诊断学 黄疸(英文)

Jaundice(黄疸)Jaundice(icterus):Whatisjaundice?meanstheSclera(巩膜),SkinandMucousmembrane(粘膜)turnedyellow

duetoascentofbilirubin(胆红素)inserum.Serumtotalbilirubin(normal1.7-17.1μmol/L)Conjugatedbilirubin:0-3.42μmol/L，Unconjugatedbilirubin:1.7-13.68μmol/L1.DEFINITION2Occultjaundice（隐性黄疸）：17.1μmol/L<TotalBilirubin(TBIL)<34.2μmol/LJaundice（黄疸）：TotalBilirubin(TBIL)>34.2μmol/L32.BILIRUBINMETABNISM（胆红素的代谢）4Importantconceptions:1）TBIL(totalbilirubin):总胆红素2）UCB(unconjugatedbilirubin,非结合胆红素）：Cannotbefiltratedthroughglomerulusbecauseitdoesnotdissolveinwater,soitwon’tshowinurine.（不溶于水，故不能从肾小球滤过，因此不出现在尿液中）3）CB(conjugatedbilirubin,结合胆红素)：water-soluble,canbefiltratedthroughglomerulusandwillshowinurine.（溶于水，能通过肾小球从尿中排出）

TBIL=UCB+CB5OriginsofUCB（非结合胆红素的来源）：

Majororigin(80-85%):

mononuclearphagocyte(单核吞噬细胞）Oldredbloodcellsbilirubin,iron,globin

(胆红素，鉄和珠蛋白)2)Anotherorigin(15-20%):bypassbilirubin（旁路胆红素）Immatureredbloodcellsinmarrow（骨髓）Proteininliverwhichcontainferroheme（亚铁血红素）6OriginsofCB（结合胆红素的来源）：UCBcombinedwithserunalbumin（UCB与血清清蛋白结合）

glucuronyltransferase

（葡萄糖醛酸转移酶）LiverCBIntestinaltractBiliarytract

Urobilinogen（尿胆原）

portalveinofliverstercobilin

（粪胆素）urine胆红素的肝肠循环(Bilirubinenterohepaticcirculation)

7***Bilirubinenterohepaticcirculation:(胆红素的肝肠循环)

CBistransportedfromlivertobileduct,andexcretedintointestinaltract,whichisdeoxidizedtourobilinogenbythedehydrogenationofintestinalbacteria.themajorityof

urobilinogenisexcretedinfeces,andTheminorityofurobilinogenisabsorbedintoliverthroughportalvein,thenconvertedintoCBandexcretedintointestinaltract.结合胆红素经过肝脏转运至胆管，随胆汁排入肠道，在肠道细菌脱氢作用下还原为尿胆原，尿胆原的大部分氧化为尿胆素从粪便中排出，又称为粪胆素，小部分在肠内被吸收，经肝门静脉回到肝内，其中的大部分再转变为结合胆红素，又随胆汁排入肠内。83.CLASSFICATION1.DependingonEtiologyHemolyticJaundice（溶血性黄疸）HepatocellularJaundice

（肝细胞性黄疸）CholestaticJaundice

（胆汁淤积性黄疸）Congenitalnon-hemolyticjaundice（先天性非溶血性黄疸）

2.DependingonbilirubinUnconjugatedbilirubinincreasedjaundiceConjugatedbilirubinincreasedjaundice9Etiology:1.Congenitalhemolyticanemia（先天性溶血性黄疸）:1)thalassemia(海洋性贫血),2)hereditaryspherocytosis(遗传性球形红细胞增多症)).2.Posteriorityacquiredhemolyticanemia（后天获得性溶血性黄疸）1)autoimmunityhemolyticanemia（自身免疫性溶血性贫血）2)hemolyticdiseaseofnewborn（新生儿溶血）3)Posttransfusionhemolysis（输血后溶血）4)Favism(蚕豆病).Mechanism:Alargenumberoferythrocytes（红细胞）destroyedrapidly,thenformedUCB,whichexceededhepaticcapacityofabsorbing,combiningandexcreting.Anemia,hypoxiaandtoxityoferythocytesmetabolismproductscanweakenedmetabolicfunctionofliver.3.1.HemolyticJaundice10HemolyticJaundicemechanism11ClinicalManifestation:

Mildjaundice,lightlemon,noskinitch(痒).Acutehemolysis（急性溶血）:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(血红蛋白尿),acuterenalfailure.Chronichemolysis（慢性溶血）:anemia,splenomegaly(脾大).12LaboratoryExamination:

1.Serum:TB↑,UCB↑,CBnormal.2.UCB↑→intestinalCB↑→fecalcolordeepen.3.IntestinalUrobilinogen(肠内尿胆原)↑→urinaryUrobilinogen(尿中尿胆原)↑andurinarybilirubinisnegative（尿胆红素阴性）.4.Acutehemolysis:occultbloodtestinurine(+)（尿隐血阳性）5.Bloodtest:anemia,reticulocyte(网织红细胞)↑,erythrocyteproliferationinmarrow↑.133.2.HepatocellularJaundiceEtiology：Hepatocytedamage:hepatitis,livercirrhosis,sepsis（败血症）Mechanism：Abilityofuptaking,conjugatingandexcretingbilirubininImpairedhepatocytesdecreased,UCB↑CBrefluxintoblood,serumCB↑→jaundice.14HepatocellularJaundicemechanism15ClinicalManifestation:

