111黄疸(英文课件)

Jaundice

GastroenterologyDepartment,FirstAffiliatedHospitalofChongqingMedicalUniversityBingqiangZhangJaundiceGastroenterologyDepa1AimsandDemands1.Grasptheconceptofjaundice,clinicalmanifestationandpointsofinquisition2.Familiartheetiologyandmechanismofjaundice3.RealizenormalbilirubinmetabolismAimsandDemands2Definition：jaundice,oricterusreferstotheyellowappearanceoftheskin,scleralandmucousmembranesresultingfromanincreasedbilirubinconcentrationinthebodyfluids.Totalbilirubin:1.7-17.1μmol/LConjugatedbilirubin:0-3.42μmol/l，Unconjugatedbilirubin:1.7-13.68μmol/l.Definition：jaundice,oricterus3LiverAlbuninHemeFerrohemetransferaseBilirubinConjugatedbilirubinKidneyUrobilinStercobilinogenUrobilinogenIntestinesAlbuminBilirubinreductaseHemeGlobinHemoglobinoxidaseBiliverdinMarrowInfantilityErythrocyteFerrohemeEnzyme15%~20%Bilirubin|AlbuminErythrocyte80%~85%UDPUDPGABilirubinglucuronolactoneurobilinogenEnterohepaticcirculationY/ZproteincathepsinErythrocyteNormalbilirubinmetabolismLiverAlbuninHemeFerrohemetrans4NormalbilirubinmetabolismNormalbilirubinmetabolism5Classification1.DependingonEtiologyHemolyticJaundiceHepatocellularJaundiceCholestaticJaundiceCongenitaljaundice

2.DependingonbilirubinUnconjungatedbilirubingincreasedjaundiceConjungatedbilirubingincreasedjaundiceClassification1.Dependingon6Etiology1.Congenitalhemolyticanemia(thalassemia,hereditaryspherocytosis).2.Posteriorityacquiredhemolyticanemia(autoimmunityhemolyticanemia,hemolyticdiseaseofnewborn,

posttransfusionhemolytic,Favism).MechanismAlargenumberoferythrocytedestroyedrapidlyAnemia,hypoxiaandtoxityoferythocytemetabolismproducts1.HemolyticJaundiceEtiology1.HemolyticJaundice7HaemolyticJaundicemechanismHaemolyticJaundicemechanism8ClinicalManifestation

Mildjaundice,lightlemon,noskinitch.Acutehemolytis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(darksauceortea),acuterenalfailure.Chronichemolysis:anemiaandsplenomegaly.ClinicalManifestation9LaboratoryExamination

1.SerumTB↑,UCB↑,CBnormal.2.UCB↑→intestinalCB↑→faecalcolordeepen.3.IntestinalUrobilinogen↑→urinaryUrobilinogen↑.4.Acutehemolytis,occultbloodtest(+).5.Bloodtest:anemia,reticulocyte↑,erythacyteproliferation↑.LaboratoryExamination102.HepatocellularJaundiceEtiologyHepatocytedamage.MechanismImpairhepatocyteuptakeing,conjugatingandexcretingbilirubin,UCB↑CBrefluxintoblood,serumCB↑→jaundice.2.HepatocellularJaundiceEtiol11HepatocellularJaundicemechanismHepatocellularJaundicemechan12ClinicalManifestation

Skinandmucosa:lighttodeepyellow,mildskinitchTired,lossofappetitehemorrhagictendency,ascites,coma.PrimarydiseasemanifestationClinicalManifestation13LaboratoryExamination

CB↑,UCB↑Icterichepatitis:CB↑↑UCB↑Urine:CB(+),urobilinogen↑Bloodtest:liverdemagedLaboratoryExamination143.CholestaticJaundiceEtiologyObstructioninliver:virushepatitis,drugcaused,drughepatitis,primarybiliarycirrhosis.ObstructionofExtrahepaticbileduct:narrow,obstruction,stone,inflammtory,tumor.MechanismObstructioncausessmallbileductandbilecapillarybroken,conjugatedbilirubinrefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombusformation.3.CholestaticJaundiceEt15CholestaticJaundicemechanismCholestaticJaundicemechanism16ClinicalfeaturesSkindarkyellow,yellowgreen.Skinitch,bradycardia,darkyellowofurine,facallightyelloworclaycolor.Courvoisier’ssign.Clinicalfeatures17LaboratoryExamination

