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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 • 124 - 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. 125 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 126 - 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 • |