Surgical jaundice

• - Hx: biliary colic or episodes of chlolecystitis.
• - Obstructive type

• - small calibre gallstones -> pass through the cystic duct.
• - In Mirizzi syndrome the stone may compress the bile duct directly- ^{one of the rare times that cholecystitis may present with jaundice}

• - Usu obstructive
• - Charcots triad: pain, jaundice, fever

• - Ascending infection of the bile ducts usually by E. coli
• - by definition occurring in a pool of stagnant bile.

painless jaundice with palpable gallbladder (Courvoisier's Law)

- Direct occlusion: distal bile duct or pancreatic duct by tumour.

- Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre.

• - bile duct is excised
•   + jaundice offers rapidly post operatively
•   + often due to diff cholecystectomy

- more insidious: bile duct stenosis <- clips or diathermy injury.

• - Primary sclerosing cholangitis is a RF
• - gradual onset obstructive pattern

US of liver and biliary trree

• establish
• - bile duct calibre
• - presence of gallstones
• - may visualise pancreatic masses and other lesions.

The most important clinical question is essentially the extent of biliary dilatation and its distribution.

• * 1st line: US liver and biliary tree
• * Next if suspect
• - pancreatic neoplasia: prancreatic protocol CT scan
• - liver tumours and cholangiocarcinoma: MRI/MRCP. If failed, ERCP. 
• - PET scans: to stage