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1、黄疸黄疸-09-09级一系级一系- -老年老年- -麻醉麻醉- -救援救援- -心理心理- -陶小红陶小红-12-04-18(1)-12-04-18(1)n nJaundice or icterus : Jaundice or icterus : What is jaundice ?n nClinically it is the yellow discoloration of the n nSclera Sclera ( (巩膜巩膜) ) n nSkinSkinn nMucous membraneMucous membranedue to deposition of bile pigment
2、(bilirubinbilirubin胆红素胆红素) ) n nSerum total bilirubin (normal 1.7-17.1 umol/lit )Conjugated bilirubin:0-3.42mol/lConjugated bilirubin:0-3.42mol/l，Unconjugated bilirubin:1.7-13.68mol/l.Unconjugated bilirubin:1.7-13.68mol/l.1. DEFINITION2. BILIRUBIN METABNISMHeme DegradationHEMEBILIVERDINO2Fe+3NADPHNA
3、DP+(opens the porphyrin ring)BILIRUBINNADPHNADP+BILIRUBIN diglucuronideBILEThe Fate of BilirubinAlb = albuminB = bilirubinGST = glutathione-S-transferaseUDPGA = uridine diphosphoglucuronic acid; CB = conjugated bilirubinUGT1A1 = UDP-glucuronosyltransferase 1A1MRP2 = Multi-drug Resistance Protein 2 A
4、dapted from Harrisons 15th Ed. “Principles of Internal Medicine”, 2001.MRP2B B+ GST+ GSTCBCBPlasmaHepatic CellBileAlbAlbB BAlbAlb?:GSTB BsERB B+ UDPGAUGT1A1Bilirubin ExcretionIntestinesLiverB BCBCBCBCBB BUrobilinogenB-glucoronidasebacteriabacteriaBileEnterohepatic circulationKidneyUrobilinoxUrobilin
5、ogenUrobilinStercobilinStercobilingogenfecesUrineoxLiverAlbuninHemeFerrohemetransferase BilirubinConjugated bilirubinKidneyUrobilinStercobilinogenUrobilinogenIntestinesAlbuminBilirubinreductaseHemeGlobinHemoglobinoxidase BiliverdinMarrowInfantility ErythrocyteFerroheme Enzyme15%20%Bilirubin |Albumin
6、Erythrocyte80%85%UDP UDPGABilirubin glucuronolactoneurobilinogenEnterohepatic circulation Y/Z protein cathepsin ErythrocyteBiochemical change of Normal bilirubin metabolism3. CLASSFICATION1. Depending on Etiology1. Depending on Etiologyn nHemolytic JaundiceHemolytic Jaundice（溶血性黄疸）（溶血性黄疸）（溶血性黄疸）（溶血性
7、黄疸）n nHepatocellular Hepatocellular JaundiceJaundice（肝细胞性黄（肝细胞性黄（肝细胞性黄（肝细胞性黄疸）疸）疸）疸）n nCholestatic JaundiceCholestatic Jaundice（胆汁淤积性黄疸）（胆汁淤积性黄疸）（胆汁淤积性黄疸）（胆汁淤积性黄疸）n nCongenital jaundiceCongenital jaundice（先天性黄疸）（先天性黄疸）（先天性黄疸）（先天性黄疸） 2. Depending on bilirubin2. Depending on bilirubinn nUnconjungated
8、bilirubin Unconjungated bilirubin increased jaundiceincreased jaundicen nConjungated bilirubin Conjungated bilirubin increased jaundiceincreased jaundicen nEtiologyEtiologyn n1.Congenital hemolytic anemia (1.Congenital hemolytic anemia (thalassemia(thalassemia(海洋性贫血海洋性贫血) ), ,hereditary spherocytosi
9、s(hereditary spherocytosis(遗传性球形红细胞增多症遗传性球形红细胞增多症).).n n2.P2.Posteriority acquired hemolytic anemia (autoimmunity osteriority acquired hemolytic anemia (autoimmunity hemolytic anemia, hemolytic disease of newborn,hemolytic anemia, hemolytic disease of newborn, posttransfusion hemolytic, Favism(postt
10、ransfusion hemolytic, Favism(蚕豆病蚕豆病) ). .n nMechanismMechanismn nA large number of erythrocyte destroyed rapidlyA large number of erythrocyte destroyed rapidlyn nAnemia,hypoxia and toxity of erythocyte metabolism productsAnemia,hypoxia and toxity of erythocyte metabolism products3.1. Hemolytic Jaund
11、iceHemolytic Jaundice mechanismn nClinical ManifestationClinical Manifestation n nMild jaundice, light lemon, no skin itch(Mild jaundice, light lemon, no skin itch(痒痒). ).n nAcute hemolysis: fever, chill, headache, vomit, backache, Acute hemolysis: fever, chill, headache, vomit, backache, anemia, he
12、moglobinuria(anemia, hemoglobinuria(血红蛋白尿血红蛋白尿), acute renal failure.), acute renal failure.n nChronic hemolysis: anemia and splenomegaly(Chronic hemolysis: anemia and splenomegaly(脾大脾大). ).n nLaboratory ExaminationLaboratory Examination n n1.Serum TB,UCB,CB normal.1.Serum TB,UCB,CB normal.n n2.UCBi
13、ntestinal CBfaecal color deepen.2.UCBintestinal CBfaecal color deepen.n n3.Intestinal Urobilinogen(3.Intestinal Urobilinogen(尿胆原尿胆原)urinary Urobilinogen.)urinary Urobilinogen.n n4.Acute hemolytis, occult blood test (+).4.Acute hemolytis, occult blood test (+).n n5.Blood test: anemia, reticulocyte(5.
