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Surgery.(GIT 2).Gallbladder > Gall bladder.3. Calcular obstructive jaundice > Flashcards

Gall bladder.3. Calcular obstructive jaundice Flashcards

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1
Q

STONES IN THE BILE DUCTS

A
  1. Alternative name
  2. ORIGIN
  3. SEQUELAE
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2
Q

Alternative name for STONES IN THE BILE DUCTS

A

Choledocholithiasis

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3
Q

ORIGIN of STONES IN THE BILE DUCTS

A

(1) Gall bladder: (Commonest)

2) Primary duct stones: (Not common

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4
Q

Gall bladder in ORIGIN of STONES IN THE BILE DUCTS

A
  1. Incidence

2. Pathogenesis

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5
Q

Incidence of Gall bladder in ORIGIN of STONES IN THE BILE DUCTS

A

Commonest

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6
Q

Pathogenesis of Gall bladder in ORIGIN of STONES IN THE BILE DUCTS

A

CBD stones are migrating from G.B.

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7
Q

Primary duct stones in ORIGIN of STONES IN THE BILE DUCTS

A
  1. Incidence

2. Pathogenesis

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8
Q

Incidence of Primary duct stones in ORIGIN of STONES IN THE BILE DUCTS

A

Not common

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9
Q

Pathogenesis of Primary duct stones in ORIGIN of STONES IN THE BILE DUCTS

A

2ry to infestation of the biliary tree by Ascaris & Clonorchis sinensis.

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10
Q

SEQUELAE of STONES IN THE BILE DUCTS

A
  1. No effect : A small stone in the CBD without obstruction.
  2. Passed stone.
  3. Calcular obstructive jaundice.
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11
Q

Pathogenesis of Passed stone in SEQUELAE of STONES IN THE BILE DUCTS

A

Passed to the duodenum

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12
Q

Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. CLINICAL PICTURE
  2. SEQUELAE & COMPLICATIONS
  3. DIFFERENTIAL DIAGNOSIS
  4. INVESTIGATIONS
  5. TREATMENT
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13
Q

CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Symptoms

2. Examination

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14
Q

Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. The patient gives history of CCC with pain & fatty dyspepsia.
  2. Jaundice
  3. Charcot’s triad
  4. Reynold’s pentad
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15
Q

Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Course
  2. Degree
  3. Associations
  4. Note on the relation between size of stone and jaundice
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16
Q

Course of Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. usually Painful
  2. Slowly progressive
  3. Fluctuating
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17
Q

Degree of Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

usually does not reach a severe degree

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18
Q

Associations of Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Associated with dark frothy urine & pale stools

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19
Q

The reason why urine is dark in Associations of Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

due to presence of direct bilirubin in urine

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20
Q

The reason why urine is frothy in Associations of Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

due to presence of bile salts in urine

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21
Q

Note on the relation between size of stone and jaundice in Jaundice in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. There is no relation between the size of the stone and the development of jaundice
  2. A tiny stone impacted in the ampulla may cause jaundice, while large stone in a dilated CBD may not cause obstruction
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22
Q

Charcot’s triad in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. List of symptoms

2. Pathogenesis

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23
Q

List of symptoms of Charcot’s triad in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Recurrent attacks of :

  • Pain.
  • Jaundice.
  • Fever and rigors.
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24
Q

Pathogenesis of pain in List of symptoms of Charcot’s triad in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Right answer: As the patient already having CCC or due to cholangitis

Wrong answer (department) due to biliary colic

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25
Q

Pathogenesis of Charcot’s triad in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Due to superadded cholangitis

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26
Q

Reynold’s pentad in Symptoms in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Charcot’s triad
  2. Septic shock.
  3. Altered mental status.
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27
Q

Examination in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Jaundice in not severe.
  2. +ve Murphy’s sign.
  3. The gallbladder is not palpable
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28
Q

The reason why the gallbladder is not palpable in Examination in CLINICAL PICTURE of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Since it is fibrosed & shrunken

2. Due to long standing CCC “Courvoisier’s Law”.

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29
Q

SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

A. Effects on the liver

B. Effects on the coagulation factors

C. Hepato-renal failure

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30
Q

Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Hydro-hepatosis
  2. Ascending cholangitis
  3. White bile
  4. 2ry biliary cirrhosis in long standing cases.
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31
Q

Definition of Hydro-hepatosis in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Dilatation of intrahepatic biliary radicles

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32
Q

Ascending cholangitis in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Alternative name

2. Pathogenesis

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33
Q

Alternative name for Ascending cholangitis in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Cholangio-hepatitis

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34
Q

Pathogenesis of Ascending cholangitis in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

due to 2ry infection.

