM, Reinhold C, Atri M, Barkun AN. Bile
duct obstruction and choledocholithiasis: diagnosis with
MR cholangiography. Radiology. 1995; 197: 109-115.