Jaundice

1. Jaundice ?????? ???? Ahimor Alon ??????? ????????, ?????? 08 ???????? ?' - ???"? ??? ????? ???? ?"? ??? ???????

2. Frequent manifestation Normal Serum bilirubin 0.5-1.3 mg/dL Jaundice: exceed 2mg/dL Pre-hepatic: Hemolysis, Gilbert�s, Crigler-Najjar. Hepatic: HepatoCellular or Cholestatic. Viral Hepatitis, Alcoholic cirrhosis, Primary biliary cirrhosis, toxic drugs, pregnancy, postoperative. Extra-hepatic: tumor, choledocholithiasis, biliary stricture. Determine Cause. ERCP, CT, US. ???? ??? ???? ???? ?? ???????? ?????? ????????? . ?????, ????? ????? ?????? ???? ????? ????? ???? ?"? ????????. ???? ?????????? ??????? ???? ??? 0.5-1.3 ??????? ????????, ???????? ?????? ???? ?-2 ?????? ?? ?????????? ?????? ????? ???????? ???? ?????? ?????? ?????. ?????? ???? ???? ?????? ????? ????? ??? ??? ??????? ???????? ??? ????? ?? ?? ???????. ????? ?????? ?? ?????? ????? ?-3 ?????? ???????: ?????????, ?????? ????? ?????? ????? ?????? ????? ???????. ??????? ???? ??? ??? ?????? ??????? ????? ?????? ????? ??? ?????, ????? ?????? ????? ???? ?? ?????????. ????? ???? ?????? ?? ???? ??? ????? ?????? ?? ?????? ????? ?- Crigler Najjar Syndrom. ????? ?????? ?? ???? ?????? ?? ?? ????? ???????? ???????????- ?? ???? ????. ?????? ????????????? ?????? ??????? ?????? ???????? ???????? ?????, ????? ??????? ????? ???? ???? ?????? ???? ????? ????? ????? ?????? ?? ??? ????? ?? ???? ??? ??? ??????, ?? ????? ?? ?????? ????????? ?????? ???????? ?????. ????? ?????? ???? ??: Primary biliary chirrosis, ???? ???????, ???? ???????? ??????, ????? ???????? ???? ???????. ????? ?????? ?????? ???? ?????? ??????? ?? ???????, ????????????????, ????? ???????, ???'... ????? ?????? ?? ??????????? ?????, ???????????? ?????, ??????? ????????, ?????????????? ?? ?????????, ?- ????????? ??????????. ???? ?????? ?????? ??? ?????? ?????? ???? ??? ????? ?? ?"? ?????? ????, ????? ???????? ??? ?????, ????? ?????? ??????? ?????. ???? ??? ???? ???? ?? ???????? ?????? ????????? . ?????, ????? ????? ?????? ???? ????? ????? ???? ?"? ????????. ???? ?????????? ??????? ???? ??? 0.5-1.3 ??????? ????????, ???????? ?????? ???? ?-2 ?????? ?? ?????????? ?????? ????? ???????? ???? ?????? ?????? ?????. ?????? ???? ???? ?????? ????? ????? ??? ??? ??????? ???????? ??? ????? ?? ?? ???????. ????? ?????? ?? ?????? ????? ?-3 ?????? ???????: ?????????, ?????? ????? ?????? ????? ?????? ????? ???????. ??????? ???? ??? ??? ?????? ??????? ????? ?????? ????? ??? ?????, ????? ?????? ????? ???? ?? ?????????. ????? ???? ?????? ?? ???? ??? ????? ?????? ?? ?????? ????? ?- Crigler Najjar Syndrom. ????? ?????? ?? ???? ?????? ?? ?? ????? ???????? ???????????- ?? ???? ????. ?????? ????????????? ?????? ??????? ?????? ???????? ???????? ?????, ????? ??????? ????? ???? ???? ?????? ???? ????? ????? ????? ?????? ?? ??? ????? ?? ???? ??? ??? ??????, ?? ????? ?? ?????? ????????? ?????? ???????? ?????. ????? ?????? ???? ??: Primary biliary chirrosis, ???? ???????, ???? ???????? ??????, ????? ???????? ???? ???????. ????? ?????? ?????? ???? ?????? ??????? ?? ???????, ????????????????, ????? ???????, ???'... ????? ?????? ?? ??????????? ?????, ???????????? ?????, ??????? ????????, ?????????????? ?? ?????????, ?- ????????? ??????????. ???? ?????? ?????? ??? ?????? ?????? ???? ??? ????? ?? ?"? ?????? ????, ????? ???????? ??? ?????, ????? ?????? ??????? ?????.

3. Bilirubin Sclerae, 3mg/dL. Tongue. Darkening of Urine (Direct). Heme � biliverdin � bilirubin (Unconjugated) � Hepatocytes � bilirubin (Conjugated) � Bile. Urobilinogen, 10-20% to portal sys. , <3mg/dL to Urine. Normal Values: Total 0.3-1.3 mg/dL, UnCon. 0.2-0.9 mg/dL. Con. 0.1-0.4 mg/dL ???? ??? ????? ????? ?? ????? ???????? ??????, ????? ???? ????? ?? ??????? ?????, ???? ????? ????? ????????? ????? ???????????????? ????? ?????? ??? ?"? ????? ??????. ????? ???? ????? ?????????? ??????? ????? ????? ????? ?? ?????? ???? ???????? ?????? ?????????? ???? ????? ?????? ?????. ???? ???? ???? ?????? ?? ???? ?????????? ?????? 3 ??????? ????????. ???? ????? ???? ??? ???? ?????. ?????? ????? ?? ???? ????? ????, ??????? ????? ?????? ?????????? ??????. ??? ???? ???? ?????? ???? ?????????? ??? ????, ????? ?????? ?? ??? ???? ?? ?? ????, ?????? ????? ????????? ???? ????? (????). ????? ????? ?? ????? ????? ????? ???? ?????? ?? ????? ?????????.? ??????????? ???. ????????? ??? ????? ???? ????? ?? ???? ?HEME, 80% ?????? ?????????? ???? ???? ?????? ??????? HEME ?? ???? ?????? ????, ?? ???? ???? ????? ?????? ??? ???? (????????? cells ???'..), ?????????.... ?????? ??????? ????? ????? ??????????????????? ????? ?????, ????? ?????? ?? ???? HEME ?"? Heme Oxigenase, ????? ???? ???? ???'..., ????? ?? ?????? ??? ????????? ??????? ?????? ??? ???? ???'... ?????? ?????? ?"? ????????? ??????? ?????? ??? ????? ????????? ???? ????. ?????? ??? ?? ?? ????, ?????? ??? ????? ????????. ??? ?????????? ???? ?? ??????????, ?????????? ???? ????????? ?"? Glucoronic Acid ????? ???? ?????. ?????????? ????? ????? ??? ????, ???? ??? ????? ???? ????? ?? ??????? ?? ??????? ????? ????? ??? ?"? ???????, ?????????? ???? ???? ???? ??? ??????????????. 80% ?????? ??????? ???? ????? ?????, 20% ??????? ?????? ????? ?????? ????????. ???? ??? ????, ???? ?-3 ?"? ???????? ????? ????? ????? ?????? ??? ????. ???? ?????????? Total?????, ??????? ???? ??? 0.3-1.3, ????? ???? ???? ??? 0.2-0.9, ?????? ???? ????? ???? ????? ??? 0.1-0.4 . ???? ??? ????? ????? ?? ????? ???????? ??????, ????? ???? ????? ?? ??????? ?????, ???? ????? ????? ????????? ????? ???????????????? ????? ?????? ??? ?"? ????? ??????. ????? ???? ????? ?????????? ??????? ????? ????? ????? ?? ?????? ???? ???????? ?????? ?????????? ???? ????? ?????? ?????. ???? ???? ???? ?????? ?? ???? ?????????? ?????? 3 ??????? ????????. ???? ????? ???? ??? ???? ?????. ?????? ????? ?? ???? ????? ????, ??????? ????? ?????? ?????????? ??????. ??? ???? ???? ?????? ???? ?????????? ??? ????, ????? ?????? ?? ??? ???? ?? ?? ????, ?????? ????? ????????? ???? ????? (????). ????? ????? ?? ????? ????? ????? ???? ?????? ?? ????? ?????????.? ??????????? ???. ????????? ??? ????? ???? ????? ?? ???? ?HEME, 80% ?????? ?????????? ???? ???? ?????? ??????? HEME ?? ???? ?????? ????, ?? ???? ???? ????? ?????? ??? ???? (????????? cells ???'..), ?????????.... ?????? ??????? ????? ????? ??????????????????? ????? ?????, ????? ?????? ?? ???? HEME ?"? Heme Oxigenase, ????? ???? ???? ???'..., ????? ?? ?????? ??? ????????? ??????? ?????? ??? ???? ???'... ?????? ?????? ?"? ????????? ??????? ?????? ??? ????? ????????? ???? ????. ?????? ??? ?? ?? ????, ?????? ??? ????? ????????. ??? ?????????? ???? ?? ??????????, ?????????? ???? ????????? ?"? Glucoronic Acid ????? ???? ?????. ?????????? ????? ????? ??? ????, ???? ??? ????? ???? ????? ?? ??????? ?? ??????? ????? ????? ??? ?"? ???????, ?????????? ???? ???? ???? ??? ??????????????. 80% ?????? ??????? ???? ????? ?????, 20% ??????? ?????? ????? ?????? ????????. ???? ??? ????, ???? ?-3 ?"? ???????? ????? ????? ????? ?????? ??? ????. ???? ?????????? Total?????, ??????? ???? ??? 0.3-1.3, ????? ???? ???? ??? 0.2-0.9, ?????? ???? ????? ???? ????? ??? 0.1-0.4 .