Skinandmucosa:lighttodeepyellow,mildskinitch(痒)Tired,lossofappetitehemorrhagictendency,ascites,coma.Primarydiseasemanifestation16LaboratoryExamination:

CB↑,UCB↑Icterichepatitis（黄疸型肝炎）:CB↑↑UCB↑Urine:urinebilirubin(+),urobilinogen（尿胆原）↑Bloodtest:hepaticfunctiondamaged173.3.CholestaticJaundiceEtiology:Obstructioninliver:

virushepatitis,druginducedhepatitis,primarybiliarycirrhosis,

Jaundiceduringpregnancy.Extrahepaticobstruction:

choledocholithiasis（胆总管结石）,biliarytractnarrow,inflammatory,tumorandascarid（蛔虫）.18Mechanism:Obstructioncausessmallbileductandbilecapillarybroken,CBwithinbilerefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombus(胆栓)formation.19CholestaticJaundicemechanism20ClinicalManifestation:Skindarkyellow,yellowgreen.Skinitch(痒),bradycardia(心动过缓),darkyellowofurine（尿色深）,facallightyelloworclaycolor（陶土便）.Courvoisier’ssign.21LaboratoryExamination：

SerumCB↑Urinebilirubin(+)Urobilinogen（尿胆原）andstercobilin(粪胆原)descendorabsenceSerumalkalinephosphataseandCholesterol(胆固醇)↑22A.Hemolyticanemiaexcesshemolysis

unconjugatedbilirubin(inblood)

conjugatedbilirubin(releasedtobileduct)-Urinebilirubin

UrobilinogenB.Hepatitis

unconjugatedbilirubin(inblood)

conjugatedbilirubin(inblood)

Urinebilirubin

UrobilinogenC.Biliaryductstone

unconjugatedbilirubin(inblood)

conjugatedbilirubin(inblood)

UrinebilirubinUrobilinogen

Jaundicemechanism233.4Congenitalnon-hemolyticjaundice（先天性非溶血性黄疸）Mechanism:Disorderofintaking,combiningandexcretionbilirubininhepatocyte.

24GeneticDisordersofBilirubinMetabolismConditionDefectBilirubinClinicalFindingsCrigler-NajjarsyndromeseverelydefectiveUDP-glucuronyltransferaseUnconjugatedbilirubin

ProfoundjaundiceGilbertssyndromereducedactivityofUDP-glucuronyltransferaseUnconjugatedbilirubin

VerymildjaundiceduringillnessesDubin-JohnsonsyndromeabnormaltransportofconjugatedbilirubinintothebiliarysystemConjugatedbilirubin

Moderatejaundice

Rotorssyndrome

deficiencyofuptakingUCBandexcretingCB,CB↑jaundice.25Threekindsofjaundicelaborotoryexaminationindentification

ClassHemolyticHepatocellularCholestatic

TBincreasedincreasedincreased

CBnormalincreasedmarkedlyincreased

CB/TB

＜15％一20％＞30％一40％＞50％一60％

urinebilirubin－

＋

＋＋

urobilinogenincreasedslightincreaseddecreasedorabsence

ALT、ASTnormalmarkedlyincreasedmayincreased

ALPnormalincreasedmarkedlyincreased

r-GTnormalincreasedmarkedlyincreased

PTnormaldelayeddelayed

VitKrespondnopoorgood

Cholesterolnormalslightincreasedordecreasedmarkedlyincreased

SerumproteinnormalAlbdecreased,Globincreasednormal

26AccessoryExamination

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)27AccompanySymptoms

Fever:

acutecholangitis,liverabscess,leptospirosis(钩端螺旋体病),septicemia(败血症),lobarpneumonia(大叶性肺炎),virushepatitis,acutehemolysis.2.Upperabdominalsharppain:1)Charcottriadsign:Rightupperabdominalsharppain,chill,highfever,jaundice,whichcanbefoundinacutepyogeniccholangitis(急性化脓性胆管炎)2)Sustainedrightupperabdominalpain:virushepatitis,hepatopostema（肝脓肿）,primarycarcinomaofliver3)firstlyabdominalpain,thenjaundice:

biliarycalculi(胆道结石),biliaryascariasis(胆道蛔虫病)28Hepatomegaly(肝大)1)Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytract2)Obviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.3)Notobviousenlargement,hard,edgenottidy,noduleonthesurface:cirrhosis.29Gallbladderenlargement:commonbileductobstruction,pancreaticheadcarcinoma,commonbileductcarcinoma,carcinomaofampulla(壶腹）.Splenomegaly:virushepatitis,leptospirosis(钩端螺旋体病),septicemia(败血症),Malaria(疟疾),cirrhosis,hemolyticanemia,lymphoma(淋巴瘤).Ascites:serioushepatitis,decompensationofcirrhosis(肝硬化失化偿期),carcinomaofliver.30InquisitionPoints（问诊要点）1.Assurejaundice2.Etiologyandonset3.Accompanysyndrome4.Timeandfluctuationofjaundice5.InfluncetotheoverallhealthInoneword:makesurethetypeofjaundice,andthenfindthepathogeny31Recognisejaundice:1)Position：sclera,skinandtonguesleeves2)Pseudojaund