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Case Scenario -History

Case Scenario -History. A 73-year-old man with 3-months H/O progressively deepening yellow discoloration of skin . He has also noticed that his urine has darkened and his stools have become pale and difficult to flush.

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Case Scenario -History

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  1. Case Scenario -History A 73-year-old man with 3-months H/O progressively deepening yellow discoloration of skin. He has also noticed that his urine has darkened and his stools have become paleand difficult to flush. His appetite has reduced significantly and he has found that his clothes have become loose.

  2. Case Scenario -Examination Patient appears underweight with yellow discoloration of the skin and sclera. The abdomen is soft with a smooth masspresent in the right upper quadrant, which moves with respiration.

  3. Case Scenario • What is the most likely diagnosis? • What is the underlying cause? • Why is stool pale? • What is Courvoisier’s law? • What further investigations are needed in this patient?

  4. Causes, Investigations & Management of Obstructive Jaundice Faisal Ghani Siddiqui MBBS; FCPS (General Surgery); PGDIP-BIOETHICS; MCPS-HPE; FICLS; (MHPE) Professor & Chairman, Department of Surgery, & Director, Directorate of Medical Education Liaquat University Of Medical & Health Sciences Jamshoro

  5. Learning Objectives At the end of the presentation, the students will be able to: • Define obstructive jaundice • Enlist causes of obstructive jaundice • Identify clinical features of obstructive jaundice • Order and interpret investigations • Outline a management plan

  6. Learning Objectives At the end of the presentation, the students will be able to: • Define obstructive jaundice • Enlist causes of obstructive jaundice • Identify clinical features of obstructive jaundice • Order and interpret investigations • Outline a management plan

  7. Normal serum level of bilirubin is17 micromoles/L

  8. Jaundice is a syndrome which is recognized clinically when serum bilirubin exceeds>40 micromoles/L

  9. Obstructive Jaundice -Definition Jaundice due to partial or complete obstruction to the flow of bile into the GIT

  10. Carcinomas Causing Obstructive Jaundice

  11. Learning Objectives At the end of the presentation, the students will be able to: • Define obstructive jaundice • Enlist causes of Obstructive jaundice • Identify clinical features of obstructive jaundice • Order and interpret investigations • Outline a management plan

  12. Obstructive Jaundice Clinical features • Jaundice • Dark urine • Clay-colored stools • Itching • Pain • Weight loss; anorexia

  13. Learning Objectives At the end of the presentation, the students will be able to: • Define obstructive jaundice • Enlist causes of Obstructive jaundice • Identify clinical features of obstructive jaundice • Order and interpret investigations • Outline a management plan

  14. Case Scenario -Investigations

  15. Role of Ultrasound in Obstructive Jaundice Ultrasonographic detection of dilated biliary tract is the first step in the investigation of patients with biochemical evidence of obstructive jaundice

  16. Role of Ultrasound in Obstructive Jaundice • Ultrasound does not provide information on the cause and site of the lesion causing obstruction • Further investigations with CT, MRCP or ERCP is required

  17. Obstructive Jaundice -ERCP • Defines cause of obstruction • Therapeutic • Sphincterotomy / stone removal • Balloon dilatation of strictures • Stenting of strictures

  18. ERCP -multiple stones in common bile duct

  19. ERCP -malignant stricture at lower end of CBD

  20. Obstructive Jaundice -CT Scan • Useful when the outcome of ultrasound/ERCP equivocal • Guided biopsy of tumours • Tumour staging

  21. Learning Objectives At the end of the presentation, the students will be able to: • Define obstructive jaundice • Enlist causes of Obstructive jaundice • Identify clinical features of obstructive jaundice • Order and interpret investigations • Outline a management plan

  22. Management of Patient with Obstructive Jaundice

  23. . . . In summary • Definition of obstructive jaundice • Causes of Obstructive jaundice • Clinical features of obstructive jaundice • Investigations in obstructive jaundice • Management

  24. Case Scenario • 73-year-old man with 3-months H/O progressively deepening yellow discoloration of skin, dark urine and pale stools, difficult to flush. Appetite is reduced and his clothes have become loose • Underweight with yellow discoloration of skin / sclera. Smooth mass in RUQ, moves with respiration

  25. Case Scenario • What is the most likely diagnosis? • What is the underlying cause? • Why is stool pale? • What is Courvoisier’s law? • What further investigations are needed in this patient?

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