6 Causes excess bilirubin production (Haemolysis) impaired uptake by the hepatocyte (hepatocellular jaundice)failure of conjugation (hepatocellular jaundice)impaired secretion of conjugated bile into the bile canaliculi (hepatocellular jaundice)impairment of bile flow subsequent to secretion by the hepatocyte (obstructive or cholestatic jaundice)
7 Obstructive Jaundice Common Infrequent Rare Common bile duct stones Carcinoma of the head of pancreasMalignant lymph nodes at the porta hepatisInfrequentAmpullary carcinomaPancreatitisLiver secondariesRareBenign strictures - iatrogenic, traumaRecurrent cholangitisMirrizi's syndromeSclerosing cholangitisCholangiocarcinomaBilary atresiaCholedochal cysts
8 History Abdominal pain, weight change, fever Drug history Injections AlcoholTransfusion blood, blood productsContact with jaundiced individualsSexual activityIngestion raw shellfish, wild mushrooms
9 Jaundice N + Haemolytic +++ ++ Hepatocellular Cholestatic AlkP Transami nasesBilirubinLiver Function Tests
10 Clinical Case 1 50 year old female Acute, severe pain in RUQ Nausea and vomitingCalls GP – pethidine pain reliefNext few days notices dark urine and pale stoolsHer husband comments she has a pale yellow tinge
11 Emergency admission What investigations would you do ? What results would you expect?
12 Abdominal Ultrasound showing multiple gallstones in gallbladder
17 Case 1 Obstructive jaundice due to gallstone in common bile duct Blood tests show high bilirubin and high alkaline phosphataseUrine contains bilirubinTreatment includes ERCP to remove stone and then plan Cholecystectomy
18 Clinical Case 2 65 year old female Loss of appetite and weight loss Develops jaundice and itchingScratch marks and bruisingLiver enlarged, palpable gallbladder
19 Emergency admissionWhat investigations and what results?
20 Abdominal Ultrasound Dilated common bile duct measuring 14mm Obstruction at lower end of bile ductCause not clear on US
21 CT Abdomen Mass in head of pancreas Obstruction of common bile duct Liver metastasisPeritoneal disease and ascites
22 Endoscopic Ultrasound showing mass in head of pancreas obstructing the CBD