Obstructive jaundice Etiology : 1_obstruction within the lumen : gall stones 2_pathology in the wall. a_ congenital atresia of common bile duct (CBD). b_ traumatic stricture. c_ chronic cholangitis. d_ tumuor of bile duct. 3_External compression a_ pancreatitis. b_ tumour of head pancereas c_ tumour of ampulla of vater

Bile duct stones (choledocholithiasis) Maybe single or multiple . 1_most CBD stones are formed within the gall bladder and migrate down the cystic duct into the CBD 2_ infection of the biliary tree due to stasis due to distal stricture or obstruction (inflammatory or malignant) 3_ infection by ascaris lumbricoids or clonorchis sinenses. What are the consequence of duct stones : 1_obstruction to bile flow 2_ infection _ cholongitis

Clinical manifestation Maybe asymptomatic, more often there are attacks of biliary colic accompainedby obstructive jaundice with cray _ coloured stools and dark urine. The attacks lasting for hours or several days . The attack ceases either when a small stone passed through the sphincter of oddi or when it disimpacts fall back into the dilated CBD. Occasionally the jaundice is progressive or rarely it in pains _If obstruction is not relieved either spontaneously or by operation ,the back pressure in the biliary system results in the 2nd biliary cirrhosis and liver failure .

If infection of CBD super venes , the jaundice and pain are accompanied by rigor , high intermittent ferver and toxaemmia here the treatment is urgent biliary drainage In contract to patient with neoplastic obstruction of the CBD or ampulla of vater Liver function test demonstrate pattern of obstructive jaundice especialy the S.Alkaline phosphatase prothrombin time is prolonged because the absorptionof Vit.k is dependend upon bile entering the intestine but a normal level can usually be achieved with parental Vit.k ,urine showed urobilinogen

Is by ultrasonorgrphy to show : The diagnosis: Is by ultrasonorgrphy to show : 1_intra hepatic bile duct dilatatoin . 2_liver tumour or cyst 3_stone in CBD . 4_bile duct tumour. 5_ pancreatic heat + periampullary tumour Liver biopsy if the duct is not dilated . //_MAR and ERCP will demonstrate the nature of obstruction. /_ERCP can be used in removing stones from CBD and stenting stricture. Management: it is essential to determine whether the jaundice is due liver disease within the duct such as sclerosing cholang it is or obstruction.

Preoperative preparation of ajauridiced patient full supportive measures are required : 1_with rehydration by I.V fluid . 2_attention to clotting disorder . 3_proper anti biotic administration . 4_exclusion of diabetes . Treat ment :- A_ broad spectrum anti biotic given before , during and after surgery . B_ parentral VIT.K 10 mg /dl / day for 5 days fresh frozen plasma.

After medical preparation of the patient to good condition , surgery include opening the CBD usually above the duodenum and extract the stones , that are liable for missing them , so added drianage procedure called 1_trans duodenal sphincteriotomy . 2_choledocho duodenostomy operation . Other way to relieve obstruction by endoscopic sphincteriotomy using dorwia basket .

Stricture of the bile duct Post operative 80% Benign Stricture Inflammatary 20% Malignant

Post operative stricture During the procetureof cholecystectomy Clinical manifeitation _ bile leakage _ jaundice Treatment If stricture is high Roux _ eny choledocho_jejunostomy If stricture is low choledochoduodenostomy

Cholangio carcinoma Either intrahepalic extrahepalic it is associated with: inflammatery bowel disease choledochal cust . Clinical features: Painless proqressive jaundice Dark urine , pale stool , steatorrhea ,loss of wt . , maybe hepatomegaly with palpable G.B Treatment : If possible pancreaticodeodenectomy Advandeced tumour stenting

Biliary fistula 1_ external biliary fistula Most important may follow operation of cholecystectomy with injury to CBD. Diagnoses by fistulogram Maybe by ERCP, MRCP,PTC 2_ internal biliary fistula. Repeated attack of acute cholecystitis tract With duodenum or colon Stone may Gall stone ileus