黄疸级一系老麻醉救援心理陶小红

Jaundice(黄疸),Department of Gastroenterology, First Affiliated Hospital of Chongqing Medical University,XIAOHONG TAO (陶小红),Jaundice or icterus : What is jaundice ?Clinically it is the yellow discoloration of the Sclera (巩膜) SkinMucous membranedue to deposition of bile pigment (bilirubin胆红素) Serum total bilirubin (normal 1.7-17.1 umol/lit )Conjugated bilirubin:0-3.42mol/l，Unconjugated bilirubin:1.7-13.68mol/l.,1. DEFINITION,2. BILIRUBIN METABNISM,Heme Degradation,HEME,BILIVERDIN,O2,Fe+3,(opens the porphyrin ring),BILIRUBIN,BILIRUBIN diglucuronide,BILE,The Fate of Bilirubin,Alb = albuminB = bilirubinGST = glutathione-S-transferaseUDPGA = uridine diphosphoglucuronic acid;CB = conjugated bilirubinUGT1A1 = UDP-glucuronosyltransferase 1A1MRP2 = Multi-drug Resistance Protein 2 Adapted from Harrisons 15th Ed. “Principles of Internal Medicine”, 2001.,MRP2,CB,Plasma,Hepatic Cell,Bile,sER,B,+ UDPGA,UGT1A1,Bilirubin Excretion,Intestines,Liver,B,CB,CB,B,Urobilinogen,B-glucoronidase,bacteria,bacteria,Bile,Enterohepatic circulation,Kidney,Urobilin,ox,Urobilinogen,Urobilin,Stercobilin,Stercobilingogen,Urine,ox,Liver,Albunin,Heme,Ferroheme,transferase,Bilirubin,Conjugated bilirubin,Kidney,Urobilin,Stercobilinogen,Urobilinogen,Intestines,Albumin,Bilirubin,reductase,Heme,Globin,Hemoglobin,oxidase,Biliverdin,Marrow,Infantility ErythrocyteFerroheme Enzyme15%20%,Bilirubin |Albumin,Erythrocyte80%85%,UDP,UDPGA,Bilirubin glucuronolactone,urobilinogen,Enterohepatic circulation,Y/Z protein,cathepsin,Erythrocyte,Biochemical change of Normal bilirubin metabolism,3. CLASSFICATION,1. Depending on EtiologyHemolytic Jaundice（溶血性黄疸）Hepatocellular Jaundice（肝细胞性黄疸）Cholestatic Jaundice（胆汁淤积性黄疸）Congenital jaundice（先天性黄疸）,2. Depending on bilirubinUnconjungated bilirubin increased jaundiceConjungated bilirubin increased jaundice,Etiology1.Congenital hemolytic anemia (thalassemia(海洋性贫血),hereditary spherocytosis(遗传性球形红细胞增多症).2.Posteriority acquired hemolytic anemia (autoimmunity hemolytic anemia, hemolytic disease of newborn, posttransfusion hemolytic, Favism(蚕豆病).MechanismA large number of erythrocyte destroyed rapidlyAnemia,hypoxia and toxity of erythocyte metabolism products,3.1. Hemolytic Jaundice,Hemolytic Jaundice mechanism,Clinical Manifestation Mild jaundice, light lemon, no skin itch(痒).Acute hemolysis: fever, chill, headache, vomit, backache, anemia, hemoglobinuria(血红蛋白尿), acute renal failure.Chronic hemolysis: anemia and splenomegaly(脾大).,Laboratory Examination 1.Serum TB,UCB,CB normal.2.UCBintestinal CBfaecal color deepen.3.Intestinal Urobilinogen(尿胆原)urinary Urobilinogen.4.Acute hemolytis, occult blood test (+).5.Blood test: anemia, reticulocyte(网织红细胞), erythrocyte proliferation.,3.2. Hepatocellular Jaundice,EtiologyHepatocyte damage.MechanismImpair hepatocyte uptakeing, conjugating and excreting bilirubin, UCBCB reflux into blood, serum CBjaundice.,Hepatocellular Jaundice mechanism,Clinical Manifestation Skin and mucosa: light to deep yellow, mild skin itch(痒)Tired, loss of appetitehemorrhagic tendency, ascites, coma.Primary disease manifestation,Laboratory Examination CB, UCBIcteric hepatitis: CB UCB Urine: CB(+),urobilinogen Blood test: liver damaged,3.3. Cholestatic Jaundice,EtiologyObstruction in liver:virus hepatitis,drug caused,drug hepatitis, primary biliary cirrhosis.Obstruction of Extrahepatic bile duct:narrow, obstruction,stone, inflammtory,tumor.MechanismObstruction