1. Supervised by Dr. Jamal Hamdi
Surgical Jaundice
Supervised by Dr. Jamal Hamdi

2. Definition Of Jaundice
yellow pigmentation of skin, mucous membrane or sclera
Jaundice clinically detected when serum
bilirubin level ( mg/dl)
Normal serum bilirubin
( mg/dl )
caused by an excess of bile
pigments in plasma
It is a symptom not a disease

3. 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 .

4. Bilirubin Metabolism RES Hepatic metabolism occurs in 3 phases:
- Uptake
- Conjugation
- excretion
RES

5. Pathophysiology Of Hyperbilirubinemia
Over production by RES
Failure of hepatocellular uptake
Failure of conjugation or excretion
Obstruction of biliary excretion into intestine

6. Classification Of Jaundice
Prehepatic:
RBC disorders
( Hereditary spherocytosis , SCA)
Auto-immune ( Mismatched blood transfusion )
Infective ( Sepsis , Malaria )
Hepatic :
Congintal ( Gilberts Syndome , Criglar-Najjar Syndrome )
Acquried ( Viral , Drugs , Alcohol , Wilson’s .. Etc )
Posthepatic
(obstructed)
surgical

7. Etiology Of Obstructive Jaundice
Common:
Common bile duct stone.
Cancer head of pancreas

8. Etiology Of Obstructive Jaundice
Less Common:
Ampullary carcinoma
Pancreatitis.
Mirrizi syndromes.
Sclorosing cholangitis.
Cholangiocarcinoma

9. Approach To Jaundice Patient ( PreHepatic , Hepatic , PostHepatic )
History
Careful History is of very important value to guide the D\D toward the cause & the type of jaundice
( PreHepatic , Hepatic , PostHepatic )

10. Approach To Jaundice Patient
History
Onset
Gradual ?
cirrhosis pancreatitis cancer
Sudden ?
CBD stone
Hepatitis

11. Approach To Jaundice Patient
History
Pattern
Progressive?
Pancreatic carcinoma
Cholangiocarcinoma
fluctuating ?
CBD stone
Ampullary carcinoma Hemolytic episodes

12. Approach To Jaundice Patient
History
Pain
Painful?
CBD stone
Pancreatic diseases
painless?
Malignancy

13. Approach To Jaundice Patient Other symptoms of obstructive jaundice
History
Other symptoms of obstructive jaundice
Pruritis
Fatty dyspepsia
Steatorrhea
Dark urine , pale stool
Bleeding disorder

14. Approach To Jaundice Patient History
RUQ pain , fever
Symptoms of anemia
Hx of SCD
G6PD deficiency ? Food related ?
Symptoms of malignancy
( weight loss & anorexia )

15. Approach To Jaundice Patient History
Past Medical
Blood transfusion
Hx of drugs
Past Hx of surgery
Family Hx of jaundice & hemolytic disorders
Alcohol
Occupation & travel
Past Surgical Hx
Family Hx

16. Approach To Jaundice Patient Stigmata of Chronic Liver Disease
Physical Examination
General Appearance
Stigmata of Chronic Liver Disease
General Examination
Cachexia
Muscle Wasting
Yellow Discoloration
Palmar erythema clubbing . flapping tremor. duputrine’s contracture . Spider nevi gynecomastia caput medosa testicular atrophy
Jaundice
Scratch marks
Pallor
Vital Signs

17. Approach To Jaundice Patient
Physical Examination
Abdominal Discolration , scars
( collen’s , Grey Tuner )
RUQ pain
Murphy sign
Palpaple Gallbladder ( Courvoisier’s law )
Abdominal masses ( malignancy ) Hepatomegaly , splenomegaly , ascitis
PR : color of stool .
Abdominal Examination

18. Obstructive Jaundice
Invistigation
Laboratory Exam
Imaging
Invasive

19. 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

20. Invistigation Obstruction Hepatitis Cirrhosis Bilirubin Alk phos 
Alk phos
 /
ALT/AST
/
gGT
PT (INR) 

21. Operative cholangiogram
Obstructive Jaundice
Invistigation
Imaging
Non-invasive
AXR US CT
MRI/MRCP
Invasive
ERCP
PTC
Operative cholangiogram
T-tube cholangiogram
Angiogram
Biopsy

22. 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
Ultrasounde
Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation.

