(hydrop GB)gallbladder in malignant obstruction of

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SURGICAL JAUNDICE
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JAUNDICE

• Yellow discoloration of skin,sclera,body fluid
  due to bile pigment

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Cause of jaundice

• Medical jx
• Prehepatic (haemolytic jaundice)
• Intrahepatic (hepatocellular jaundice and
  intrahepatic cholestasis)
• Surgical jx
• - Posthepatic (obstruction)

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????????? surgical jaundice

• Painful vs painless
• Obstruction can be
• Luminal (stone)
• Stricture (benign vscholangiocarcinoma)
• Extraluminal (pancreas cancer, lymph nodes)

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???????????????????? Obstructive Jaundice
???????? 2??????????

• 1.benign ??????
• -CBD STONE
• -STRICTURE
• -POST SURGERY
• -CHRONIC PANCREATITIS
• 2.Malignant
• -CA head pancreas
• -CA ampulla
• -CA 2nd part duodenum
• -CA common bile duct
• -CA common hepatic duct
• -CA gallbladder invade common bile duct

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??????????? surgical jaundice

• ??????? ??? ??????????
• ????????????????????????,???????,?????,PR????????
  ??
• LFTAkl phos ?????,indirect bilirubin ?????
• InvestigationU/S,CT scan,
• ERCP,MRCP,PTC,EUS
• U/S,CT scan ?????????????????????????????????????
  ????????,??????????
• ERCP,MRCP,PTC ???????????????????????????,??????
  ??????????????,?????????????????????

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Benign jaundice

• ???????????????
• -???????????
• -???????????????????????????
• -???????????????????????RUQ????????
• -????????????????????? ???????????????????????????
  ?????????????

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Malignant jaundice

• ????????????? Malignant jaundice
• -painless obstructive jaundice20
• -weight loss50
• -RUQ pain or backpain???????????????????????????50
  
• -????? steatorrhea,DM

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Courvoisiers sign

• Palpable(hydrop GB)gallbladder in malignant
  obstruction of distal CBD

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Investigation of obstructive jaundice

• U/s abdomen
• CT scan abdomen
• ERCP (endoscopic retrograde cholangiopancreatograp
  hy)
• PTC(percutaneous transhepatic cholangiogram)
• HIDA scan
• MRCP(magnetic resonace cholangiopancreatography)
• EUS(endoscopic ultrasound)

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US ABDOMEN,CBD STONE
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ERCP
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???????????????????????ERCP

• ?????
• -???????? cholangiography???????????????80
• -??????????????????????????????biliary
  obstruction
• -??????cytologic diagnosis
• -??????? therapeutic??? ????EST with stone
  extraction
• ???????
• -??technical failure rate 20
• -?????????????? 0.5-3 ?????????????0.2-0.7
  ??????????? septic cholangitis,acute
  pancreatitis,instrumental injury

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CT SCAN
?? dilate bile duct,stone,mass
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HIDA SCAN

• ???????????????? imino-diacetic acid derivative
  ??labelled ???? tecchnichim 99 ?????????????????
  ??????????? uptake ???????? cell
  ??????????????????? ????? demonstrate biliary
  tract ???
• ???????? HIDA SCAN???
• -?????????????????????? jaundice ????? total
  bilirubin lt5mg/dl
• -????????????????????????????????????????????
  ????????????????????
• -?????????????? biliary enteric shunt
• - ????????????????? choledochal
  cyst?????????????????neonatal hepatitis???
  biliary atresia???

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PTC
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MRCP
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??????????????????MRCP

• ?????
• -??????????????????????????????
• ???????
• -??? therapeutic ??????
• -?????? tissue diagnosis

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LIVER FUNCTION AND TEST
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Abnormal LFTs

•  
• Obstruction
  Hepatitis
• Bilirubin ? ?
  ????????????? ??
• Alk phos ? ?
  ??????????? ?
• ALT/AST ? ??????????
  ??
• Direct bilirubin ?? ?
• Indirect bilirubin ? ????????????
  ?????????

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Common disease of surgical Jaundice
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CBD STONE

• Primary CBD stone ??? stone ????????????common
  bile duct ??? ?????????? ???? ??????????
  ?????????????? ??????????????????????????
  ??????? infected bile
• Secondary stone ???stone ???????????? gall
  bladder ??????????????????? ??????????????????????
  ????
• Cholangitis is common complication

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CHOLANGITIS

• CHACHOTS TRIAD
• -fever with chill
• -RUQ pain
• -jaundice(80)
• Three symptoms present in about 70 of patient
• Some patients only have chills and fever with
  minimal abdominal symptoms.
• Most common organismE.coli,other
  organismklebsella,proteus,anaerobe(bacteroides,cl
  ostidium),enterocooci etc.

