BYPROF/ GOUDA ELLABBAN

Surgical jaundiceSurgical jaundice

Jaundice is a yellow color in the skin, the mucous membranes, or the eyes. The yellow pigment is from bilirubin (product of old red blood cells). 

Jaundice is a condition produced when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin), causing a yellowish appearance of the skin and the whites of the eyes.due to increase elastin in the eyes 

When serum bilirubin level increases more When serum bilirubin level increases more then two times the normal limit bilirubin then two times the normal limit bilirubin is deposited in the tissues of the body is deposited in the tissues of the body mainly in tissues containing elastin.that is mainly in tissues containing elastin.that is why deposition in the sclera is obvious why deposition in the sclera is obvious due to increase elastin in the scleradue to increase elastin in the sclera

Jaundice is the only condition causing yellow Jaundice is the only condition causing yellow sclerasclera

What other causes of yellow skin do you What other causes of yellow skin do you know?know?

Normal bilirubin = 0.3- 1.3 mg/dlThe conjugated (direct) = 0.1-0.3 mg/dlThe unconjugated (indirect) = 0.2-0.7 mg/dl

Jaundice can be either due to conjugated, unconjugated bilirubin or mixed.

Jaundice is detected clinically when bilirubin is above 3 mg/dl

Grades of jaundice

Mild: pale lemon yellow.Moderate: yellow orange.Sever: brown.Very severe : greenish grayish yellow

Jaundice is due to:Jaundice is due to: Increase production of bilirubin from Increase production of bilirubin from

increase distruction of RBC’sincrease distruction of RBC’s Obstruction to bile flow from the liver.Obstruction to bile flow from the liver. Hepatocellular carcinomaHepatocellular carcinoma Severe congestive cardiac failure.Severe congestive cardiac failure. Prosthetic heart valve induced hemolysisProsthetic heart valve induced hemolysis

Causes of jaundice

Pre hepaticHepatic

Post hepatic

Pre-hepatic i.e. over production:

Excessive hemolysis.Large hematoma.

Hepatic:

Infectious hepatitis.Liver cirrhosis.Gilber syndrome.Crigler-Najjar syndrome.

Post hepatic: 

Gall  stone.Malignancies e.g. pancreas, bile duct.Biliary atresia.

Abdominal painAbdominal pain

Differential diagnosisDifferential diagnosis

Stones in biliary system.Stones in biliary system.Hepatits.Hepatits.Cholecystitis.Cholecystitis.Pancreatic tumor.Pancreatic tumor.

What else?What else?

StonesStones Stone can be in gall bladder Stone can be in gall bladder

((cholelithiasischolelithiasis, , gall stonegall stone) or in ) or in bile duct (bile duct (choledolithiasischoledolithiasis).).

This can cause obstructive jaundice.This can cause obstructive jaundice.

Characterized by :Characterized by :i.i. Biliary colic Biliary colic

ii.ii. Pale feces and dark urinePale feces and dark urine

iii.iii. Itching of the skinItching of the skin

CholecystitisCholecystitis The most common cause of The most common cause of

cholecystitis is gall stone.cholecystitis is gall stone. Pain is in Rt hypochondrium often Pain is in Rt hypochondrium often

radiate to Rt shoulder. Pain is radiate to Rt shoulder. Pain is aggravated by movement of breathing.aggravated by movement of breathing.

In chronic cholecystitis the pain always In chronic cholecystitis the pain always follow the meal i.e. indigestion pain.follow the meal i.e. indigestion pain.

Extra hepatic biliary obstuctionExtra hepatic biliary obstuction

(gallstones,carcinoma of head of (gallstones,carcinoma of head of pancreas or bile ducts,strictures of pancreas or bile ducts,strictures of bile duct)bile duct)

Intra hepatic Intra hepatic cholestasis(drugs,recurrent jaundice cholestasis(drugs,recurrent jaundice of pregnancy)of pregnancy)

Obstuction of the cystic duct will not Obstuction of the cystic duct will not lead to jaundicelead to jaundice

Obstruction of the common bile duct Obstruction of the common bile duct due to carcinoma of the head of due to carcinoma of the head of pancreas or bile stone will lead to pancreas or bile stone will lead to jaundicejaundice

In this case we think of the following:In this case we think of the following: Carcinoma of the head of pancreasCarcinoma of the head of pancreas Lower biliary tree resulting in Lower biliary tree resulting in

obstructive jaundiceobstructive jaundice

Corvoisier’s law: when the gallbladder Corvoisier’s law: when the gallbladder is palpable and the patient is is palpable and the patient is jaundiced it is least likely to be due jaundiced it is least likely to be due to obstruction of the bile duct to obstruction of the bile duct because previous attacks of because previous attacks of inflammation will have caused the inflammation will have caused the gallbladder to have a thickened gallbladder to have a thickened wall,fibrotic and not distensiblewall,fibrotic and not distensible

exeptions of corvoisier’s law:exeptions of corvoisier’s law: Stones that form in the bile duct (not Stones that form in the bile duct (not

in gallbladder) may obstruct the duct in gallbladder) may obstruct the duct with normal distensible gallbladder.with normal distensible gallbladder.

