《黄疸》-09级一系-老年-麻醉-救援-心理-陶小红-12-04-18(1).ppt

Jaundice(黄疸),DepartmentofGastroenterology,FirstAffiliatedHospitalofChongqingMedicalUniversity,XIAOHONGTAO(陶小红),Jaundiceoricterus:Whatisjaundice?ClinicallyitistheyellowdiscolorationoftheSclera(巩膜)SkinMucousmembraneduetodepositionofbilepigment(bilirubin胆红素)Serumtotalbilirubin(normal1.7-17.1umol/lit)Conjugatedbilirubin:0-3.42mol/l，Unconjugatedbilirubin:1.7-13.68mol/l.,1.DEFINITION,2.BILIRUBINMETABNISM,HemeDegradation,HEME,BILIVERDIN,O2,Fe+3,(openstheporphyrinring),BILIRUBIN,BILIRUBINdiglucuronide,BILE,TheFateofBilirubin,Alb=albuminB=bilirubinGST=glutathione-S-transferaseUDPGA=uridinediphosphoglucuronicacid;CB=conjugatedbilirubinUGT1A1=UDP-glucuronosyltransferase1A1MRP2=Multi-drugResistanceProtein2AdaptedfromHarrisons15thEd.“PrinciplesofInternalMedicine”,2001.,MRP2,CB,Plasma,HepaticCell,Bile,sER,B,+UDPGA,UGT1A1,BilirubinExcretion,Intestines,Liver,B,CB,CB,B,Urobilinogen,B-glucoronidase,bacteria,bacteria,Bile,Enterohepaticcirculation,Kidney,Urobilin,ox,Urobilinogen,Urobilin,Stercobilin,Stercobilingogen,Urine,ox,Liver,Albunin,Heme,Ferroheme,transferase,Bilirubin,Conjugatedbilirubin,Kidney,Urobilin,Stercobilinogen,Urobilinogen,Intestines,Albumin,Bilirubin,reductase,Heme,Globin,Hemoglobin,oxidase,Biliverdin,Marrow,InfantilityErythrocyteFerrohemeEnzyme15%20%,Bilirubin|Albumin,Erythrocyte80%85%,UDP,UDPGA,Bilirubinglucuronolactone,urobilinogen,Enterohepaticcirculation,Y/Zprotein,cathepsin,Erythrocyte,BiochemicalchangeofNormalbilirubinmetabolism,3.CLASSFICATION,1.DependingonEtiologyHemolyticJaundice（溶血性黄疸）HepatocellularJaundice（肝细胞性黄疸）CholestaticJaundice（胆汁淤积性黄疸）Congenitaljaundice（先天性黄疸）,2.DependingonbilirubinUnconjungatedbilirubinincreasedjaundiceConjungatedbilirubinincreasedjaundice,Etiology1.Congenitalhemolyticanemia(thalassemia(海洋性贫血),hereditaryspherocytosis(遗传性球形红细胞增多症).2.Posteriorityacquiredhemolyticanemia(autoimmunityhemolyticanemia,hemolyticdiseaseofnewborn,posttransfusionhemolytic,Favism(蚕豆病).MechanismAlargenumberoferythrocytedestroyedrapidlyAnemia,hypoxiaandtoxityoferythocytemetabolismproducts,3.1.HemolyticJaundice,HemolyticJaundicemechanism,ClinicalManifestationMildjaundice,lightlemon,noskinitch(痒).Acutehemolysis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(血红蛋白尿),acuterenalfailure.Chronichemolysis:anemiaandsplenomegaly(脾大).,LaboratoryExamination1.SerumTB,UCB,CBnormal.2.UCBintestinalCBfaecalcolordeepen.3.IntestinalUrobilinogen(尿胆原)urinaryUrobilinogen.4.Acutehemolytis,occultbloodtest(+).5.Bloodtest:anemia,reticulocyte(网织红细胞),erythrocyteproliferation.,3.2.HepatocellularJaundice,EtiologyHepatocytedamage.MechanismImpairhepatocyteuptakeing,conjugatingandexcretingbilirubin,UCBCBrefluxintoblood,serumCBjaundice.,HepatocellularJaundicemechanism,ClinicalManifestationSkinandmucosa:lighttodeepyellow,mildskinitch(痒)Tired,lossofappetitehemorrhagictendency,ascites,coma.Primarydiseasemanifestation,LaboratoryExaminationCB,UCBIcterichepatitis:CBUCBUrine:CB(+),urobilinogenBloodtest:liverdamaged,3.3.CholestaticJaundice,EtiologyObstructioninliver:virushepatitis,drugcaused,drughepatitis,primarybiliarycirrhosis.ObstructionofExtrahepaticbileduct:narrow,obstruction,stone,inflammtory,tumor.MechanismObstructioncausessmallbileductandbilecapillarybroken,conjugatedbilirubinrefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombus(胆栓)formation.,CholestaticJaundicemechanism,ClinicalManifestationSkindarkyellow,yellowgreen.Skinitch(痒),bradycardia(心动过缓),darkyellowofurine,faecallightyelloworclaycolor.Courvoisierssign.,LaboratoryExaminationSerumCBUrinebilirubin(+)Urobilinogen,stercobilin(粪胆原)orabsenceSerumalkalinephosphataseandCholesterol(胆固醇),5.GeneticDisordersofBilirubinMetabolism,RotorssyndromedeficiencyofuptakingUCBandexcretingCB,CBjaundice.,Crigler-NajjarsyndromeGilbertssyndrome,Threekindsofjaundicelaborotoryexaminationindentification,ClassHemolyticHepatocellularCholestaticTBincreasedincreasedincreasedCBnormalincreasedmarkedlyincreasedCB/TB15一2030一4050一60urinebilirubin十十十urobilinogenincreasedslightincreaseddecreasedorabsenceALT、ASTnormalmarkedlyincreasedmayincreasedALPnormalincreasedmarkedlyincreasedr-GTnormalincreasedmarkedlyincreasedPTnormaldelayeddelayedVitKrespondnopoorgoodCholesterolnormalslightincreasedordecreasedmarkedlyincreasedSerumproteinnormalAlbdecreased,Globincreasednormal,AccessoryExamination,1.Ultrosound2.Xray3.ERCP(Endoscopicretrogradecholangiopancreatography,逆行胰胆管造影)4.PTC(Percutaneoustranshepticcholangiography,经皮肝穿刺胆管造影)5.CT(Computedtomography)6.MRI(Magneticresonancecholangiopancreatography)7.LiverBiopsyandLC(Laparoscopy，腹腔镜),AccompanyingSymptoms,Fever:acutecholangitis,liverabscess,leptospirosis(钩端螺旋体病),septicemia(败血症),lobarpneumonia(大叶性肺炎).Feverthenjaundice:virushepatitis,acutehemolysis.Upperabdominalsharppain:biliarycalculi(胆道结石),liverabscess,biliaryascariasis(胆道蛔虫病),Rightupperabdomsharppain,chill,highfever,jaundice,Charcottriadsign:acutepyogeniccholangitis(急性化脓性胆管炎),Sustainedrightupperabdominalblurorswellpain:virushepatitis,liverabscess,primarycarcinomaofliver,Hepatomegaly(肝大)Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytractObviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.Notobviousenlargement,hard,edgenottidy,noduleonthesurface:cirrhosis.,Gallbladderenlargement:commonbileductobstruction,pancreaticheadcarcinoma,commonbileductcarcinoma,carcinomaofampulla.Splenomegaly:virushepatitis,leptospirosis(钩端螺旋体病),septicemia(败血症),Malaria(疟疾),cirrhosis,hemolyticanemia,lymphoma(淋巴瘤).Acites:serioushepatitis,decompensationofcirrosis(肝硬化失化偿期),carcinomaofliver.,InquisitionPoints（问诊要点）,1.Assurejaundice2.Etiologyandonset3.Accompanysyndrome4.Timeandfluctuationofjaundice5.InfluncetotheoverallhealthInoneword:makesurethetypeofjaundice,andthenfindthepathogeny,RecognisejaundicePosition：sclera,skinandtonguesleevesPseudojaundice(假性黄疸):eatCarotene(胡罗卜素)food(Carotene,pumpkin(南瓜),tomato,orange)alsocancauseskinstainedyellow,butbilirubinisnotincreased.Oldpeoplefataccumulationatbulbarconjunctiva(球结膜),yellow,unevendistribution,Questions,1)Unconjugatedhyperbilirubinemiausuallyresultsfromaintra-orextrahepaticbiliaryobstruction.A