causes small bile duct and bile capillary broken, conjugated bilirubin reflux to blood.Failure of hepatocyte excreting CB,bilirubin deposit and bile thrombus(胆栓) formation.,Cholestatic Jaundice mechanism,Clinical ManifestationSkin dark yellow, yellow green.Skin itch (痒), bradycardia (心动过缓), dark yellow of urine, faecal light yellow or clay color. Courvoisiers sign.,Laboratory Examination Serum CBUrine bilirubin (+)Urobilinogen , stercobilin(粪胆原) or absenceSerum alkaline phosphatase and Cholesterol(胆固醇),5. Genetic Disorders of Bilirubin Metabolism,Rotors syndrome deficiency of uptaking UCB and excreting CB, CB jaundice.,Crigler-Najjar syndromeGilberts syndrome,Three kinds of jaundice laborotory examination indentification,Class Hemolytic Hepatocellular Cholestatic TB increased increased increased CB normal increased markedly increased CB/TB 15一20 30一40 50一60 urine bilirubin 十 十十 urobilinogen increased slight increased decreased or absence ALT、AST normal markedly increased may increased ALP normal increased markedly increased r-GT normal increased markedly increased PT normal delayed delayed Vit K respond no poor good Cholesterol normal slight increased or decreased markedly increased Serum protein normal Alb decreased,Glob increased normal,Accessory Examination,1.Ultrosound2.X ray3.ERCP (Endoscopic retrograde cholangiopancreatography, 逆行胰胆管造影)4.PTC (Percutaneous transheptic cholangiography, 经皮肝穿刺胆管造影)5.CT (Computed tomography)6.MRI (Magnetic resonance cholangiopancreatography)7.Liver Biopsy and LC (Laparoscopy，腹腔镜),Accompanying Symptoms,Fever: acute cholangitis, liver abscess, leptospirosis(钩端螺旋体病), septicemia(败血症), lobar pneumonia(大叶性肺炎). Fever then jaundice: virus hepatitis, acute hemolysis.Upper abdominal sharp pain: biliary calculi(胆道结石), liver abscess, biliary ascariasis(胆道蛔虫病), Right upper abdom sharp pain, chill, high fever, jaundice, Charcot triad sign: acute pyogenic cholangitis(急性化脓性胆管炎), Sustained right upper abdominal blur or swell pain: virus hepatitis, liver abscess, primary carcinoma of liver,Hepatomegaly(肝大) Mild or moderate, soft or moderate hard, smooth surface: Virus hepatitis, acute infection of biliary tract. obstruction of biliary tract Obvious enlargement, hard, ragged surface: primary or secondary carcinoma of liver. Not obvious enlargement, hard, edge not tidy, nodule on the surface: cirrhosis.,Gallbladder enlargement: common bile duct obstruction, pancreatic head carcinoma, common bile duct carcinoma, carcinoma of ampulla.Splenomegaly: virus hepatitis, leptospirosis(钩端螺旋体病), septicemia(败血症), Malaria(疟疾), cirrhosis, hemolytic anemia, lymphoma(淋巴瘤).Acites: serious hepatitis, decompensation of cirrosis(肝硬化失化偿期), carcinoma of liver.,Inquisition Points（问诊要点）,1.Assure jaundice2.Etiology and onset 3.Accompany syndrome4.Time and fluctuation of jaundice5.Influnce to the overall healthIn one word: make sure the type of jaundice, and then find the pathogeny,Recognise jaundice Position：sclera, skin and tongue sleeves Pseudojaundice(假性黄疸): eat Carotene(胡罗卜素) food (Carotene,pumpkin(南瓜), tomato, orange) also can cause skin stained yellow, but bilirubin is not increased. Old people fat accumulation at bulbar conjunctiva(球结膜), yellow, uneven distribution,Questions,1) Unconjugated hyperbilirubinemia usually results from a intra- or extrahepatic biliary obstruction.A. TrueB. False,2) Clinica