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35
Q

White bile in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Pathogenesis

2. Significance

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36
Q

Pathogenesis of White bile in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

In severe cases liver cells stop to secrete bile while bile ducts will continue to secrete pale yellow mucous (white bile).

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37
Q

Significance of White bile in Effects on the liver in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

indicates severe liver damage.

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38
Q

Effects on the coagulation factors in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Bile salts fail to reach the intestine )> failure of absorption of fat soluble vitamins especially Vit K )> Hypoprothrombinemia

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39
Q

Hepato-renal failure in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Alternative name

2. Pathogenesis

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40
Q

Alternative name for Hepato-renal failure in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Renal shut down

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41
Q

Pathogenesis of Hepato-renal failure in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Absence of bile salts in the intestine leads to bacterial overgrowth )> bacterial transclocation
    which may fail to be filtered by hepatic “Kupffer cells”.
  2. This gram -ve endotoxemia causes renal cortical necrosis & acute renal failure.
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42
Q

Pathogenesis of renal cortical necrosis & acute renal failure in Pathogenesis of Hepato-renal failure in SEQUELAE & COMPLICATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Shift of blood from cortex to medulla

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43
Q

DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Malignant obstructive jaundice

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44
Q

Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Age and gender
  2. Pain
  3. Course of jaundice
  4. Degree of jaundice
  5. Palpation of gall bladder
  6. Murphy’s sign
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45
Q

Age and gender of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Middle age females

46
Q

Age and gender of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Old age males

47
Q

Pain of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Painful

48
Q

Pain of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Usually painless

49
Q

Course of jaundice of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Intermittent

50
Q

Course of jaundice of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Progressive except in periampullary carcinoma

51
Q

Degree of jaundice of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Light Yellow

52
Q

Degree of jaundice of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Deep yellow

53
Q

Palpation of gall bladder of Calcular obstructive in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTSjaundice

A

Gallbladder not palpable

54
Q

Palpation of gall bladder of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Palpable gallbladder

55
Q

Murphy’s sign of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

+ve Murphy’s sign

56
Q

Murphy’s sign of Malignant obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

-ve Murphy’s sign

57
Q

The reason why jaundice is intermittent in Course of jaundice of Calcular obstructive jaundice in Difference between Calcular obstructive jaundice and Malignant obstructive jaundice in DIFFERENTIAL DIAGNOSIS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Due to remission and exacerbation of attacks of inflammation around the stone obstructing the CBD )> fluctuation of dilatation and constriction of the passage )> fluctuation of serum total bilirubin and bile salts )> intermittent jaundice

58
Q

INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

A. Laboratory

B. Radiological

59
Q

Laboratory investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

1) Liver function tests
2) Kidney function tests: * Serum creatinine, BUN & K
3) CBC :
4) Prothrombin time.

60
Q

Liver function tests in Laboratory investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Elevated total, direct bilirubin, ALP & Gamma GT.

2. ALT & AST are high only if there is cholangitis.

61
Q

Finidings of CBC in Laboratory investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Normal TLC

2. Leucocytosis

62
Q

Significance of Leucocytosis in Finidings of CBC in Laboratory investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Leucocytosis means cholangitis.

63
Q

Cholangitis is diagnosed by

A

LFT: show high ALT & AST

CBC: show Ieucocytosis

64
Q

Radiological investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

1) Abdominal U.S : the most appropriate investigation

2) ERCP : Diagnostic & therapeutic.

65
Q

Abdominal U.S in Radiological investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Significance

2. Advantages

66
Q

Significance of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

The most appropriate investigation of Calcular obstructive jaundice

67
Q

Advantages of Abdominal U.S in Radiological investigations in INVESTIGATIONS of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. It reveals dilated CBD & dilated IHBR
  2. It reveals gall stones.
  3. Differentiate between obstructive and cholestatic jaundice (swollen hepatocytes)
68
Q

TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

A. Initial management

B. Definitive management

69
Q

Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Hospitalization.
  2. Liver support
  3. Vit K administration
  4. Antibiotics
  5. Prevention of renal failure
70
Q

Liver support in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

high glucose intake in the form of Glucose 10% I.V

71
Q

Vit K administration in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Route

2. Benefits

72
Q

Route of Vit K administration in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Via drip

73
Q

Benefits of Vit K administration in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

To correct the coagulation abnormalities

74
Q

Antibiotics in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. List

2. Benefits

75
Q

List of Antibiotics in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

3rd generation cephalosporins

76
Q

Benefits of Antibiotics in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

To prevent cholangitis.

