الفهرس 
Empryology and anatomy of the biliary systemOnly 14 pages are availabe for public view
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Abstract
Jaundice is the yellow discolouration of the skin
and oonjgnctiva reoognized by the patient or his relatives
pushing him to seek medioal advice. This simple
definition hides the great complexity of the underlying
bioohemioal disorder that aotually leads to this yellow
discolouration •
Jaundice may be : Medioal : responding to oonservative
medioal treatment, usually the haemolytic and the
hepatocellular types, and surgical : or cholestatic,
where only surgery is of radicalBu~e to the patient •
The main causeS of obstructive jaundice are choledooholithiasis
, pancreaticoduodenal cancer, and stricture
of the COllllllboinle duct either traumatic or inflammatory
•
Stones in the common bile duct may be present~for
many years without giving rise to symptoms. causing actually
ohronic incomplete obstruction insufficient to
cause jaundice. Stones in the common bile duct may be
primary, formed in the duct itself, or secondary being
formed in the gall bladder then migrating along the
oystio duct to reach the common bile duct • Secondary
deposits are laid over this small stone from the lithogenic
bile and so the secondary stone increases in size.
Choledocholithiasis gives rise to intermittent
obstructive jaundice, but acute obstruction of the common
bile duct by gall stones is not uncommon and gives
rise to aoute obstructive ajundice. The obstruction here
is due to the bulk of the stone, muscular spasm and oedema
of the duct wall. After few days the stone either
passes to the duodenum or the spasm and oedema subside
aliLowing bile to flow freely again, thus the jaundice
is characteristically fluctuant •
Malignant obstructive jaundioe is DoSt commonly
oaused by oaroinoma of the head of the pancreas.Here
jaundice is usually insidious and as the disease progresses
it becomes very deep and remains so until the end.
The chronic oourse of the disease, previous history
of epigastric pain, baokache, nausea, loss of weight,
increasing pruritis, dilated palpable gall bladder and
the presence of bilirubin in urine and its absence in
the putty like faeces are factors suggesting a diagnosis
of carcinoma •
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Tne diagnostic evaluation of patients with obstructive
jaundice should include a comprehensive history
and physical examination wnic~ usually lead to a correct
diagnosis. A detailed informative nistory may be
in some patients more important than most elaborate
investigations • Abdominal examination is also important
• A palpable gall bladder in the presence of progressively
deepening jaundice points to a malignant aetiology
• A tender gall bladder with a positive Murphy’s
sign and intermittent jaundice points to choledocholithiasis.
A palpable pancreatic mass in tne ~pigastrium
nearly always signifies surgical incurability. A small
liver exoludes extra~patio oholestasis in which the
liver is enlarged and smooth •
Biocnemioal investigations are the mainstays in
the diagnosis of jaundioe. Absenoe of faeoal and urinary
urobilinogen persistantlY for a long period usually points
to a malignant oondition, while fluotuating level
of faecal and urinary urobilinogen is seen in choledoonoli
thiasis •
Serum bilirubin level is markedly higher in malignant
obstructive jaundice than caloular obstruotion.
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Early in the ooUl’seof obstruotive jaundice .the S.
G.P,T. and S.G.O.T. levels are raised specially in the
presence of oholangitis, wbile serum alkaline phosphatase
is still beginning to rise, and reaches high levels
as obstruction persists •
Remarkable new techniques to investigate a case of
jaundice have recently developed. They are entirely safe,
painless, require no speoial technique, independant of
organ function, and above all non invasive •
By ultrasonography and C.T., the diagnosis of cho l>
estatic jaundice can be very accurately achieved on observing
dilatation of the intrahepatic and i or the extrahepatic
portion of the biliary tract. Pancreatic tumours
, dilated biliary radicles, dilated splenic and
portal veins could be easily and accurately delineated.
Because C.T. is expensive and associated with radiation
exposure, it remains the procedure of second choice
after Ultrasonography in investigating a case with jaundice.
The nature, level, and cause of obstruction could
be demonstrated using either P.T.C. or E.R.C.P. Both
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P.T.C. and E.R.C.P., when successful, provide valuable
preoperative information in planning the operation and
they eliminate time - consuming intraoperative manipulations
like cholangiography and pancreatography(Aranha
et. al., 1984 ).
A point worth mentioning is the potential use of
P.T.C. as a method of temporary or permanent biliary
drainage in poor risk patients •
The case is accordingly managed after thorough preoperative
preparation •