4. Unconjugated hyperbilirubinemia: Hemolytic disorder or Impaired conjugation. Hemolytic rarely exceeds bilirubin of 5 mg/dL. Chronic hemolysis, high Incidence of pigmented gallstones. Impaired uptake: Drugs, Crigler Najjar, Gilbert�s. Conjugated Hyperbilirubinemia: hepatitis, cirrhosis, Drug Induced cholestasis. Obstructions: choledocholithiasis, biliary strictures, cholangiocarcinoma, primary sclerosing cholangitis. ?????????? ????? ????? ?? ?????? ??? ????? ????????? ?????? ?????????? ????. ???????????????? ????? ?????? ??????: ????? ????? ?? ?????????. Uptake ????, ?????????, ?? ????? ????????? ???????. ????? ?????????? ???? ?? ???? ???? ?????????? ?????? ?? ???? ??? ??????. ????? ????????? ?? ???? ????? ?????? ?????, Uptake ????, ?? ????????? ?????. ????? ????????? ???? ????? ?????? ????? ??? ???? ???? ?? ?????. ?????? ???????? ?????? ???? ?? ???? ??: ??? ??? ?????? ????? ?? ??? ?????? ??? ?????? ????????? ?????? ????? ?? ???? ??????? ???????????????? ???? ?????: ?????? ??? ????? ??????. ??? ????? ???? ??????????? ?????? ???? ????- ????? ??????????- ???????, ?????? ?????? ???'... ????? ????????? ?? ?????? ?? ??????. ??? Sickle cell anemia� ?????? ???'... ?????? ???? ????????? ??"? ?? ???? ?? ???? ?-5 ?"? ????????. ?????? ????? ?? ??????? ??????, ?? ?????? ????? ???? ?? ???? ?????? ????? ????, ???? ?? ????? ?????? ?? ?? ?????? ?? ????? ????????????????? ????? ?? ????? ???? ????? ???????. ????? ???? ??????? ?? ???? ?????? ????? ????????? ????? ??????, ????? ?????? ????? ??? ?????? ??'?, ?????? ???????. ???????????????? ?????: ????? ?????? ?? ????????? ???? ?????? ??????? ???????? ?? ??????, ???????, ?????????? ???????. ??? ??????? ????? ??? ???????? ???? ?????? ????? ????, ??????? ????? ????? � ????????????????, ????? ?????? ????? ????, ????? ?????????? ?? ????, ????? ????? ????, ?? Primary sclerosing cholangitis. ?????????? ????? ????? ?? ?????? ??? ????? ????????? ?????? ?????????? ????. ???????????????? ????? ?????? ??????: ????? ????? ?? ?????????. Uptake ????, ?????????, ?? ????? ????????? ???????. ????? ?????????? ???? ?? ???? ???? ?????????? ?????? ?? ???? ??? ??????. ????? ????????? ?? ???? ????? ?????? ?????, Uptake ????, ?? ????????? ?????. ????? ????????? ???? ????? ?????? ????? ??? ???? ???? ?? ?????. ?????? ???????? ?????? ???? ?? ???? ??: ??? ??? ?????? ????? ?? ??? ?????? ??? ?????? ????????? ?????? ????? ?? ???? ??????? ???????????????? ???? ?????: ?????? ??? ????? ??????. ??? ????? ???? ??????????? ?????? ???? ????- ????? ??????????- ???????, ?????? ?????? ???'... ????? ????????? ?? ?????? ?? ??????. ??? Sickle cell anemia� ?????? ???'... ?????? ???? ????????? ??"? ?? ???? ?? ???? ?-5 ?"? ????????. ?????? ????? ?? ??????? ??????, ?? ?????? ????? ???? ?? ???? ?????? ????? ????, ???? ?? ????? ?????? ?? ?? ?????? ?? ????? ????????????????? ????? ?? ????? ???? ????? ???????. ????? ???? ??????? ?? ???? ?????? ????? ????????? ????? ??????, ????? ?????? ????? ??? ?????? ??'?, ?????? ???????. ???????????????? ?????: ????? ?????? ?? ????????? ???? ?????? ??????? ???????? ?? ??????, ???????, ?????????? ???????. ??? ??????? ????? ??? ???????? ???? ?????? ????? ????, ??????? ????? ????? � ????????????????, ????? ?????? ????? ????, ????? ?????????? ?? ????, ????? ????? ????, ?? Primary sclerosing cholangitis.

5. Epidemiology Newborns, older adults. Congenital abnormalities. Hepatitis. Common duct stones, Neoplastic jaundice, alcoholic liver. In men: cirrhosis, chronic hepatits B, hepatoma, pancreatic cancer, sclerosing cholangitis. In women: Duct stones, Primary biliary cirrhosis, Carcinoma of gallbladder. ??? ?????????????: ?????? ???? ????? ???? ?????. ??? ?????? ??????? ???????? ?? ???? ?? ??????? ???????. ??????? A ??? ????? ?????? ????? ???? ?????, ?????. ????? ????? ????, ??? ???????? ????? ??????? ?? ?????? ??????? ???? ???????. ???? ?????? ??? ???? ??????? ??: ???????, ??????? B, ????? ?????, ?????????? ?????????. ????? ?????? ??????? ??: ???? ???, Primary biliary cirrosis, ??????, ?????? ???? ????. ??? ?????????????: ?????? ???? ????? ???? ?????. ??? ?????? ??????? ???????? ?? ???? ?? ??????? ???????. ??????? A ??? ????? ?????? ????? ???? ?????, ?????. ????? ????? ????, ??? ???????? ????? ??????? ?? ?????? ??????? ???? ???????. ???? ?????? ??? ???? ??????? ??: ???????, ??????? B, ????? ?????, ?????????? ?????????. ????? ?????? ??????? ??: ???? ???, Primary biliary cirrosis, ??????, ?????? ???? ????.

6. History Single most important part. Age, Sex, Habits, Drugs. Choledocholithiasis: biliary colic, fever, chills, previous attacks, With digestion. Malignant obstruction: Deep seated pain, dull, position, Weight loss. Viral Hepatitis. Light color Stool, Dark urine. Pruritus, Severe discomfort. ???? ???? ?????? ?????? ??? ????? ?? ???? ???? ????? ????? ?????? ???? ?? ????, ?????? ??. ???? ???? ????? ?????? ?????, ??? ???, ???, ???? ???? ?? ?????: ?????? ?????, ????, ???????, ?????? ???????, ????? ??????, ??????? ????, ????? ?? ??? ?????, ???????, ??????. ????? ?? ???? ????? ?? ???????? � ????? ????? ????, ????? ???? ??? ????? ?????? ??????, ??? ??, ????? "chiils", ??????? ?????? ?? ??????? ????? ???? ????. ???? ?????? ????? ?????? ????? ???, ??? ???? ???? ?????, ?????? ?????? ??? ????? ????, ?????? ????. ??????? ?????? ?? ????? ??????? ?? ????? ????? ????, ????? ??????. ????? ????? ?? ???? ????? ???? ???. ????? ????????? ????? ????? ???? ?"? ????? ????? ???? ?????, ????? ?????? ???? ????? ?????, ?? ???? ?????? ???? ????. ?????? ???? ?? ????? ????? ????? ?????? ???????? ???? ????? ?? ???. ???? ???? ?????? ?????? ??? ????? ?? ???? ???? ????? ????? ?????? ???? ?? ????, ?????? ??. ???? ???? ????? ?????? ?????, ??? ???, ???, ???? ???? ?? ?????: ?????? ?????, ????, ???????, ?????? ???????, ????? ??????, ??????? ????, ????? ?? ??? ?????, ???????, ??????. ????? ?? ???? ????? ?? ???????? � ????? ????? ????, ????? ???? ??? ????? ?????? ??????, ??? ??, ????? "chiils", ??????? ?????? ?? ??????? ????? ???? ????. ???? ?????? ????? ?????? ????? ???, ??? ???? ???? ?????, ?????? ?????? ??? ????? ????, ?????? ????. ??????? ?????? ?? ????? ??????? ?? ????? ????? ????, ????? ??????. ????? ????? ?? ???? ????? ???? ???. ????? ????????? ????? ????? ???? ?"? ????? ????? ???? ?????, ????? ?????? ???? ????? ?????, ?? ???? ?????? ???? ????. ?????? ???? ?? ????? ????? ????? ?????? ???????? ???? ????? ?? ???.