Double pathology:stones in cystic Double pathology:stones in cystic duct which lead to gallbladder duct which lead to gallbladder distention associated with carcinoma distention associated with carcinoma or stone blocking of the lower end of or stone blocking of the lower end of the ductthe duct

Jaundice without palpable gallbladder Jaundice without palpable gallbladder does not mean that the cause is does not mean that the cause is stones.Obstruction may be due to stones.Obstruction may be due to cancer of the head of pancreas and cancer of the head of pancreas and distention is insufficient to be palpable.distention is insufficient to be palpable.

Also carcinoma of bile or hepatic ducts Also carcinoma of bile or hepatic ducts above entry of the cystic duct into the above entry of the cystic duct into the bile duct.bile duct.

mirizzi’s syndrome : when cystic duct mirizzi’s syndrome : when cystic duct is closely applied to the common is closely applied to the common hepatic duct or is very short , a stone hepatic duct or is very short , a stone impact in it can inflame and obstruct impact in it can inflame and obstruct the bile duct and cause jaundice the bile duct and cause jaundice (gallbladder is oftenly distended)(gallbladder is oftenly distended)

Physical features of enlarged gallbladder Physical features of enlarged gallbladder ::

1.1. Appear beneath the tip of the right ninth Appear beneath the tip of the right ninth rib.rib.

2.2. Moves with respiration.Moves with respiration.

3.3. Smooth and hemi ovoid.Smooth and hemi ovoid.

4.4. There is no space between the lump and There is no space between the lump and the liver massthe liver mass

5.5. Dull on percussion.Dull on percussion.

If there is a gallbladder mass :If there is a gallbladder mass :

It will be diffuse and tender in the right It will be diffuse and tender in the right hypochondrium and there is not hypochondrium and there is not much movement with respiration.much movement with respiration.

When infection subsides it will be less When infection subsides it will be less tender , more discrete and more tender , more discrete and more mobile.mobile.

Carcinoma of pancreasCarcinoma of pancreas

85% arise in head of pancreas 85% arise in head of pancreas Although many present with jaundice Although many present with jaundice

and weight loss the main symptom is and weight loss the main symptom is usually abdominal pain.usually abdominal pain.

Pain: Pain: continueous , dull , boring , in continueous , dull , boring , in the epigastic region radiating to the the epigastic region radiating to the back , worse at night and releived by back , worse at night and releived by leaning forward.leaning forward.

Radiation to the right hypocondrium is Radiation to the right hypocondrium is common while radiation to the left common while radiation to the left indicates an infiltrating tumorof the indicates an infiltrating tumorof the tail of the gland.tail of the gland.

Jaundice is in 90% of patients and is Jaundice is in 90% of patients and is charecteristicaly progressive but charecteristicaly progressive but rarely painless.rarely painless.

pale stoolpale stoolDark urineDark urinePruritisPruritisAll indicative of obstructive jaundiceAll indicative of obstructive jaundiceWeight loss is almost universal.Weight loss is almost universal.Steatorrhea , epigastric bloating , Steatorrhea , epigastric bloating ,

flatulance, diarrhea , vomitting and flatulance, diarrhea , vomitting and constipation in 20-30%constipation in 20-30%

In 10% of patients (mostly over 45 In 10% of patients (mostly over 45 years old) they complain of years old) they complain of thrombophlebitis migrans in the armsthrombophlebitis migrans in the arms

Physical findings of carcinoma of Physical findings of carcinoma of pancreas:pancreas:

Obstructive jaundice , palpable Obstructive jaundice , palpable gallbladder , enlarged liver which gallbladder , enlarged liver which may lead to the carcinoma of the may lead to the carcinoma of the head of the pancreas.head of the pancreas.

In early stages physical signs are In early stages physical signs are absent.absent.

InvestigationInvestigation

BloodUrine Stool

Radiology

BloodBlood

• Serum bilirubin.Serum bilirubin.• LFTLFT• CBCCBC• Coagulation profileCoagulation profile• Hep. Profile.Hep. Profile.

UrineUrine

• UrobilinogenUrobilinogen• Conjugated bilirubinConjugated bilirubin• HB ureaHB urea

StoolStool

• Color of the stool Color of the stool • Occult bloodOccult blood

RadiologyRadiology

• USUS• CTCT• ERCPERCP• PTCPTC