 So it's already been a busy morning, but I want to take some time to talk to you about obstructive jaundice So you might get asked that in the oral exam. You might get a clinical case Or you might actually face a patient with obstructive jaundice So we're talking an obstruction to the flow of bile into the duodenum the surgical patients surgical jaundice Now I want to show you on the screen here a list of causes that we see locally Now we haven't looked at this for a long time as far as the research projects concerned So really this year I want to give it to one of the trainees just to do some research into The proper order of the causes that we do see locally But just in a rough order of what we do see and what you might see locally Remember the following our number one cause always is going to be coladocolothiasis We do see patients with stones in their bile ducts causing obstruction to flow remember these patients though will present with colongitis We do see a biliary tract tumors unfortunately, and we spoke about those the calendio carcinomas We also see extra apathetic compression on the biliary tree We see that from nodal disease whether that be lymphoma or other causes the sister Mass extrinsic to the bile ducts causing obstruction of flow in the bile ducts we see parasitic infections and Our number one would be a scaris But you can see other parasites as well with accumulation of those products in the bile duct causing an obstruction to flow We see HIV colon geography that is sometimes from the HIV the virus itself from cytomagallivirus or from cryptospiridium We see that colon geography Lymphomas we've seen one or two cases of lymphomas present to us were referred to us as an obstructive Jaundice on investigation turns out to be lymphoma and that can also be one of the causes of extra Extra bile duct compression We see coladocol cysts. We've seen a few of those over the last couple of years, but they'll also present to our pediatric Colleagues both acute and chronic pancreatitis can lead to Obstruction distally in the flow of bile. We have seen Maritzi syndrome. That is Colicostitis we have a stone and heartburn spout. There's a big inflammatory mass and it compresses on the bile duct Causing obstructive jaundice We haven't seen lately But you have to always think about primary sclerosis and colonitis of course as well as a cause of an obstruction to flow Then there's some other causes that we see in our patients in the critical care unit We do see it in the cases of severe sepsis and hyper perfusion We do see it as a perineoplastic syndrome usually renal cell carcinoma We've seen one of those one or two of those and also patients on total parenteral nutrition You've got to watch out for these patients as far as the obstructive jaundice is concerned So how are you going to see these patients? Well, they're going to complain of jaundice They're going to be yellow the family members bring them in they bring themselves in and they've got these yellow Yellow all over now remember there's an obstruction of flow of bile so bile does not get into the small bowel It does not get converted to starker bilinear gene So the stools are pale because that is what gives the stool is brown color that starker bilinear gene Is they not available for reabsorption into the plasma and excretion in the urine as urabilinogen? So if you have access to urinary dipsticks and they can do urabilinogen You're not going to see urabilinogen You are going to see bilirubin in that abundance of bilirubin is going to give the dark color to the urine So ask your patient dark urine and pale stools together with a jaundice You are thinking an obstruction to the flow of bile obstructive jaundice So what are you going to do? Well, you've got to confirm that this is obstructive jaundice so the first thing you might do is laboratory investigations and What you want to look for there is your your liver enzymes and you are going to see high bilirubin levels total bilirubin and the largest fraction of those is going to be a conjugated bilirubin so the conjugated hyper bilirubinemia is what you're going to see There will be an increase in the unconjugated fraction then as well because remember this conjugated form accumulates in their parasites There might be a reversal of the conjugation process and through the fusion or reabsorption that Unconjugated bilirubin gets reabsorbed or transferred into the plasma and that rises as well The majority though is going to be of a mostly conjugated Fraction that you're going to see the ductal enzymes are usually going to be raised And that is your alfos and your gamma gt and that is going to be raised out of proportion with the cellular enzymes Which are AST and ALT so in a nutshell there is your your your obstructive jaundice You've got to go from there to find the cause of this confirmation of obstructive jaundice in the cause You're going to do get to through imaging you can start with an ultrasound at least it's going to show you that dilatation of the bile ducts if there's an obstruction to flow proximal to that the ducts are going to start dilating We can go from there to a CT scan which is going to give us slightly more information Remember and you might even have to go to an MRCP ERCP But these patients please refer them to a unit that deals with this so that they can manage it If you do admit these patients usually please put up an IV line for them start hydrating them Number one causes of jaundice obstructive jaundice still going to be colonitis These are septic patients with pain and fever together with the jaundice give them antibiotics give them fluid Remember before that to take blood cultures always irrespective of this put your patient on an IV line Patients can become dehydrated in severe cases in special circumstances and we might talk about that a bit later We can talk about we may have to mention herpaternal syndrome So protect those kidneys by giving your jaundice patients good good hydration. So I hope that gives you a framework to talk about Obstructive jaundice in the exam situation or at least guide you when you start seeing these patients in the ward See you next time