14、Blood test: anemia, reticulocyte(网织红细胞网织红细胞), erythrocyte ), erythrocyte proliferation. proliferation. 3.2. Hepatocellular Jaundice3.2. Hepatocellular Jaundicen nEtiologyEtiologyn nHepatocyte damage.Hepatocyte damage.n nMechanismMechanismn nImpair hepatocyte uptakeing, conjugating and excreting Impa
15、ir hepatocyte uptakeing, conjugating and excreting bilirubin, UCBbilirubin, UCBn nCB reflux into blood, serum CBjaundice.CB reflux into blood, serum CBjaundice.Hepatocellular Jaundice mechanismn nClinical ManifestationClinical Manifestation n nSkin and mucosa: light to deep yellow, mild skin itchSki
16、n and mucosa: light to deep yellow, mild skin itch( (痒痒) )n nTired, loss of appetiteTired, loss of appetiten nhemorrhagic tendency, ascites, coma.hemorrhagic tendency, ascites, coma.n nPrimary disease manifestationPrimary disease manifestationn nLaboratory ExaminationLaboratory Examination 1. 1.CB,
17、UCBCB, UCB2. 2.IctericIcteric hepatitis: CB UCB hepatitis: CB UCB 3. 3.Urine: Urine: CB(+),urobilinogenCB(+),urobilinogen 4. 4.Blood test: liver damaged Blood test: liver damaged 3.3. Cholestatic Jaundice 3.3. Cholestatic Jaundicen nEtiologyEtiologyn nObstruction in liver:virus hepatitis,drug caused
18、,drug hepatitis, Obstruction in liver:virus hepatitis,drug caused,drug hepatitis, primary biliary cirrhosis.primary biliary cirrhosis.n nObstruction of Extrahepatic bile duct:narrow, obstruction,stone, Obstruction of Extrahepatic bile duct:narrow, obstruction,stone, inflammtory,tumor.inflammtory,tum
19、or.n nMechanismMechanismn nObstruction causes small bile duct and bile capillary broken, Obstruction causes small bile duct and bile capillary broken, conjugated bilirubin reflux to blood.conjugated bilirubin reflux to blood.n nFailure of hepatocyte excreting CB,bilirubin deposit and bile Failure of
20、 hepatocyte excreting CB,bilirubin deposit and bile thrombus(thrombus(胆栓胆栓) formation.) formation.Cholestatic Jaundice mechanismn nClinical ManifestationClinical Manifestationn nSkin dark yellow, yellow green.Skin dark yellow, yellow green.n nSkin itch Skin itch ( (痒痒) ), bradycardia (, bradycardia
21、(心动过缓心动过缓), dark ), dark yellow of urine, faecal light yellow or clay yellow of urine, faecal light yellow or clay color. color. n nCourvoisiers sign.Courvoisiers sign.n nLaboratory ExaminationLaboratory Examination n nSerum CBSerum CBn nUrine bilirubin (+)Urine bilirubin (+)n nUrobilinogen , sterco
22、bilin(Urobilinogen , stercobilin(粪胆原粪胆原) or ) or absenceabsencen nSerum alkaline phosphatase and Serum alkaline phosphatase and Cholesterol(Cholesterol(胆固醇胆固醇)A. Hemolytic anemiaexcess hemolysis unconjugated bilirubin (in blood) conjugated bilirubin (released to bile duct) UB UrobilinogenB. Hepatiti
23、s unconjugated bilirubin (in blood) conjugated bilirubin (in blood) UB UrobilinogenC. Biliary duct stone unconjugated bilirubin (in blood) conjugated bilirubin (in blood) UB Urobilinogen 5.GeneticDisordersofBilirubinMetabolismConditionConditionDefectDefectBilirubinBilirubinClinicalClinical FindingsF
24、indingsCrigler-Najjar Crigler-Najjar syndromesyndromeseverely defective severely defective UDP-glucuronyl UDP-glucuronyl transferasetransferaseUnconjugated Unconjugated bilirubinbilirubin Profound Profound jaundicejaundiceGilberts Gilberts syndromesyndromereduced activity of reduced activity of UDP-
25、glucuronyl UDP-glucuronyl transferasetransferaseUnconjugated Unconjugated bilirubinbilirubin Very mild Very mild jaundice during jaundice during illnessesillnessesDubin-Dubin-Johnson Johnson syndromesyndromeabnormal transport of abnormal transport of conjugated bilirubin into conjugated bilirubin in