23. Obstructive Jaundice Invistigation Imaging Ultrasounde
Is the most useful initial study for evaluation of intra/extrahepatic biliary dilatation.

24. Obstructive Jaundice Invistigation Imaging
Non-invasive
Determine the specific causes and level of obstruction
CT scan can only image calcified stones
CT Scan

25. Obstructive Jaundice Invistigation Imaging CT Scan
High-resolution, helical CT scan in a patient with obstructive jaundice. The scan demonstrates a tumor (large arrow) anterior to the portal vein with a stent (white area adjacent to large arrow) in place. Dilated intrahepatic bile ducts (small arrows) are evident in the right lobe of the liver.

26. Obstructive Jaundice Invistigation Imaging
Non-invasive
Routine investigation-base-line & may
show specked calcification in the region of
pancreas.
X-Ray

27. Magnatic resonance cholangiopancreatography (MRCP)
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

28. 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

29. Obstructive Jaundice
Invistigation
Imaging
ERCP

30. Obstructive Jaundice
Invistigation
Imaging
ERCP

31. Useful for lesions proximal to common hepatic duct
Obstructive Jaundice
Invistigation
Imaging
Invasive
Percutaneous transhepatic cholangiogram (PTC )
Useful for lesions proximal to common hepatic duct
PTC

32. Obstructive Jaundice
Treatment
According To The Cause

33. Obstructive Jaundice Treatment Goal of Treatment
• Relief of Obstruction
• Prevent Complication
• Prevent Recurrence

34. Jaundice caused by Gallstones
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

35. Jaundice caused by Gallstones
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

36. Jaundice caused by Gallstones
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

37. CBD Exploration – Surgical Options Jaundice caused by Gallstones
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

38. Carcinoma Head Of Pancreas
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

39. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Resectable
Non Resectable
Carcinoma Head Of Pancreas
Surgical treatment
Non surgical treatment
(metal stents)

40. Carcinoma Head Of Pancreas
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

41. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas

42. Carcinoma Head Of Pancreas Non-resectable pancreatic head tumor
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Non-resectable pancreatic head tumor

43. Non surgical treatment Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Non surgical treatment
Inoperable Patient :-
- Endoscopic expandable metallic stent
Bypassed By Hepatojejunostomy
( Roux-en-Y)
Carcinoma Head Of Pancreas

44. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
surgical treatment
Operable Patient :-
Whipple’s Operation
Pancreaticoduodenectomy
Curative ?
Carcinoma Head Of Pancreas

45. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Is It Curative ??

46. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation

47. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation

48. Carcinoma Head Of Pancreas
Obstructive Jaundice
Treatment
Carcinoma Head Of Pancreas
Whipple’s Operation

49. Obstructive Jaundice Treatment Bile Duct Stricture
Traumatic stricture:-
by passed
Malignant stricture: -
resection with reconstruction by hepatico jejunostomy .
Sclerosing cholongitis:
Surgical excision
Per cuteneous dilation
Bile Duct Stricture

50. Complications Of Obstructive Jaundice
Ascending cholangitis
Clotting disorders
Hepato-renal syndrome
Drug Metabolism
Impaired wound healing
Be Aware Of
life threatening Complications

51. Bailey & Love short practice of surgery
References
Bailey & Love short practice of surgery
Clinical Surgery By : A.Cuschieri
Lecture Note : General Surgery 11th Edition

52. Abbas A. Damanhori Abdulmajeed Fairaq Abdulrahman R. Nazer
Done By
Abbas A. Damanhori
Abdulmajeed Fairaq
Abdulrahman R. Nazer
Hassan Abu Rokbah