7. Duration of jundice, arthralgias, myalgias, rash, anorexia, weight loss, abdominal pain, fever, Urine, Stools. Post Cholecystectomy: �Left over� Stones, Bile Duct Injury. ???-?? ??? ??? ??? ????? ?????, ?????? ?????? ??????: ????????? � ??????, ????????, ??????, ????? ????, ???? ???, ???, ????? ?????, ???????? ???? ???????. ???? ???? ?? ??? ??? ???? ????? ??????, ?????? ????? �chills�, ?????? ????? ?? ?????? ?? ????? ????? ????, ?? ?????????. ?? ????? ????? ???? ?????????????, ????? ?????? ?????? ?????, ?? ??? ????? ????. ???-?? ??? ??? ??? ????? ?????, ?????? ?????? ??????: ????????? � ??????, ????????, ??????, ????? ????, ???? ???, ???, ????? ?????, ???????? ???? ???????. ???? ???? ?? ??? ??? ???? ????? ??????, ?????? ????? �chills�, ?????? ????? ?? ?????? ?? ????? ????? ????, ?? ?????????. ?? ????? ????? ???? ?????????????, ????? ?????? ?????? ?????, ?? ??? ????? ????.

8. Physical Examination Nutrional status, Temporal wasting. Spider angiomata, caput medusa, ascites, splenomegaly, Palmar Erythema, Dupuytren�s contracture. Hepatomegaly: hepatic and post-hepatic, malignancy, cirrhosis. Virchow�s Node, Sister mary Joseph�s Nodule? malignancy. Non-tender, palpable gallbladder?malignant obstruction. Murphy�s sign (cholistitis, Ascending cholangitis) Ascites+jaundice. ?????? ??????: ????? ?????? ?? ????? ????? ????? ??? ??????, ????? ????: Temporal Wasting ,Interosseues ??????? ??"? ???? ????? ??? ????? ??????????? ???????. ??????? ?? ???? ??? ??????: ?????? ????? Spider Angiomata, ???? ?????, ?????. ???-?? ????? ????, Palmar Erythema, Dupuytren�s contracture, ??????????. ????????? ???????? ?? ?????? ?????? ??? ???? ??????, ????? ???? ???? ????? ?? ??????? ?? ???? ???????. ????? ?????? ?????? ?? ?????Sister mary joseph (????? ?????????????), ?????? ????? ?? ????? ?????????. ????? ????? ???: ??? ??? ????? ???? ??? ????? ???? ????? ?? ????? ?????? ???? (?? ????), ???? ?????, Courvoisier�s Law. ???? ?????? ?????? ???? ??????. ????? ?????? ???????? ?????? ???? ????, ?????? ?????, ?? ????? ??? ?? ????. ???? ???? ????? ?? ????? ????? ???? ????. ????? ?????? ?? ???? ????? ????? ?? ??????? ?? ????? ????? ???????????. ?????? ??????: ????? ?????? ?? ????? ????? ????? ??? ??????, ????? ????: Temporal Wasting ,Interosseues ??????? ??"? ???? ????? ??? ????? ??????????? ???????. ??????? ?? ???? ??? ??????: ?????? ????? Spider Angiomata, ???? ?????, ?????. ???-?? ????? ????, Palmar Erythema, Dupuytren�s contracture, ??????????. ????????? ???????? ?? ?????? ?????? ??? ???? ??????, ????? ???? ???? ????? ?? ??????? ?? ???? ???????. ????? ?????? ?????? ?? ?????Sister mary joseph (????? ?????????????), ?????? ????? ?? ????? ?????????. ????? ????? ???: ??? ??? ????? ???? ??? ????? ???? ????? ?? ????? ?????? ???? (?? ????), ???? ?????, Courvoisier�s Law. ???? ?????? ?????? ???? ??????. ????? ?????? ???????? ?????? ???? ????, ?????? ?????, ?? ????? ??? ?? ????. ???? ???? ????? ?? ????? ????? ???? ????. ????? ?????? ?? ???? ????? ????? ?? ??????? ?? ????? ????? ???????????.

9. Laboratory Tests Battery of tests: Total, Direct bilirubin ; Albumin; alkaline Phosphatase, AST, ALT; PT. Differentiate hepatic from cholestatic. Albumin. PT elevated: Vit.K deficiency, Hepatocellular dysfunction. Hemolytic Disease: unconj� bilirubin, Total bilirubin less than 5 mg/dL. Hepatocellular disease: conj� and unconj� levels of bilirubin are high. Intrahepatic cholestasis & extrahepatic obstruction: high conj� bilirubin, bilirubinuria, high bilirubin 25-30mg/dL. Extrahepatic obstruction- neoplasms: high than 10mg/dL. ?????? ?????: ????? ?????? ????????? ?????? ?? ???? ?? ????? ?????? ????????? ????? ?????, ??????? ALK, AST, ALT, PT. ?????? ???????? ?????? ??? ?????? ??? ????? ???? ????????. ????? ALK ??? ?????? ????? ?????? ?? ???? ????. ?????? ?????? ?????? ??????? ?????? ????? ????. ??????? ???? ???? ????? ?? ????? ????? ??? ??????? ?? ?????. ??????? ???? ???? ????? ?? ??????? ??????? ???? ??? ????????? ?? ?????. PT ???? ???? ????? ??? ?? ????? ??????? K ... ????? ???????? ??"? ???????????? ???? ????? ?? ????????? ??? ???? ?? ??? 5 ?"? ????????, ?? ?????-????? ??? ????? ??????. ????? ??????????? ?? ????? ?????????? ???? ??????. ???? ???? ????? ??"? ???? ?? ???? ????? ????. ?? ????? ???????? ??? ????? ??? ?????? ??? ??? ?????, ?????????? ????? ??? ?????, ???-?? ????? ???? ????. ????? ??? ????? ???????? ?? ?????, ??? ????? ???? ?????? ?????? ?? ?? ??? ???, ?????????????. ??????? ????? ?? ???? ???? ???? ???? ???????? ?? ?????????? ????? ?? ?? 30, ????? ?????? ???? ?? ?????? ???? ?? ????? ?????? ????? ?? ??????? ?? ????? ?????? ???? ??? ????? ???? ???? ?? ?????????? ????. ??????? ??? ?????? ??????? ????????, ?????????? ????? ??"? ???? ?? 10 ?"?, ???????? ???? ?? 18 ????. ?????? ?????: ????? ?????? ????????? ?????? ?? ???? ?? ????? ?????? ????????? ????? ?????, ??????? ALK, AST, ALT, PT. ?????? ???????? ?????? ??? ?????? ??? ????? ???? ????????. ????? ALK ??? ?????? ????? ?????? ?? ???? ????. ?????? ?????? ?????? ??????? ?????? ????? ????. ??????? ???? ???? ????? ?? ????? ????? ??? ??????? ?? ?????. ??????? ???? ???? ????? ?? ??????? ??????? ???? ??? ????????? ?? ?????. PT ???? ???? ????? ??? ?? ????? ??????? K ... ????? ???????? ??"? ???????????? ???? ????? ?? ????????? ??? ???? ?? ??? 5 ?"? ????????, ?? ?????-????? ??? ????? ??????. ????? ??????????? ?? ????? ?????????? ???? ??????. ???? ???? ????? ??"? ???? ?? ???? ????? ????. ?? ????? ???????? ??? ????? ??? ?????? ??? ??? ?????, ?????????? ????? ??? ?????, ???-?? ????? ???? ????. ????? ??? ????? ???????? ?? ?????, ??? ????? ???? ?????? ?????? ?? ?? ??? ???, ?????????????. ??????? ????? ?? ???? ???? ???? ???? ???????? ?? ?????????? ????? ?? ?? 30, ????? ?????? ???? ?? ?????? ???? ?? ????? ?????? ????? ?? ??????? ?? ????? ?????? ???? ??? ????? ???? ???? ?? ?????????? ????. ??????? ??? ?????? ??????? ????????, ?????????? ????? ??"? ???? ?? 10 ?"?, ???????? ???? ?? 18 ????.

