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06-06-2008, 02:34 PM
Aetiology:
1- Pancretic carcinoma
ÄCA head of pancreas. Ä Periampullary carcinoma.
2- 2ry L.N. at porta hepatis.
3- Malignancy of the liver
Ä 2ries "the commonest malignancy"
Ä Hepatoma, cholangioma & mixed.
Pathology:
1- At the site : the cause.
2- Above the Obst.: the same as calc. obst. but the G.B. is usually distended according to courvoisier's low Except in:
a) Cases with assosciated ch. cholecystitis.
b) Obstruction is high above the cystic duct.
3- Below the obst: The same as calc. obst. jaundice.
Clinical Picture:
Usually progressive painless jaundice.
If pain occurred it is dull aching pain in the epigastrium and referred to the back.
Manifestations of underlying malignancy.
Investigations: The same as calc. obst. Jaundice.
Treatment:
1. General preoperative preparation patient with obstructive jaundice: See before.
2. Percutaeneous transhepatic drainage of bile is done for dranage as a preoperative preparation and through it a choledochoscopy and palliative stents can be inserted.
3. The surgery can be planned according to the situation:
Operable cases of cancer head of pancreas or periampullary carcinoma treated by radical resection, see later.
Inoperaple cases in whome stents failed to be inserted may need palliative bypass according to the site of obstruction:
If obstruction at lower part of the common bile duct: Cholecystojejunostomy is simple operation but narrow cystic duct decrease its popularity. Choledochojejunostomy or choledocho-duodenostomy gives more wide drainage.
If obstruction is at the level of porta hepatis, hepaticojejunostomy can be performed by cutting through the liver and anastomosing wide intrahepatic duct to a loop of jejunum.
SOURCE: DR. AYMAN SALEM'S BOOK
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