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TOXIC CHOLANGITIS

• (acute suppurative cholangitis)
• Reynolds pentad
• -fever with chill
• -RUQ pain
• -jaundice
• -alteration of concious
• -shock

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??????????????????????

• ????????? open explore CBD(CBDE)
• ????????? Laparoscopic explore CBD
• ?? ERCP(endoscopic retrograde cholangiopancreatogr
  aphy) with stone extraction(EST)
• Remove stone ??????? T-tube tract (??case retain
  CBD stone)

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?????????????? explore common bile duct(CBDE)

• Absolute
• -??????????? CBD(99 accuracy)
• -jaundice with cholangitis97
• -cholangiography ?????? 85

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?????????????? explore common bile duct(CBDE)

• Relative
• -????????? jaundice
• -????????? pancreatitis
• -multiple small gall stone ??? cystic duct ??
• -CBD dilate gt12 mm.
• -facet stone

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??????????? explore common bile duct
?????????????????

• ??? T-tube
• ?? bypass
• -choledocho-enteric bypass
• choledochoduodenostomy bypass
• R-Y choledocho-enteric bypass

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??????? ??????????????T tube ??? (choledochostomy
tube)

• ??????????????? 7-10 ????????????? ????????????
  permanent tract ?????????????????????????????
• ????????????????????????? ???jaundice ????
• ??????????????? ?????????????? 300 ??/???
• ?????????? 24-48 ??????? ?????????????????
  ???????
• ?? T-tube cholangiogram ???????????????????????

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Benign stricture

• -post surgery
• -chronic pancreatitis
• ????????Benign stricture
• 1.????????? biliary bypass
• -Roux en Y choledochojejunostomy bypass
• -Roux en Y hepaticojejunostomy bypass
• -choledochoduodenostomy bypass
• 2.??ERCP with stent/-dilate

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Periampullary CA

• -CA head pancreas
• -CA ampulla
• -CA 2nd part duodenum
• -CA distal common bile duct

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Nonsurgical treatment for periampullrary CA

• -Endoscopic treatment(ERCP with stent)
• -external drainagePTBD(percutaneous trans
  hepatic biliary drainage)

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Surgical treatment for periampullrary CA

• Whipples operation ??????????????pancreaticoduode
  nectomy ?????????????????
• (CA Head of pancreasprognosis?????????,
• CA Ampulla of vaterprognosis ????????)
• Surgical palliative bypass
• -choledochojejunostomy bypass
• -gastrojejunostomy bypass

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Chemotherapy for pancreatic cancer

• ??????? palliative
• ????????? 10-20

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BILE DUCT CANCER(CHCA)

• INTRA HEPATIC CHCA
• -MASS
• EXTRA HEPATIC CHCA
• -HILAR CHCA(KLATSKINS TUMOR)
• -CA OF BILE DUCT

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BILE DUCT CANCER
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What is cholangiocarcinoma

• ????Adeno CA.??? bile duct
• Classification ????????
• -Intra hepatic bile duct type?liver mass ???
• -Hilar type or central type(most common)?jaundice
• (???????????????????? extrahepatic bile duct
  canaer ????CHCA)
• Causeliver fluke,sclerosing cholangitis

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Classification of CHCA and presentation

• PERIPHERAL TYPE CHCA
• -LIVER MASS
• CENTRAL TYPE CHCA(HILAR)
• -OBSTRUCTIVE JAUNDICE

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PERIPHERAL TYPE CHCA

• TREATMENT
• -SURGERYhepatectomy
• -CHEMOTHERAPY(efficacy 10-20)
• -etc

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HILAR CHCA

• TREATMENT
• -SURGERYhilar resection/-hepatectomy,bypas
  s
• -ENDOSCOPIC DRAINAGE(ERCP
• STENT)
• -PERCUTANEOUS DRAINAGE(PTBD)
• -ETC

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ERCP,STENT
ERCPSTENT
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Pancreatic Cancer

• 5th leading cause of death from cancer
• 90 die within a year
• Present with jaundice, weight loss,
• abdominal pain
• Surgery Whipples procedure
• (pancreaticoduodenectomy)

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????????????????????????????obstructive jx

• -?????????????????????? ??????????????????????????
  ?????????? ???????????????????????????????????????
  ???????????????????????????????? (abnormal
  choagulogram) ??????????vit k(
  ???????FFP?????????? choagulogram?????????????????
  ???????????????????)
• -?????????????????????? vit.k ????????????????????
  
• PT(INR),PTT

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????????????????????????????obstructive
jx????????? liver resectoin

• Pre op drainagePTBD
• Pre op CTvolummetric CT scan
• Pre opIndocyyanine green retention

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