10. ALK Levels: Intrahepatic cholestasis, cholangitis, Extrahepatic obstruction. NOT always with jaundice? metastasis, Pyogenic abcess, Tumor. ALK, ???????: ???? ?? ?? ????? ??? ?????? ?? ?????, ???? ?????. ?????? ?? ???? ??? ??? ???? ?????? ?????? ?? ?????? ????, ???? ????? ?????? ?? ????? ?-Lange, ????? ?? ???? ????? ?????????. ?? ???? ????? ???? ??????, ???? ??????? ?????? ??????? ??? ???????, Pyogenic abcess, ??????? ??????? ???? ?? Duct ???? ??? , ?? ????? ??? ???? ??? ????? ?????? ?? ????. ALK ???? ???? ????? ??????? ???? ???? ?????????? ?? ?????, ????? ?????? ????? ?? ????? ??????. ?? ?????? ??? ?????? ??? ??????? ????? ?? ALK.ALK, ???????: ???? ?? ?? ????? ??? ?????? ?? ?????, ???? ?????. ?????? ?? ???? ??? ??? ???? ?????? ?????? ?? ?????? ????, ???? ????? ?????? ?? ????? ?-Lange, ????? ?? ???? ????? ?????????. ?? ???? ????? ???? ??????, ???? ??????? ?????? ??????? ??? ???????, Pyogenic abcess, ??????? ??????? ???? ?? Duct ???? ??? , ?? ????? ??? ???? ??? ????? ?????? ?? ????. ALK ???? ???? ????? ??????? ???? ???? ?????????? ?? ?????, ????? ?????? ????? ?? ????? ??????. ?? ?????? ??? ?????? ??? ??????? ????? ?? ALK.

11. Diagnosis Usually passes 24-48 hours. First test: US (dilation >10mm , stones). EUS. ERCP (lower end obstruction). THC (PTC), 2-5% Risk of complication. CT (neoplastic obstruction), Vascular involvement. MRCP. HIDA. Treatment while diagnosing: common bile duct stones, 85-90% success. Malignant biliary strictures. ???? ????? ???????? ???? ?????? ??. ???? ??????? ?? ?? ?????? ??? ????? ?? ?????? ???? ???? ????? ???? ???? ?????, ???? ?????? ?? ?????? ????? ????? ??????. ????? ???? ?????, ??? ?????? ??? ???? ??????? ??????? ???? ??? ?????? ???? ???? ??????? ???? ?? ??????. ???? ?????? ?????? ?????? ?????? ????? ?? ?? ????? ???? ????? ?????? ???? ??????. ?? ????????? ??? ?????? ????? ??"? ????? ?????. ?????? ???????? ?????? ??: ????? ???? ????? ?????? ?????, ????? ?????? ???????, ?????? ?????? ?????? ?????. ?? ????? ??? ??? ???????? ???????, ??? ???? ????? ????? ?? 48 ???? ????????. ???? ??? ???? ?????? US, ?? ?????????????. ???? ?????? ??????? ???? US, ?????? ?????? ??? ????? ?? ???? ????, ?????? ?? ?????, ?? ?????? ??? ?????, ????? ????? ?????? ???????? ???. ????? ?? ??? 10 ?? ????? ???? ???? ?????? ????? ?? ?????, ???? ???? ??? ?????? ????? ??? 4 ??. US ???? ?? ?????? ??????? ?? ????, ??????? ?????? ???? ????. ????? ??????????? ??????????, ???-???????, ??? ?????? ?????. ???? ????? ???????? ????????? ????? ????? ?????? ????. ???? ?? ?? ???? ???? ?????? ??????? ??????? ??????. ?????? ??? ???"? ?????? ?????? ???????? ??????? ?????? ?? ?????? ???????? ?? ???? 100%, ????? ????? ????? ???? ????? ??? ?????????????, ????? ?????? ?????? ??? US ??? ??? ??????. ???? ????? ???? ??????? ?"? ERCP ?? PTC, ????? ???????. ?????? ??? ?? ?????? ????? ????????, ????? ?????????? ????, ???? ?? ????? ?? ??? 2-5%. ERCP ???? ?????? ???????? ???????????? ??????. MRCP ??? ????? ????? ??? ??????????, ?? ???? ?????? ?????, ???? ????. ????? ????? ?????? ??? ?????? ???????? ??????, ????? CT ??? ?????? ?? US. ??? CT ???? ??? ????? ???? ???? ?? ??????, ????????, ?????? ???????? ?????? ????? ??? ??????. CT ???? ??? ????? ???? ?? ?? ????? ???? ???, ?? ???? ???? ?? ?????. HIDA (hepatobiliaty imino diacetic acid)- ?????? ????? ????? ?????? ??????????? ?????? ??????? ????? ?? ???? ????. ???? ????? ?????? ??????? ?? ?????? ????? ???? ??? ??????. ???? ????? ????? ????? ???????: ??? ? ???? ???? ? ??? ????. ??? ?????????. ???? ????? ???????? ???? ?????? ??. ???? ??????? ?? ?? ?????? ??? ????? ?? ?????? ???? ???? ????? ???? ???? ?????, ???? ?????? ?? ?????? ????? ????? ??????. ????? ???? ?????, ??? ?????? ??? ???? ??????? ??????? ???? ??? ?????? ???? ???? ??????? ???? ?? ??????. ???? ?????? ?????? ?????? ?????? ????? ?? ?? ????? ???? ????? ?????? ???? ??????. ?? ????????? ??? ?????? ????? ??"? ????? ?????. ?????? ???????? ?????? ??: ????? ???? ????? ?????? ?????, ????? ?????? ???????, ?????? ?????? ?????? ?????. ?? ????? ??? ??? ???????? ???????, ??? ???? ????? ????? ?? 48 ???? ????????. ???? ??? ???? ?????? US, ?? ?????????????. ???? ?????? ??????? ???? US, ?????? ?????? ??? ????? ?? ???? ????, ?????? ?? ?????, ?? ?????? ??? ?????, ????? ????? ?????? ???????? ???. ????? ?? ??? 10 ?? ????? ???? ???? ?????? ????? ?? ?????, ???? ???? ??? ?????? ????? ??? 4 ??. US ???? ?? ?????? ??????? ?? ????, ??????? ?????? ???? ????. ????? ??????????? ??????????, ???-???????, ??? ?????? ?????. ???? ????? ???????? ????????? ????? ????? ?????? ????. ???? ?? ?? ???? ???? ?????? ??????? ??????? ??????. ?????? ??? ???"? ?????? ?????? ???????? ??????? ?????? ?? ?????? ???????? ?? ???? 100%, ????? ????? ????? ???? ????? ??? ?????????????, ????? ?????? ?????? ??? US ??? ??? ??????. ???? ????? ???? ??????? ?"? ERCP ?? PTC, ????? ???????. ?????? ??? ?? ?????? ????? ????????, ????? ?????????? ????, ???? ?? ????? ?? ??? 2-5%. ERCP ???? ?????? ???????? ???????????? ??????. MRCP ??? ????? ????? ??? ??????????, ?? ???? ?????? ?????, ???? ????. ????? ????? ?????? ??? ?????? ???????? ??????, ????? CT ??? ?????? ?? US. ??? CT ???? ??? ????? ???? ???? ?? ??????, ????????, ?????? ???????? ?????? ????? ??? ??????. CT ???? ??? ????? ???? ?? ?? ????? ???? ???, ?? ???? ???? ?? ?????. HIDA (hepatobiliaty imino diacetic acid)- ?????? ????? ????? ?????? ??????????? ?????? ??????? ????? ?? ???? ????. ???? ????? ?????? ??????? ?? ?????? ????? ???? ??? ??????. ???? ????? ????? ????? ???????: ??? ? ???? ???? ? ??? ????. ??? ?????????.

13. ???? ?? 33, 3 ?????? ???? ????? ??????? ???. ?????? ?? ?????? ?????? ?? ???? ???. ???? ??? ??? ???? ???????????, ????. ??"? ??????? ??????? ???? ?????? ??????? ???? ??? ????? ??? ?? ???? ?-30 ????. ?????? ??? ????? ????? ???? (????? ????????????). ????? ???? ?????: ???? ?? 33, 3 ?????? ???? ????? ??????? ???. ?????? ?? ?????? ?????? ?? ???? ???. ???? ??? ??? ???? ???????????, ????. ??"? ??????? ??????? ???? ?????? ?????? ???? ??? ????? ??? ?? ???? ?-30 ????. ?? ?? ???? ?????? ????? ?????? ????? ????, ????? ??? ???? ????? ???????????? ??. ?????? ???? ????? ???? ???????? ????, ?????? ?????? ???. ????? ???? ?????: ???? ?? 33, 3 ?????? ???? ????? ??????? ???. ?????? ?? ?????? ?????? ?? ???? ???. ???? ??? ??? ???? ???????????, ????. ??"? ??????? ??????? ???? ?????? ?????? ???? ??? ????? ??? ?? ???? ?-30 ????. ?? ?? ???? ?????? ????? ?????? ????? ????, ????? ??? ???? ????? ???????????? ??. ?????? ???? ????? ???? ???????? ????, ?????? ?????? ???.