26、to the biliary systemthe biliary systemConjugated Conjugated bilirubinbilirubin Moderate Moderate jaundicejaundiceRotors syndromeRotors syndrome deficiency of uptaking UCB deficiency of uptaking UCB and excreting CB, and excreting CB, CBCB jaundice. jaundice.Crigler-Najjar syndromeCrigler-Najjar syn
27、dromeGilberts syndromeGilberts syndromeThree kinds of jaundice laborotory examination indentificationThree kinds of jaundice laborotory examination indentification Class Hemolytic Hepatocellular Cholestatic Class Hemolytic Hepatocellular Cholestatic TB increased increased increased TB increased incr
28、eased increased CB normal increased markedly increased CB normal increased markedly increased CB/TB CB/TB 1515一一2020 3030一一4040 5050一一6060 urine bilirubin urine bilirubin 十十 十十十十 urobilinogen increased slight increased decreased or absence urobilinogen increased slight increased decreased or absence
29、 ALT ALT、AST normal markedly increased may increasedAST normal markedly increased may increased ALP normal increased markedly increased ALP normal increased markedly increased r-GT normal increased markedly increased r-GT normal increased markedly increased PT normal delayed delayed PT normal delaye
30、d delayed Vit K respond no poor good Vit K respond no poor good Cholesterol normal slight increased or decreased markedly increased Cholesterol normal slight increased or decreased markedly increased Serum protein normal Alb decreased,Glob increased normal Serum protein normal Alb decreased,Glob inc
31、reased normalAccessory ExaminationAccessory Examination n n1.Ultrosound1.Ultrosoundn n2.X ray2.X rayn n3.ERCP 3.ERCP (Endoscopic retrograde cholangiopancreatography,(Endoscopic retrograde cholangiopancreatography, 逆行胰胆管造影逆行胰胆管造影) )n n4.PTC 4.PTC (Percutaneous transheptic cholangiography,(Percutaneou
32、s transheptic cholangiography, 经皮肝穿刺胆管造影经皮肝穿刺胆管造影) )n n5.CT 5.CT (Computed tomography(Computed tomography) )n n6.MRI 6.MRI (Magnetic resonance cholangiopancreatography)(Magnetic resonance cholangiopancreatography)n n7.Liver Biopsy and LC 7.Liver Biopsy and LC (Laparoscopy(Laparoscopy，腹腔镜，腹腔镜) )Accom
33、panying SymptomsAccompanying Symptoms 1. 1.Fever: acute Fever: acute cholangitischolangitis, liver abscess, , liver abscess, leptospirosisleptospirosis( (钩端钩端螺旋体病螺旋体病), septicemia(), septicemia(败血症败血症), lobar pneumonia(), lobar pneumonia(大叶大叶性肺炎性肺炎). Fever then jaundice: virus hepatitis, acute ). Fe
34、ver then jaundice: virus hepatitis, acute hemolysishemolysis. .2. 2.Upper abdominal sharp pain: Upper abdominal sharp pain: biliarybiliary calculi( calculi(胆道结石胆道结石), ), liver abscess, liver abscess, biliarybiliary ascariasisascariasis( (胆道蛔虫病胆道蛔虫病), ),3. 3. Right upper Right upper abdomabdom sharp
35、pain, chill, high fever, sharp pain, chill, high fever, jaundice, Charcot triad sign: acute jaundice, Charcot triad sign: acute pyogenicpyogenic cholangitischolangitis( (急性化脓性胆管炎急性化脓性胆管炎), ),4. 4. Sustained right upper abdominal blur or swell pain: Sustained right upper abdominal blur or swell pain:
36、 virus hepatitis, liver abscess, primary carcinoma of livervirus hepatitis, liver abscess, primary carcinoma of liver3. 3.HepatomegalyHepatomegaly( (肝大肝大) )4. 4. Mild or moderate, soft or moderate hard, smooth Mild or moderate, soft or moderate hard, smooth surface: Virus hepatitis, acute infection