SerumCB↑Urinebilirubin(+)Urobilinogen,stercobilin↓orabsenceSerumalkalinephosphataseandCholesterol↑LaboratoryExamination18Threekindsofjaundicelaborotoryexaminationindentification

ClassHaemolyticHepatocellularCholestatic

TBincreased(UCB)increasedincreasedCBnormalincreasedmarkedlyincreasedCB/TB＜15％一20％＞30％一40％＞50％一60％urinebilirubin—十十十urobilinogenincreasedslightincreaseddecreasedorabsenceALT、ASTnormalmarkedlyincreasedmayincreasedALPnormalincreasedmarkedlyincreasedr-GTnormalincreasedmarkedlyincreasedPTnormaldelayeddelayedVitKrespondnopoorgoodCholesterolnormalslightincreasedordecreasedmarkedlyincreasedSerumproteinnormalAlbdecreased,Globincreasednormal

Threekindsofjaundicelaboro194.CongenitalNonhemolyticJaundiceDuetothedeficiencyofthehepatocyteinuptakeing,conjugatingandexcretingbilirubinUncommon4.CongenitalNonhemolyticJaun201.Gilbersyndrome:hepatocyteuptakingUCBabnormal,deficiencyofglucuronyltransferase,→UCB↑→jaundice(nosymptom,liverfunctionnormal).2.Dubin-Johnson’ssyndrome:abnormalofHepatocyteexcretingCBandsomeaniontobilecapillary→CB↑→jaundice.3.Crigler-Najjar’ssyndrome:absenceofglucuronyltransferaseinhepatocyte,UCBcan’tbetransferedtoCB，serumUCB↑→jaundice,UCB↑↑↑→nuclearjaundic,newborn,poorprediction.4.Rotor’ssyndrome:deficiencyofHepatocyteuptakingUCBandexcretingCB,→bilirubin↑→jaundice.1.Gilbersyndrome:hepatocyteu21AccessoryExamination1.Ultrosound2.Xray3.ERCP(Endoscopicretrogradecholangiopancreatography)4.PTC(Percutaneoustranshepticcholangiography)5.CT(Computedtomography)6.MRI(Magneticresonancecholangiopancreatography)7.RadioNuclideExamination8.LiverBiopsyandLC(Laparoscopy)AccessoryExamination1.Ultro22AccompanyingSymptomsFever:acutecholangitis,liverabscess,leptospirosis,septicemia,lobarpneumonia.Feverthenjaundice:virushepatitis,acutehemolysis.Upperabdominalsharppain:biliarycalculi,liverabscess,biliaryascariasis,Rightupperabdomsharppain,chill,highfever,jaundice,Charcottriadsign:acutepyogeniccholangitis,Sustainedrightupperabdominalblurorswellpain:virushepatitis,liverabscess,primarycarcinomaofliverAccompanyingSymptomsFever:ac23Hepatomegaly①Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytract②Obviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.③Notobviousenlargement,hard,edgenottidy,noduleonthesurface:cirrosis.Hepatomegaly24Gallbladderenlargement:commonbileductobstruction,pancreaseheadcarcinoma,commonbileductcarcinoma,carcinomaofampulla.Splenomegaly:virushepatitis,leptospirosis,septicemia,Malaria,biliarycirrhosis,hemolyticanemia,lymphoma.Acite:serioushepatitis,decompensationofcirrosis,carcinomaofliver.Gallbladderenlargement:common25InterrogatoirePoints1.Assurejaundice2.Etiologyandonset3.Accompanysyndrome4.Timeandfluctuationofjaundice5.InfluncetotheoverallhealthInoneword:makesurethetypeofjaundicethenfindthepathogenyInterrogatoirePoints1.Assure26RecognisejaundicePosition：sclera,skinandtonguesleeves