77
Q

Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

A. General measures

B. Specific measures

78
Q

General measures in Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

a. Mannitol I.V (osmotic diuretic).

b. Adequate hydration by I.V. fluids.

79
Q

Specific measures in Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. List

2. Benefits

80
Q

List of Specific measures in Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Oral bile salts

81
Q

Oral bile salts in List of Specific measures in Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

Ursofalk 200mg

ursodeoxycholic acid

82
Q

Benefits of Specific measures in Prevention of renal failure in Initial management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

To diminish liability of endotoxaemia.

83
Q

Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

a) ERCP
b) Open cholecystectomy
c) Missed CBD stones

84
Q

ERCP in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Success rate

2. Principle

85
Q

Success rate of ERCP in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

90%

86
Q

Principle of ERCP in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Sphincterotomy
  2. Stone extraction by dormia basket or balloon catheter
  3. Followed by laparoscopic cholecystectomy 3 months later
87
Q

The reason why laparoscopic cholecystectomy is done 3 months later in Principle of ERCP in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

So that all lab investigations become normal

88
Q

Oral question : Can we do laparoscopic cholecystectomy now instead of the wait for 3 months ?

A

Yes in cases of normal or mild elevation of lab investigations

89
Q

Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Indication

2. Principle

90
Q

Indication of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

when ERCP fails to remove the stone.

91
Q

Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. CBD exploration and Choledocholithotomy

2. Ways of closure of the CBD after choledocholithotomy

92
Q

Principle of CBD exploration and Choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. The supradudenal part of CBD is exposed, opened between 2 stay suture
  2. Calculi are extracted by stone forceps
  3. Confirming absence of stenosis or missed stones
93
Q

Confirming absence of stenosis or missed stones in Principle of CBD exploration and Choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Bake’s dilator is passed in the CBD to the ampulla
  2. Flushing the duct with saline
  3. Intra-operative cholangiography
  4. Choledocoscope
94
Q

Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

a. Choledocho-duodenostomy
b. Closure of the CBD over a T-tube
c. Trans-dudenal sphincteroplasty

95
Q

Indications of Choledocho-duodenostomy in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. CBD diameter > 1.5 cm.
  2. Presence of intrahepatic stones.
  3. Impacted stone in lower end CBD.
96
Q

Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Indication

2. Post operative Care of T-tube

97
Q

Indication of Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

CBD diameter

98
Q

Post operative Care of T-tube in Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. The T-tube is connected to a receptacle (urinary bag).
  2. It is left in place for 10-14 days & before its removal
  3. Confirming absence of missed stones before removal
  4. The small opening in the CBD after removal of T - tube closes spontaneously within a week provided there is no distal obstruction.
99
Q

The reason why it is left in place for 10-14 days & before its removal in Post operative Care of T-tube in Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

To allow Formation of fibrous tissue around the tube )> fibrous track

100
Q

Confirming absence of missed stones before removal in Post operative Care of T-tube in Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Clamping of The T-tube as a test for 48 hours

2. T-tube cholangiography

101
Q

Clamping of The T-tube as a test for 48 hours in Confirming absence of missed stones before removal in Post operative Care of T-tube in Closure of the CBD over a T-tube in Ways of closure of the CBD after choledocholithotomy in Principle of Open cholecystectomy in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

There must be

a. No abdominal pain.
b. No fever.
c. No jaundice.
d. No escape of bile around the tube.
e. Normal faecal coloration means that bile is reaching the gut.

102
Q

Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Incidence

2. Management

103
Q

Incidence of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

2%

104
Q

Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

A. Patient with T - tube

B. Patient without T - tube

105
Q

Management of Patient with T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

one of the Followings

  1. Flushing with saline.
  2. Dissolution of stones
  3. Percutaneous extraction
  4. ERCP, sphincterotomy & stone extraction (Best).
106
Q

Dissolution of stones in Management of Patient with T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. Chenodeoxycholic acid.
  2. Heparin.
  3. MTBE.
107
Q

Percutaneous extraction in Management of Patient with T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A
  1. The T-tube is removed 4-6 weeks after surgery instead of 10-14 days
  2. The stone is removed using dormia basket through its fibrous track
108
Q

The reason why The T-tube is removed 4-6 weeks after surgery instead of 10-14 days in Percutaneous extraction in Management of Patient with T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

To form more fibrous tissue )> strong fibrous track

109
Q

Best management in Management of Patient with T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

ERCP, sphincterotomy & stone extraction

110
Q

Management of Patient without T - tube in Management of Missed CBD stones in Definitive management in TREATMENT of Calcular obstructive jaundice in SEQUELAE of STONES IN THE BILE DUCTS

A

ERCP & sphincterotomy

Surgery.(GIT 2).Gallbladder (3 decks)

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