Jaundice.pdf - ACS/ASE Medical Student Core Curriculum...

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ACS/ASE Medical Student Core CurriculumJaundiceAmerican College of Surgeons Division of EducationPage 1 of 11Blended Surgical Education and Training for Life®JaundiceAnatomyThe complexity of the biliary tree can be broken down into much simpler segments. Theintrahepatic ducts converge to form the right and left hepatic ducts which exit the liver andjoin to become the common hepatic duct. The cystic duct branches off the common hepaticduct and drains into the gallbladder. The common hepatic duct continues towards theduodenum, but it is called the common bile duct (CBD) after the take-off of the cystic duct.The CBD then joins the pancreatic duct prior to draining into the second portion of theduodenum.Obstruction, inflammation, or infection of the biliary tract changes the baseline anatomy andsize of the various ducts. The normal calibers of the CBD and pancreatic duct are < 8mmand < 4mm, respectively. The gallbladder wall is typically < 4mm in thickness.Rokitansky-Aschoff sinusesare epithelial invaginations in the gallbladder wall that from asa result of increased gallbladder pressures.Ducts of Luschkaare biliary ducts that lie in gallbladder fossa and connect directly betweenliver and the gallbladder. These can result in bile leak after cholecystectomy.PathophysiologyJaundice is the yellowing of the skin and sclera due to abnormally elevated levels of bilirubinin the blood. It can be characterized into three different categories including pre-hepatic,intra-hepatic, or post-hepatic. Pre-hepatic and intra-hepatic causes are known as medicaljaundice, while post-hepatic (or obstructive jaundice) is considered surgical jaundice.PRE-HEPATICIn pre-hepatic jaundice, there isexcess productionof bilirubin that overtakes the ability ofliver to conjugate the bilirubin and excrete into the gut. This is predominantlyunconjugatedhyperbilirubinemia. The most common cause of pre-hepatic jaundice is hemolytic anemiawhich causes excess heme breakdown.INTRA-HEPATICIntra-hepatic causes are due to parenchymal liver disease with inability to either conjugate orexcrete bilirubin. In this case, the fraction of bilirubin that is elevated varies. Viral hepatitisoften has a predominantly unconjugated bilirubinemia. A conjugated hyperbilirubinemia isseen with cholestasis from drugs or primary biliary cholangitis.
ACS/ASE Medical Student Core CurriculumJaundiceAmerican College of Surgeons Division of EducationPage 2 of 11Blended Surgical Education and Training for Life®POST-HEPATICIn post-hepatic jaundice orobstructive jaundice, there is an impediment to the flow of biledue to a partial or complete obstruction of the extrahepatic biliary passage between the liverand duodenum. Obstruction can occur within the biliary ducts themselves or more distalwithin the pancreas.This is predominantly aconjugated hyperbilirubinemia.

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