Pseudojaundice:eatCarotenefood(Carotene,pumpkin,tomato,orange)alsocancauseskinstainedyellow,butbilirubinisnotincreased.Oldpeoplefataccumulationatbulbarconjunctiva，yellow,unevendistributionRecognisejaundice27Jaundiceisacommonsymptomandsigninclinicalwork,gettoknowthemechanismcanhelpusidentifydifferentkindsofjaundices.hemolyticjaundiceisduetotherapidlydestroyederythocyte,sotheUCBincreased.hepatocellularjaundicereferstouptakeing,conjugatingandexcretingbilirubin,sobothCBandUCBincreased.Cholestaticjaundiceduetotheobstructionofbiletrack,sotheCBincreasedandurinebilirubinpositive.SummaryJaundiceisacommonsymptoma281.A13yearsoldmale,chiefcomplaints“Findingskinandsclerayellowandfeelingrightupperabdomenswellpainfor1week”Whatarethepossiblediagnosesandyoursuggestedexaminations.QuestionQuestion29ReferencebooksCecilmecidine23rdedition.Davidson’principlesandpracticeofmedicine.Harrison'sprinciplesofinternalmedicine.16thedition.ReferencebooksCecilmecidine30Jaundice

GastroenterologyDepartment,FirstAffiliatedHospitalofChongqingMedicalUniversityBingqiangZhangJaundiceGastroenterologyDepa31AimsandDemands1.Grasptheconceptofjaundice,clinicalmanifestationandpointsofinquisition2.Familiartheetiologyandmechanismofjaundice3.RealizenormalbilirubinmetabolismAimsandDemands32Definition：jaundice,oricterusreferstotheyellowappearanceoftheskin,scleralandmucousmembranesresultingfromanincreasedbilirubinconcentrationinthebodyfluids.Totalbilirubin:1.7-17.1μmol/LConjugatedbilirubin:0-3.42μmol/l，Unconjugatedbilirubin:1.7-13.68μmol/l.Definition：jaundice,oricterus33LiverAlbuninHemeFerrohemetransferaseBilirubinConjugatedbilirubinKidneyUrobilinStercobilinogenUrobilinogenIntestinesAlbuminBilirubinreductaseHemeGlobinHemoglobinoxidaseBiliverdinMarrowInfantilityErythrocyteFerrohemeEnzyme15%~20%Bilirubin|AlbuminErythrocyte80%~85%UDPUDPGABilirubinglucuronolactoneurobilinogenEnterohepaticcirculationY/ZproteincathepsinErythrocyteNormalbilirubinmetabolismLiverAlbuninHemeFerrohemetrans34NormalbilirubinmetabolismNormalbilirubinmetabolism35Classification1.DependingonEtiologyHemolyticJaundiceHepatocellularJaundiceCholestaticJaundiceCongenitaljaundice

2.DependingonbilirubinUnconjungatedbilirubingincreasedjaundiceConjungatedbilirubingincreasedjaundiceClassification1.Dependingon36Etiology1.Congenitalhemolyticanemia(thalassemia,hereditaryspherocytosis).2.Posteriorityacquiredhemolyticanemia(autoimmunityhemolyticanemia,hemolyticdiseaseofnewborn,

posttransfusionhemolytic,Favism).MechanismAlargenumberoferythrocytedestroyedrapidlyAnemia,hypoxiaandtoxityoferythocytemetabolismproducts1.HemolyticJaundiceEtiology1.HemolyticJaundice37HaemolyticJaundicemechanismHaemolyticJaundicemechanism38ClinicalManifestation

Mildjaundice,lightlemon,noskinitch.Acutehemolytis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(darksauceortea),acuterenalfailure.Chronichemolysis:anemiaandsplenomegaly.ClinicalManifestation39LaboratoryExamination

1.SerumTB↑,UCB↑,CBnormal.2.UCB↑→intestinalCB↑→faecalcolordeepen.3.IntestinalUrobilinogen↑→urinaryUrobilinogen↑.4.Acutehemolytis,occultbloodtest(+).5.Bloodtest:anemia,reticulocyte↑,erythacyteproliferation↑.LaboratoryExamination402.HepatocellularJaundiceEtiologyHepatocytedamage.MechanismImpairhepatocyteuptakeing,conjugatingandexcretingbilirubin,UCB↑CBrefluxintoblood,serumCB↑→jaundice.2.HepatocellularJaundiceEtiol41HepatocellularJaundicemechanismHepatocellularJaundicemechan42ClinicalManifestation

