Gall bladder and bile ducts 2 Obstructive jaundice

Obstructive jaundice

1_obstruction within the lumen : gall stones
2_pathology in the wall.
a_ congenital atresia of common bile duct (CBD).
Etiology :
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

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
Stricture
Malignant
Benign
Post operative 80%
Inflammatary 20%

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