14. Gallstones 10-20% in Israel, specially Europe descendent. Risk Factors: Stasis, Hunger, Drugs, Pregnancy, overweight, diabetes. Cholesterol Gallstones (80%), pregnancy Risk. Brown pigment stones, Asia. Post TPN. Black pigment stones (calcium, bilirubin). Clinical findings: Biliary colic, Stasis, RUQ/Epigastric pain, nausea, Fever, jaundice-Sclerae. 80% asymptomatic (20 years). Complications: Cholecystitis, pancreatitis, ileus, Carcinoma, Choledocholithiasis, Ascending cholangitis (charcot triad). ???? ???. ?????? ?? ?????? ???? ???? ????????? ?????? ?? ??? 10-20%. ?????? ???? ????? ??????, ??? ???? ??????. ?-10% ????? ????? ?? ????? ?? ????? ????. ???? ????? ???? ????? ??????. ?????? ????? ???? ?? ????? ???? ??????. ????? ??????? ?? ???? ?????. ????? ????? ??????: ?????? (???? ?????? ????????? ?? ????? ???? ????), ??? ?? ???, ?????? ????? ??? ???????, ?????, ????? ???????? ?? ????? ?????? ?? ????????, ???????? ?????, ????? ???'... ????? ?????? ?? ???? ????????, ?-80%, ???? ???????? ???? ????. ?? ????? ????? ????? ??? ?????? ???? ???, ????? ?????? ????? ??? ?????: ??? ?"? ?-6 ?"?. ???? ?? ??????. ???????? ?? ???????? ????? ???? ????? ???? ?????????????? ????. ?? ?? ????? ????? ?? ?????? ?????? ??????? ?????? ?????. ???? ????? ?? ???????????? ?????? ??? ??? biliary colic ??????. ????? ?????? ??, ???? ?????? ???- ?????? ????? ???? ????. ?????? ????? ????? ????? (???? ???????? ???????) . ???? ?????? ???? (????, ?????????)- ????? ??????????, ???????, ??????? ????????, ????? ?????, ?????, ???? ???????. ????? CF ?? ?? ?? ????? ????? ??????. ?? ????? ???????? ??? billiary colic- ???? ????? (???? ??? ???, ???),??????? ?-CCK ?????, ????? ?????, ???? ??? ????? ???? ????. ??? ????? ????? ?-RUQ ?? ????????. ????? ?????. ????? ?? ????? ??? ?? ???? ?? ??? ???? (myoropson sign). ???? ???? ????? ?????? ???, ??????, ????. ???? ???? ?????? ????? (?? ??? ???? ???? ?????? ???? ?? ??????). ??? ???? (37.5), ???? ??? ???????. ???? ????? ?? ???? ?? ???? (2/3 ??? ???) ??"? ??????? ?? ?????? ??????? ?? ??????. ???? ?????? 80% ???? ?? ?????????? ???? ????? ?? ??????, ???? ????? ?? 20 ???. ??????? ?? ????? ???? ???? ??????: ??????????? � ???? ????? ?? ?????? ??? ???? ??????? ????? ??????? ???? ???????? ?????????, ???????????, ??????, ???????? , ????? ????? ??? -???????????????, ???? ?????? ????? ?????? ???? ?????. ??????????: ?????? ???? ????, ???? ??????? ?? ?????:??? ??? ????? ??????, ??? ???, ??? ???????? ?????. ??????? ???? ?????? ?? ???????, ???????? � ???????, secondary biliary cirrosis-?????? ?????, ???? ?????. ???? ??? ????? ???? ?-99% ??????? ?? ???? ?? ??? ????. ????? ??????? ?????? ?? ?????????? ?? ????? ?? ???? ???? ??? ??? ??? ???. ???????? ??? ??? ?????? ??? ??? 70 ?? ????? ?? ????? ??? ????, ???? ???? ???. ???? ???. ?????? ?? ?????? ???? ???? ????????? ?????? ?? ??? 10-20%. ?????? ???? ????? ??????, ??? ???? ??????. ?-10% ????? ????? ?? ????? ?? ????? ????. ???? ????? ???? ????? ??????. ?????? ????? ???? ?? ????? ???? ??????. ????? ??????? ?? ???? ?????. ????? ????? ??????: ?????? (???? ?????? ????????? ?? ????? ???? ????), ??? ?? ???, ?????? ????? ??? ???????, ?????, ????? ???????? ?? ????? ?????? ?? ????????, ???????? ?????, ????? ???'... ????? ?????? ?? ???? ????????, ?-80%, ???? ???????? ???? ????. ?? ????? ????? ????? ??? ?????? ???? ???, ????? ?????? ????? ??? ?????: ??? ?"? ?-6 ?"?. ???? ?? ??????. ???????? ?? ???????? ????? ???? ????? ???? ?????????????? ????. ?? ?? ????? ????? ?? ?????? ?????? ??????? ?????? ?????. ???? ????? ?? ???????????? ?????? ??? ??? biliary colic ??????. ????? ?????? ??, ???? ?????? ???- ?????? ????? ???? ????. ?????? ????? ????? ????? (???? ???????? ???????) . ???? ?????? ???? (????, ?????????)- ????? ??????????, ???????, ??????? ????????, ????? ?????, ?????, ???? ???????. ????? CF ?? ?? ?? ????? ????? ??????. ?? ????? ???????? ??? billiary colic- ???? ????? (???? ??? ???, ???),??????? ?-CCK ?????, ????? ?????, ???? ??? ????? ???? ????. ??? ????? ????? ?-RUQ ?? ????????. ????? ?????. ????? ?? ????? ??? ?? ???? ?? ??? ???? (myoropson sign). ???? ???? ????? ?????? ???, ??????, ????. ???? ???? ?????? ????? (?? ??? ???? ???? ?????? ???? ?? ??????). ??? ???? (37.5), ???? ??? ???????. ???? ????? ?? ???? ?? ???? (2/3 ??? ???) ??"? ??????? ?? ?????? ??????? ?? ??????. ???? ?????? 80% ???? ?? ?????????? ???? ????? ?? ??????, ???? ????? ?? 20 ???. ??????? ?? ????? ???? ???? ??????: ??????????? � ???? ????? ?? ?????? ??? ???? ??????? ????? ??????? ???? ???????? ?????????, ???????????, ??????, ???????? , ????? ????? ??? -???????????????, ???? ?????? ????? ?????? ???? ?????. ??????????: ?????? ???? ????, ???? ??????? ?? ?????:??? ??? ????? ??????, ??? ???, ??? ???????? ?????. ??????? ???? ?????? ?? ???????, ???????? � ???????, secondary biliary cirrosis-?????? ?????, ???? ?????. ???? ??? ????? ???? ?-99% ??????? ?? ???? ?? ??? ????. ????? ??????? ?????? ?? ?????????? ?? ????? ?? ???? ???? ??? ??? ??? ???. ???????? ??? ??? ?????? ??? ??? 70 ?? ????? ?? ????? ??? ????, ???? ???? ???.

15. Diagnosis: US first (95% in gallbladder). CT ( Less than 75%), Not good for cholesterol stones. MRCP. EUS. Considered as best, but invasive. ERCP. Other DD. ????? ??????: ????? ?????? ?????? ??? US. ???? ????? ????, ????, ????? ????? ????? ???? ??? ?????. ?? ?? ?????? ?? 95% ???? ????. ?????? ??? ????? ???? ?? ??????? ????? ???? (40-60%). ??? ??? ??? CT- ??? ?? ?? ?????? ????? (???? ?-75%), ?? ???? ???? ???????? (?????? ??? ????). ???? ?? ?? ?? ??????????. ?? ????? ????? ???? ???? CT ???? ???? ?? ???? ,?????? ?? ?-CT ??? ?????? ?? ????? ????? ???? ?? ???? ?????. MRCP- ???? ????? ????? ?????. EUS- ??? ???? ?????? ??? ???-???????. ERCP- ???? ???????. ???? ????? ?????? ???? ?????? ?? ??????, ??? ??????, ?????, ????. {?????? ?????}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{?????? ?????} ?? ???? ?? ?? ??????? ??"? ???? ???????? ????? ???: ??????, ?? ????? ?????? ???? ?? ?????? ?????? ??????- ????? ??? ????? ???? ????? ?????? ????? ????? ?????? ??? ?????????. ?? ???? ??? ???? ????? ??????. ??? ?? ??? ??? ?????- ???? ????? ??? ?????, ?????? ??"? ???? ???? ??? ???????

16. ???? ????? ?????? ?????? ???? ?? ?????. ????? ??? ???? ERCP, ?? ??? ????? ????? ??? ???? ???????. ??? ???? ?????? US. ???? ??? ???? CT.???? ????? ?????? ?????? ???? ?? ?????. ????? ??? ???? ERCP, ?? ??? ????? ????? ??? ???? ???????. ??? ???? ?????? US. ???? ??? ???? CT.