Skinandmucosa:lighttodeepyellow,mildskinitchTired,lossofappetitehemorrhagictendency,ascites,coma.PrimarydiseasemanifestationClinicalManifestation43LaboratoryExamination

CB↑,UCB↑Icterichepatitis:CB↑↑UCB↑Urine:CB(+),urobilinogen↑Bloodtest:liverdemagedLaboratoryExamination443.CholestaticJaundiceEtiologyObstructioninliver:virushepatitis,drugcaused,drughepatitis,primarybiliarycirrhosis.ObstructionofExtrahepaticbileduct:narrow,obstruction,stone,inflammtory,tumor.MechanismObstructioncausessmallbileductandbilecapillarybroken,conjugatedbilirubinrefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombusformation.3.CholestaticJaundiceEt45CholestaticJaundicemechanismCholestaticJaundicemechanism46ClinicalfeaturesSkindarkyellow,yellowgreen.Skinitch,bradycardia,darkyellowofurine,facallightyelloworclaycolor.Courvoisier’ssign.Clinicalfeatures47LaboratoryExamination

SerumCB↑Urinebilirubin(+)Urobilinogen,stercobilin↓orabsenceSerumalkalinephosphataseandCholesterol↑LaboratoryExamination48Threekindsofjaundicelaborotoryexaminationindentification

ClassHaemolyticHepatocellularCholestatic

TBincreased(UCB)increasedincreasedCBnormalincreasedmarkedlyincreasedCB/TB＜15％一20％＞30％一40％＞50％一60％urinebilirubin—十十十urobilinogenincreasedslightincreaseddecreasedorabsenceALT、ASTnormalmarkedlyincreasedmayincreasedALPnormalincreasedmarkedlyincreasedr-GTnormalincreasedmarkedlyincreasedPTnormaldelayeddelayedVitKrespondnopoorgoodCholesterolnormalslightincreasedordecreasedmarkedlyincreasedSerumproteinnormalAlbdecreased,Globincreasednormal

Threekindsofjaundicelaboro494.CongenitalNonhemolyticJaundiceDuetothedeficiencyofthehepatocyteinuptakeing,conjugatingandexcretingbilirubinUncommon4.CongenitalNonhemolyticJaun501.Gilbersyndrome:hepatocyteuptakingUCBabnormal,deficiencyofglucuronyltransferase,→UCB↑→jaundice(nosymptom,liverfunctionnormal).2.Dubin-Johnson’ssyndrome:abnormalofHepatocyteexcretingCBandsomeaniontobilecapillary→CB↑→jaundice.3.Crigler-Najjar’ssyndrome:absenceofglucuronyltransferaseinhepatocyte,UCBcan’tbetransferedtoCB，serumUCB↑→jaundice,UCB↑↑↑→nuclearjaundic,newborn,poorprediction.4.Rotor’ssyndrome:deficiencyofHepatocyteuptakingUCBandexcretingCB,→bilirubin↑→jaundice.1.Gilbersyndrome:hepatocyteu51AccessoryExamination1.Ultrosound2.Xray3.ERCP(Endoscopicretrogradecholangiopancreatography)4.PTC(Percutaneoustranshepticcholangiography)5.CT(Computedtomography)6.MRI(Magneticresonancecholangiopancreatography)7.RadioNuclideExamination8.LiverBiopsyandLC(Laparoscopy)AccessoryExamination1.Ultro52AccompanyingSymptomsFever:acutecholangitis,liverabscess,leptospirosis,septicemia,lobarpneumonia.Feverthenjaundice:virushepatitis,acutehemolysis.Upperabdominalsharppain:biliarycalculi,liverabscess,biliaryascariasis,Rightupperabdomsharppain,chill,highfever,jaundice,Charcottriadsign:acutepyogeniccholangitis,Sustainedrightupperabdominalblurorswellpain:virushepatitis,liverabscess,primarycarcinomaofliverAccompanyingSymptomsFever:ac53Hepatomegaly①Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytract②Obviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.③Notobviousenlargement,hard,edgenottidy,noduleonthesurface:cirrosis.Hepatomegal