37、of surface: Virus hepatitis, acute infection of biliarybiliary tract. tract. obstruction of obstruction of biliarybiliary tract tract5. 5. Obvious enlargement, hard, ragged surface: Obvious enlargement, hard, ragged surface: primary or secondary carcinoma of liver.primary or secondary carcinoma of l
38、iver.6. 6. Not obvious enlargement, hard, edge not tidy, Not obvious enlargement, hard, edge not tidy, nodule on the surface: cirrhosis.nodule on the surface: cirrhosis.4. 4.Gallbladder enlargement: common bile duct Gallbladder enlargement: common bile duct obstruction, pancreatic head carcinoma, co
39、mmon bile obstruction, pancreatic head carcinoma, common bile duct carcinoma, carcinoma of duct carcinoma, carcinoma of ampullaampulla. .5. 5.SplenomegalySplenomegaly: virus hepatitis, : virus hepatitis, leptospirosisleptospirosis( (钩端螺旋钩端螺旋体病体病), septicemia(), septicemia(败血症败血症), Malaria(), Malaria
40、(疟疾疟疾), cirrhosis, ), cirrhosis, hemolytic anemia, hemolytic anemia, lymphomalymphoma( (淋巴瘤淋巴瘤). ).6. 6.AcitesAcites: serious hepatitis, : serious hepatitis, decompensationdecompensation of of cirrosiscirrosis( (肝肝硬化失化偿期硬化失化偿期), carcinoma of liver.), carcinoma of liver.Inquisition Inquisition Points
41、 Points（问诊要点）（问诊要点）（问诊要点）（问诊要点）n n1.Assure jaundice1.Assure jaundicen n2.Etiology and onset 2.Etiology and onset n n3.Accompany syndrome3.Accompany syndromen n4.Time and fluctuation of jaundice4.Time and fluctuation of jaundicen n5.Influnce to the overall health5.Influnce to the overall healthn nIn
42、one word: make sure the type of jaundice, and In one word: make sure the type of jaundice, and then find the pathogenythen find the pathogenyn nRecognise jaundiceRecognise jaundice Position Position：sclera, skin and sclera, skin and tongue sleevestongue sleeves Pseudojaundice(Pseudojaundice(假性黄疸假性黄疸
43、): ): eat eat Carotene(Carotene(胡罗卜素胡罗卜素) food ) food (Carotene,pumpkin(Carotene,pumpkin(南瓜南瓜) ), tomato, orange) also can cause , tomato, orange) also can cause skin stained yellow, but bilirubin is not increased. skin stained yellow, but bilirubin is not increased. Old people fat Old people fat ac
44、cumulation at bulbar conjunctiva(accumulation at bulbar conjunctiva(球结膜球结膜) ), , yellow, yellow, uneven distributionuneven distributionQuestionsn n1) Unconjugated hyperbilirubinemia usually 1) Unconjugated hyperbilirubinemia usually results from a intra- or extrahepatic biliary results from a intra-
45、 or extrahepatic biliary obstruction.obstruction.n nA. TrueA. Truen nB. FalseB. Falsen n2) Clinical features of cholecystitis include all of the following except:n nA. RUQ abdominal painA. RUQ abdominal painn nB. Radiation to R upper backB. Radiation to R upper backn nC. Nausea, VomitingC. Nausea, V
46、omitingn nD. + Murphys signD. + Murphys signn nE. FeverE. Fevern n3) A marker of acute hepatocyte injury is:n nA. PTA. PTn nB. ALTB. ALTn nC. AlbuminC. Albuminn nD. Direct bilirubinD. Direct bilirubinn nE. AmmoniaE. Ammonia1.A 13 years old male, chief complaints “Finding skin and sclera yellow and f
47、eeling right upper abdomen swell pain for 1 week” Blood test: TBil:80mol/L, DBil:50mol/L, ALT:1200U/L.B Ultrasound: normal.What are the possible diagnoses and your suggested examinations.Hepatocellular and Cholestetic jaundice.Hepatitis virus test, Urine test, or MRCP.QuestionReference booksReference booksn nCecil mecidine 23Cecil mecidine 23rdrd edition. edition.n nDavidson principles and practice of medicine.Davidson principles and practice of medicine.n nHarrisons principles of internal medicine.16Harrisons principles of internal medicine.16thth edition. edition.结束语结束语谢谢大家聆听！谢谢大家聆听！37