17. Treatment: Lap. Surgery :?????? ?-100% ???????, ??????? ??????: ??? ????? ????, ?????????, ????, ?????? ????? ??????. ????? ?? 1.2%-0.5%. ??????? ?? ???? ???? ??????. ???? ?? ??????. ERCP. ????? ??????: ????? ????????? ?????? ??? ???? � ?????????. ?????? ?-100% ???????. ???? ???? ????? ???? 24-48 ????. ??????? ??????? ??????? ????? ?????? ???? ?????? ????? ????? ????, ?????????, ????, ?????? ????? ?????. ?? ?????? ?? ????? ?????? ?????. ?????? ????? ????? 1.2%-0.5% ???? ?????? ?????, ????? ???? ???????? ??????. ???? ?????? ????? ???? ?? ?????? ???? ???, ?????? ??? ?? ????, ?? ???? ??????? ?? ????, ?-5% ??????? ???? ??????? ???? ??. ????? ???? ??? ???? ?? ?????? URSO/chenodeoxycholic acid . , ?? ????? ???????? ????? ?????? ????. ???? ????? ????? ?????? (??? ???) ??? ????? ????. ????? ???? ?????? ????? ???? ??? ?-ERCP. ????? ??????: ????? ????????? ?????? ??? ???? � ?????????. ?????? ?-100% ???????. ???? ???? ????? ???? 24-48 ????. ??????? ??????? ??????? ????? ?????? ???? ?????? ????? ????? ????, ?????????, ????, ?????? ????? ?????. ?? ?????? ?? ????? ?????? ?????. ?????? ????? ????? 1.2%-0.5% ???? ?????? ?????, ????? ???? ???????? ??????. ???? ?????? ????? ???? ?? ?????? ???? ???, ?????? ??? ?? ????, ?? ???? ??????? ?? ????, ?-5% ??????? ???? ??????? ???? ??. ????? ???? ??? ???? ?? ?????? URSO/chenodeoxycholic acid . , ?? ????? ???????? ????? ?????? ????. ???? ????? ????? ?????? (??? ???) ??? ????? ????. ????? ???? ?????? ????? ???? ??? ?-ERCP.

18. Cholecystitis Stone & bacterial infection (Ecoli, klebsiella, Strep. , clostridium). Ischemia. Usually repeating event, more painful, Fever, nausea, vomiting, murphy�s sign, palpable mass. Treatment with cholecystectomy and antibiotics. Complications: empyema, perforation, peritonitis, fistula, carcinoma, sepsis, illeus. ???????????. ????? ?? ????????? ?"? ??"? ??? ????? + ????? ?????? ?????? (escherichia coli, klebsiella, streptococcus, clostridium ). ?? ?????, ???? ?????? ?????? (????? ?? ????? ????), ??? ????, ???? ???? ????? ?? ????? ?????? ??? ????? ???? ??? ??????? ?????? ????? ????. ??????? ?????? ????? (?? ??? ?? ????) ??????? ?????? ?? ??????? ?????, ?? ????????????? ???? ???? (????? ??60% ????? ??? 5 ????). ???? ???? ???? ??? (?-RUQ ???????????). ?? ???, ?????, ????, ???? ????, ??? ??????. ?? ?????? ?? ?????? ???? ??"? ??????, ??? ????? US ?? HIDA ??? ????? ?? ?????? ??????. ??????? ?? ???? ????????????. ?????? ?????? ??? ???????. ????? ????? ??? ???"? ??? ????? ????????? ?????. ?-CT ????? ???? ?????? ????, ???? ?????, ???? ????? ?? ???? ??? ??????. ?????? ????? ????? ????? ????? ???? ????. ???? ????? ??? ??? ????????. ?????? ?????? ??????????? ?? ??? ???? ?????? ????????? ???????????. ???? ????? ???? ???. ????? ????? ????????? ???? ??? ???? ????? ???? ?? ??????. ???????? ?? ???? ???????: ???????, ????????, ??????????, ???????, ????????, ?????, ??????. ???????????. ????? ?? ????????? ?"? ??"? ??? ????? + ????? ?????? ?????? (escherichia coli, klebsiella, streptococcus, clostridium ). ?? ?????, ???? ?????? ?????? (????? ?? ????? ????), ??? ????, ???? ???? ????? ?? ????? ?????? ??? ????? ???? ??? ??????? ?????? ????? ????. ??????? ?????? ????? (?? ??? ?? ????) ??????? ?????? ?? ??????? ?????, ?? ????????????? ???? ???? (????? ??60% ????? ??? 5 ????). ???? ???? ???? ??? (?-RUQ ???????????). ?? ???, ?????, ????, ???? ????, ??? ??????. ?? ?????? ?? ?????? ???? ??"? ??????, ??? ????? US ?? HIDA ??? ????? ?? ?????? ??????. ??????? ?? ???? ????????????. ?????? ?????? ??? ???????. ????? ????? ??? ???"? ??? ????? ????????? ?????. ?-CT ????? ???? ?????? ????, ???? ?????, ???? ????? ?? ???? ??? ??????. ?????? ????? ????? ????? ????? ???? ????. ???? ????? ??? ??? ????????. ?????? ?????? ??????????? ?? ??? ???? ?????? ????????? ???????????. ???? ????? ???? ???. ????? ????? ????????? ???? ??? ???? ????? ???? ?? ??????. ???????? ?? ???? ???????: ???????, ????????, ??????????, ???????, ????????, ?????, ??????.

19. Hyperplastic cholecystoses �Polyp�, usually made of cholesterol. strawberry gallbladder. Surgery only when symptomatic. Adenoma. ?????????? ???????????: ????? ????? ??????? ???? ?????. ???? ?????, ???? ???? ????????, ??? ???? ?????? ????? ??????? ???? ????? ?????? ????? ???? ????- " strawberry gallbladder. ??? ???? ???????? ?????? ??? ??? ?????? ????? ???????? ????? ?? ???? ????????. ?????? ?? ??? ???? ??????????? ?? ???? ????? ????? ????. ??????: ????? ?? ???????????? ????? ??????. ???? ?? ?"? ??? ?????. ???????? ?? ?? ?? ????? ????? ????????. ??????? ?? ?? ??? ????? US. ?????????? ???????????: ????? ????? ??????? ???? ?????. ???? ?????, ???? ???? ????????, ??? ???? ?????? ????? ??????? ???? ????? ?????? ????? ???? ????- " strawberry gallbladder. ??? ???? ???????? ?????? ??? ??? ?????? ????? ???????? ????? ?? ???? ????????. ?????? ?? ??? ???? ??????????? ?? ???? ????? ????? ????. ??????: ????? ?? ???????????? ????? ??????. ???? ?? ?"? ??? ?????. ???????? ?? ?? ?? ????? ????? ????????. ??????? ?? ?? ??? ????? US.

20. Pancreatic Tumor ????? ?????? ?????????, ????? ???????? ?? ???? ????? 70%, ?????? ???? ?????. ?? 2 ??????, ??? ????? 55 , ??? ????? ?????. ????? ??????: ?????, ????? ????? ??????, ???? ?????? ?????, ????. ????? ???????, ????? ????? ?????. 1. ????? ?????? 2. ????????????? ??????????? 3.??? ???? ????? 4. ??????? ????????. ?????: ????? ??-????? ?? ???? ?????. ????? ?? ????? ????? ???? ?????????, ????? ?????? ??? ?????? ?????? ??????: ????? ??????? ????? (???? ????? ??????) ; ??????? ?? ????? ; ????? ?? ???? ??? ?????. ????? ?????. ????? ?? ????? ?? ????? ??????? ?????? ?????. ???? ?????? ??? ?????? ??????????. ??? ???????? ?? ???? ????? (70%) ??? ?????? ???? ????? ???? ????? (2-3 ?"?). ?? 2 ??????. ??? ????? 55, ??? ????? ?-7. ). ????? ?????: ?????, ????? ????? ??????, ???? ?????? ?????, ????. ???? ????? ??? ???? ????? ?? ????? ??????? ?????? ????? ??? ???"? ????. ???????: 1.???? ?????? ??? ????? ?????? 2. ????? ??? ?????? ??? ?????? ?? ????? ???? ?? ????? 3. ??? ???? ???? 4. ??? ?? ???????? ??????? ???? ?? ?????? (???????? ???? ?? ????) �?????? ?? ????? ????? ?????, ?"? ???? ????? ????????. ???? ???? ?????? , ?????????? ??????. (20?40?70). ????? ????? ?? ????? ????? ???? ????????? ???? ????? ?????? ?????, ???? ???. ????? ??????? ??? ?????? ?????? ??????: ????? ????? ?????, ????? ???? ????? ???? ???? ????. ??????? ?????? ????? ?? ??????, ?????? ?? ???? ??? ?????. ????? ?????. ????? ?? ????? ?? ????? ??????? ?????? ?????. ???? ?????? ??? ?????? ??????????. ??? ???????? ?? ???? ????? (70%) ??? ?????? ???? ????? ???? ????? (2-3 ?"?). ?? 2 ??????. ??? ????? 55, ??? ????? ?-7. ). ????? ?????: ?????, ????? ????? ??????, ???? ?????? ?????, ????. ???? ????? ??? ???? ????? ?? ????? ??????? ?????? ????? ??? ???"? ????. ???????: 1.???? ?????? ??? ????? ?????? 2. ????? ??? ?????? ??? ?????? ?? ????? ???? ?? ????? 3. ??? ???? ???? 4. ??? ?? ???????? ??????? ???? ?? ?????? (???????? ???? ?? ????) �?????? ?? ????? ????? ?????, ?"? ???? ????? ????????. ???? ???? ?????? , ?????????? ??????. (20?40?70). ????? ????? ?? ????? ????? ???? ????????? ???? ????? ?????? ?????, ???? ???. ????? ??????? ??? ?????? ?????? ??????: ????? ????? ?????, ????? ???? ????? ???? ???? ????. ??????? ?????? ????? ?? ??????, ?????? ?? ???? ??? ?????.

21. ??? ?????? ???? ????? ??? ??? ???? ?? ?????? ???? ??????, ???? ???? ????????, ????? ?????.??? ?????? ???? ????? ??? ??? ???? ?? ?????? ???? ??????, ???? ???? ????????, ????? ?????.

22. ???? ?????: ??????? ????????, ????? ??????? ??????, ?????? � ????? ???????, ???, ?????. ??????? ?? ?????? ???? ????? Whipple. ??????? ???????: SMA, SMV, ???? ?????? ???'... 20% ????????? ?????? ??????. ????? ?? 5% ?????? Whipple. ???? ?????? ????? ?? ??????? ???????? ?? ??????, ????? ??????? ??????, ?????? ???'... ?????? ??????? ?? ?????? ?? ????? ????? ????? ?????. ???? ?????? ?????? ?? ?-SMA, SMV, ????? ??????? ??-celiac ?? ?????? ???? ????. ?? ??? ??? ????? ?? ?? ???? ????. 20% ????????? ???? ????? ?? ??????. ????? ????? ?? 5%. ???? ?????? ????? ?? ??????? ???????? ?? ??????, ????? ??????? ??????, ?????? ???'... ?????? ??????? ?? ?????? ?? ????? ????? ????? ?????. ???? ?????? ?????? ?? ?-SMA, SMV, ????? ??????? ??-celiac ?? ?????? ???? ????. ?? ??? ??? ????? ?? ?? ???? ????. 20% ????????? ???? ????? ?? ??????. ????? ????? ?? 5%.

23. Ampulary Tumor Malignant epithelial tumor , ampula of vater. Presents with jaundice, weight loss. Abd or back pain Age: mean 65 yrs, no sex predeliction Prognosis: depends on nodal status and differentiation of tumor, better than panc ca. 5 yrs- 50% if resected Treatment: pancreaticoduodenectomy Double duct sign. (CT) ????? ???????, ?????? ?? ???????????? ??????? ?? ????. ?? ????? ??? ????? ?? ????? ????? ????? ??? ????? ???? ?? ??? ???. ????? ???? ????? ??? (????? ????, ????, ??? ?? ?? ???) ??? ???? ???? ???? ????? ???? ????? ????. ??? ????? ????? ???????? ?? ?????? ?? ????. ????????? ?? ???? (???? ???? ????? ????) ?????? ????????? ???????? ?????? ?????. ????? ????? ?? ????? ????? ??????????. ??????? ?-5 ???? 50% ???? ?????, ????? ???? ??????. ?????? ?????? ?????? ??????- double duct sign- ????? ?? ??? ???????? ??????? ????????? ???? ???????? ?? ???? ??? ?? ?????? ???????.????? ???????, ?????? ?? ???????????? ??????? ?? ????. ?? ????? ??? ????? ?? ????? ????? ????? ??? ????? ???? ?? ??? ???. ????? ???? ????? ??? (????? ????, ????, ??? ?? ?? ???) ??? ???? ???? ???? ????? ???? ????? ????. ??? ????? ????? ???????? ?? ?????? ?? ????. ????????? ?? ???? (???? ???? ????? ????) ?????? ????????? ???????? ?????? ?????. ????? ????? ?? ????? ????? ??????????. ??????? ?-5 ???? 50% ???? ?????, ????? ???? ??????. ?????? ?????? ?????? ??????- double duct sign- ????? ?? ??? ???????? ??????? ????????? ???? ???????? ?? ???? ??? ?? ?????? ???????.

24. Cholangiocarcinoma Cholangio-cellular carcinoma, arises from the IHBD or EHBD epithelium. 2ND most common primary hep tumor. Age: 6-7th decade, . Risk: biliary lithiasis, clonorchiasis, rec. pyogenic infections, PSC? IBD, caroli/Lynch disease, choledochal cyst, BD papilomatosis,alpha-1 anti-tripsin. D. Presentation: by location,jaundice, weight loss, abd pain, palpable mass., Fever, hepatomegaly, ALP, CEA, CA19-9 (80%). US, Doppler, CT, MRCP, ERCP, PTC?Biopsy. ????????????????, ????? ????? ????. ???????? ?? ???? ???? ?????? ?????? ?? ???? ????. ??? ???? ????? ???? ???? ???? ???? ?????? ?? ?-??? ??????, common bile duct, ??? ???? ????? ???? ?????????? ?? Hepatic Duct. ?? ?????? ?????? ?-2 ???????? ????. ????? ??????? ????? ????? 6-7 , ??? ???? ??? ???? ??????. ????? ?? 3% ??????? ?-GI. ????? ?????? ??????: ?????, ??????, ??????, ????????, PSC (?????? ?? UC), ???? (???????????, caroli, Lynch, ???????? ?? ?????? ?????? ?- ???, ??? ???, ????? ????, ????, ??? ???, ???? ?????, ???, ??????, ?????????, ALP ????. CEA ?-CA-19-9 ???? ?-80% ??????? (???? ??????- ) , ????? ?? ????? ???? ??????. US: ????? ????? ?? ???? ???? ?????? ??? (??????????), ???? ???? ????? ???? ?????? ??????? ??? ??. CT: ??? ?????????, ????? ?? ???? ???? ?? ?????? ???'... ?????????????, ERCP u-, PTC, ?????? ???? ????? ?????????? ????????. ????????????????, ????? ????? ????. ???????? ?? ???? ???? ?????? ?????? ?? ???? ????. ??? ???? ????? ???? ???? ???? ???? ?????? ?? ?-??? ??????, common bile duct, ??? ???? ????? ???? ?????????? ?? Hepatic Duct. ?? ?????? ?????? ?-2 ???????? ????. ????? ??????? ????? ????? 6-7 , ??? ???? ??? ???? ??????. ????? ?? 3% ??????? ?-GI. ????? ?????? ??????: ?????, ??????, ??????, ????????, PSC (?????? ?? UC), ???? (???????????, caroli, Lynch, ???????? ?? ?????? ?????? ?- ???, ??? ???, ????? ????, ????, ??? ???, ???? ?????, ???, ??????, ?????????, ALP ????. CEA ?-CA-19-9 ???? ?-80% ??????? (???? ??????- ) , ????? ?? ????? ???? ??????. US: ????? ????? ?? ???? ???? ?????? ??? (??????????), ???? ???? ????? ???? ?????? ??????? ??? ??. CT: ??? ?????????, ????? ?? ???? ???? ?? ?????? ???'... ?????????????, ERCP u-, PTC, ?????? ???? ????? ?????????? ????????.

25. Treat: surgical resection , radiation, chemo, stenting. 5 YS: 5-10% without surgery, 10-30% with. ?????? ???? ????? ???? ??? ???-??????, ??? ??? ??????? ????? ?? ?? ??? ????? ??????????. ?????: ?-PSC ????????? ?????? ???? ????. ??????? ?????? ?? ????? ????? ????? ??????? ?????? ????? ?????, ????? ?????????? ?????? ???? ?????? ?????? ???? ??????? ?????? ?? 10 ??????, ???? ?? ???? ????? ???????? ????? ??? ????????. ??????? ?-5 ????: ??? ????? 5-10%, ?? ????? 10-30%. ?????? ???? ????? ???? ??? ???-??????, ??? ??? ??????? ????? ?? ?? ??? ????? ??????????. ?????: ?-PSC ????????? ?????? ???? ????. ??????? ?????? ?? ????? ????? ????? ??????? ?????? ????? ?????, ????? ?????????? ?????? ???? ?????? ?????? ???? ??????? ?????? ?? 10 ??????, ???? ?? ???? ????? ???????? ????? ??? ????????. ??????? ?-5 ????: ??? ????? 5-10%, ?? ????? 10-30%. ?????? ???? ????? ???? ??? ???-??????, ??? ??? ??????? ????? ?? ?? ??? ????? ??????????.

26. Gallbladder Adenocarcinoma Risk: Chronic Gallstones: 70-90% presence Estrogens / Female sex / Obesity 75% older than 65y Choledocal cyst Salmonella typhi carriers Porcelain gallbladder (neglected cholecystitis) Carcinogens Gallbladder polyps Smoking, Alcohol consumption PSC ????? ?? ??? ????. ????? ????? ??????: ????? (?-70-90% ???????), ????? ???? ??????? ?? �??, ?????????, ?????, ???, 75% ??????? ??? ??? 65, ??????, ????? ?? ??????? ?????, ????- ???????????? ??????? ????????? ????? porcelain gallbladder ???????? ????? ???? ?? ?????? ?????? ?????? ?? ???????? ?-25% ??????? ???? ????? ????????, ???-?? ?????? ?????? ?? ??????????, ???????, ?????, ???????, PSC. ???? ???? ????? ???? ????? ?? 2, ?????? ???????? ?????? ???????? ?????????. Clostridium perfringens ???? ?????? ????????????? ????? ??????. ????? ?? ??? ????. ????? ????? ??????: ????? (?-70-90% ???????), ????? ???? ??????? ?? �??, ?????????, ?????, ???, 75% ??????? ??? ??? 65, ??????, ????? ?? ??????? ?????, ????- ???????????? ??????? ????????? ????? porcelain gallbladder ???????? ????? ???? ?? ?????? ?????? ?????? ?? ???????? ?-25% ??????? ???? ????? ????????, ???-?? ?????? ?????? ?? ??????????, ???????, ?????, ???????, PSC. ???? ???? ????? ???? ????? ?? 2, ?????? ???????? ?????? ???????? ?????????. Clostridium perfringens ???? ?????? ????????????? ????? ??????.

27. Fifth most common GI malignancy. Incidental finding in lap. excised gallbladders. Patients in early stages show signs and symptoms that mimic cholelithiasis and/or cholecystitis. weight loss, hepatomegaly, and jaundice, which are considered poor prognostic signs. Duodenal or colonic obstruction or cholecystenteric fistula may signal GB carcinoma . Typically unresectable at presentation Prognostic is poor with the exception of early-stage cases. Overall mean survival rate of 6 months, and the 5-year survival rate is 5%. In locally advanced gallbladder cancer, radical surgery with negative tumor margins is an accepted treatment. ????? ?????? ???????? ?-GI. ?????? ?????? ???? ????? ???? ?????? ??? ???. ?????? ??????? ?????? ?????? ?????? ?????? ????? ???? ??? ??? ?? ????????????. ?????? ??????? ???? ?????? ????? ????, ?????????, ???? (?????? ???????? ?????). ???? ??????? ?? ??????? ?? ????? ???. ???? ?????? ??? ?????? ??????? ????? ?????? ?? ????? ????? ???? ????, ????? ?????? ???? ??????? ????? ?? ?????? ?? ???? ???????, ???? ???? ?????? ???? ???? ?? ????? ?? ??? ???? ??????? ??? ????. ?? ????? ????????? ??? ????? ???? ????? ???????. ??????? ?????? ?? ?????? ??? 6 ?????? ????. 5 year survival rate ??? 5%. ??????? ?????? ??? ????? ???????? ?? ??????, ????????? ???? ??? ?-Staging ???. ????? ?????? ???????? ?-GI. ?????? ?????? ???? ????? ???? ?????? ??? ???. ?????? ??????? ?????? ?????? ?????? ?????? ????? ???? ??? ??? ?? ????????????. ?????? ??????? ???? ?????? ????? ????, ?????????, ???? (?????? ???????? ?????). ???? ??????? ?? ??????? ?? ????? ???. ???? ?????? ??? ?????? ??????? ????? ?????? ?? ????? ????? ???? ????, ????? ?????? ???? ??????? ????? ?? ?????? ?? ???? ???????, ???? ???? ?????? ???? ???? ?? ????? ?? ??? ???? ??????? ??? ????. ?? ????? ????????? ??? ????? ???? ????? ???????. ??????? ?????? ?? ?????? ??? 6 ?????? ????. 5 year survival rate ??? 5%. ??????? ?????? ??? ????? ???????? ?? ??????, ????????? ???? ??? ?-Staging ???.

29. Pancreatic pseudocyst Collection of fluid, enzymes, and necrotic tissue. In pancreas, or in the Lesser Sac. Walls from inflammatory fibrosis of peritoneal, mesenteric, serosal membranes. Without epithelium lining. Usually as comp. from pancreatits, doesn�t subside after cure. Failure to recover from panc. Palpable mass in epigastrium, Pain, Fever, Weight loss, tenderness. Jaundice. CT may discover before any symptoms or signs appear. Spontaneous resolution (40%), Drainage, Cystogastrostomy. ???? ?? ???? ???? ???????? ?????? ????, ??????? ????? ?? ?-Lesser sac, ?????? ?????? ?? ??????? ????? ???? ????. ?????? ?????? ?????? ?????? ?? ??????? ??????????: ?? ???????????, ???????? ???????? ??????? ???????? ?? ?????? ???????. ??? ???? ????????? ???? ?????? ???????. ???? ?????? ?????? ?????????????, ???? ?? ????? ?? ??????? ????? ??? ??? ???? ???? ??????. ????? ?????? ???? ?????. 2% ????? ???????????? ????? ????? ?????, ???? ????? ??? ?-85%, ?? ???? ????? ???? ??????. ????? ?????? ????? ?? ???? ????? ?????? ?????????????, ???? ???? ???? ???? ??????? ????? ????????, ????? ????? ?????. ????? CT ??? ???????? ?????? ????? ???? ??????? ?????? ??????, ????? ?????? CT ??? ?????? ?????? ?? ???????????, ???? ???? ????? ????. ?????? ?????? ????? ????? ?-50% ??????? ?? ??? ??, ???, ????? ????, ??????, ?????? ??? ?? ?????? ????? ???? ?????? ????? ?-Bile Duct ????? ?????. ??????? ????? ???? ????? ?????? ?????, ????????????, ????????? ?????. ??? ???????? ?? ????? ????? ??????? ?? ???? ????? ???? ??? ?????? (40% ???????), ?????? ???? ?????? ??????? ??? 5 ?"?, ??? ???? ????, ?? ?????? ??????????? ?? Open Cystogastrostomy< ???? ?? ???? ???? ???????? ?????? ????, ??????? ????? ?? ?-Lesser sac, ?????? ?????? ?? ??????? ????? ???? ????. ?????? ?????? ?????? ?????? ?? ??????? ??????????: ?? ???????????, ???????? ???????? ??????? ???????? ?? ?????? ???????. ??? ???? ????????? ???? ?????? ???????. ???? ?????? ?????? ?????????????, ???? ?? ????? ?? ??????? ????? ??? ??? ???? ???? ??????. ????? ?????? ???? ?????. 2% ????? ???????????? ????? ????? ?????, ???? ????? ??? ?-85%, ?? ???? ????? ???? ??????. ????? ?????? ????? ?? ???? ????? ?????? ?????????????, ???? ???? ???? ???? ??????? ????? ????????, ????? ????? ?????. ????? CT ??? ???????? ?????? ????? ???? ??????? ?????? ??????, ????? ?????? CT ??? ?????? ?????? ?? ???????????, ???? ???? ????? ????. ?????? ?????? ????? ????? ?-50% ??????? ?? ??? ??, ???, ????? ????, ??????, ?????? ??? ?? ?????? ????? ???? ?????? ????? ?-Bile Duct ????? ?????. ??????? ????? ???? ????? ?????? ?????, ????????????, ????????? ?????. ??? ???????? ?? ????? ????? ??????? ?? ???? ????? ???? ??? ?????? (40% ???????), ?????? ???? ?????? ??????? ??? 5 ?"?, ??? ???? ????, ?? ?????? ??????????? ?? Open Cystogastrostomy<

30. Chronic Pancreatitis. Malignant involvement of porta hepatis lymph nodes. ????? ?????? ??????? ????? ????? ??? ?????? ??? ?? ????, ??????? ??????: ??????????? ????? ????? ????? ?????. ???????? ??????? ?? ?????? ?????? ?????, ??? ????, ?????? ?????? ?? ???? ????. ????? ?????? ??????? ????? ????? ??? ?????? ??? ?? ????, ??????? ??????: ??????????? ????? ????? ????? ?????. ???????? ??????? ?? ?????? ?????? ?????, ??? ????, ?????? ?????? ?? ???? ????.