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张顺财-黄疸鉴别nullDifferencial Diagnosis of JaundiceDifferencial Diagnosis of JaundiceZhang shuncai Department of Gastroenterology, Zhongshan HospitalSummarizationSummarizationDefinition: serum total bilirubin (STB) > 34µmol/L, causing a yellow color of skin, sclera and tis...

张顺财-黄疸鉴别
nullDifferencial Diagnosis of JaundiceDifferencial Diagnosis of JaundiceZhang shuncai Department of Gastroenterology, Zhongshan HospitalSummarizationSummarizationDefinition: serum total bilirubin (STB) > 34µmol/L, causing a yellow color of skin, sclera and tissue fluid Latent icterus: an increase of STB but not more than 34µmol/L, without color changes of skin and sclera False jaundice: yellow skin and sclera but without hyperbilirubinemia, due to ingestion of some drugs and foodsMetabolism of BilirubinMetabolism of BilirubinSource of bilirubin Transport of bilirubin Absorbed by hepatocytes Conjugation of bilirubin Excretion of bilirubinSource of BilirubinSource of BilirubinSenile red blood cell (RBC) 80~85 % RBC’s lifetime: about 120 days Immature RBC 10~15% Others 1~5%, like free heme in liver and some proteins containing hemeTransport of BilirubinTransport of BilirubinCharacteristic of free bilirubin: Unconjugated with glucuronate transferase Undissolvable Poisonous to biotic membrane which contains phospholid Transport formation: Conjugated with albumin forming albumin-bilirubin complex, and transport to hepatocyte Absorption of BilirubinAbsorption of Bilirubin1. Intake of unconjugated bilirubin by ? 2. Separation of albumin from bilirubin. 3. Bilirubin enters the hepatic cell. 4. To the microsome by Y,Z proteinConjugation of BilirubinConjugation of BilirubinConjugated with glucuronate 75%, by glucuronide transferase Others 25%, conjugated with glucose, glycine Characteristic of conjugated bilirubin Dissolvable Nonpoisonous to biomembrane which contains phospholipid Elimination through urineExcretion of BilirubinExcretion of Bilirubin CB Golgi bile capillary bile tubule bile duct intestine Urobilinogen fecalbilinogen excretion lower ileum,colon reabsorption portal vein liver bilirubin biles intestine Classification of Bilirubin (1)Classification of Bilirubin (1)By etiology: Hemolytic jaundice Hepatic jaundice Obstructive jaundice Congenital jaundice Classification of Bilirubin (2)Classification of Bilirubin (2)By the type of bilirubin Hyperbilirubinemia mainly by unconjugated bilirubin Over-produced bilirubin: hemolytic jaundice Bilirubin absorption blocked: Gilbert syndrome Bilirubin conjugation blocked: Gilbert syndrome Hyperbilirubinemia mainly by conjugated bilirubin Post-hepatic obstruction: cholelithiasis, cancer of the head of the pancreas Intra-hepatic obstruction: hepatolithiasis Intra-hepatic chlolestasis: hepatitis, drugs,infectionMechanism and Character of Jaundice (1)Mechanism and Character of Jaundice (1)Hemolytic jaundice Either kind of hemolysis could make an overproduction of bilirubin. once the capacity of the bilirubin metabolism by hepatocytes is exceeded, the serum unconjugated bilirubin increased and the jaundice forms: such as congenital and acquired hemolytic jaundiceCharacter of Hemolytic JaundiceCharacter of Hemolytic JaundiceA lightly lemon color of sclera Fever, back pain, pale skin Without itch Splenomegaly Compensatively active bone-marrow proliferation Hyperbilirubinemia mainly by unconjugated bilirubin: <85 µ mol/L Urobilinogen ↑, urobilin (-) Hemoglobin urine, urinary siderosisHepatic Jaundice (1)Hepatic Jaundice (1)Etiology and mechanism: hepatocytes may be injured in any liver diseases Disorder in the absorption, conjugation and excretion: UCB↑ Bilirubin draining disorder: CB↑ Hepatic Jaundice (2)Hepatic Jaundice (2)A light yellow or golden color of skin and sclera There may be skin itch CB↑ UCB↑ urobilin (+) , urobilinogen↑ Impaired liver function Liver biopsyCholestatic Jaundice (1)Cholestatic Jaundice (1)Etiology and Mechanism 1. Extra-hepatic obstuctive cholestasis: Intra-hepatic biliary obstruction: cholelithiasis, carcinoma of bile duct Extra-hepatic biliary obstruction: cancer of the head of the pancreas, carcinoma of ampulla 2. Intra-hepatic obstructive cholestasis: Intra-hepatic muddy stone, Clonorchis sinesis disease Bile duct obstructed→cholanjiectasis→rupture of bile duct→bile retroflows to the blood→conjugated bilirubin increasedCholestatic Jaundice (2)Cholestatic Jaundice (2)Intra-hepatic cholestasis: bile production and excretion↓ infection, drugs. Changes in the structure and function of the hepatic cell membrane Dysfunction of microtubule and microfilament The permeability of bile capillary membrane and tight junction ↑ Disorder in the bile acid metabolismCharacter of Cholestatic JaundiceCharacter of Cholestatic JaundiceDark yellow skin Obvious skin itch Hyperbilirubinemia mainly by conjugated bilirubin Urobilin (+) Urobilinogen ↓or (-) Fecal : light gray or potter’s clay color Cholesterol, γ-GT and ALP↑↑↑ Congenital Nonhemolytic Jaundice (1)Congenital Nonhemolytic Jaundice (1)Gilbert syndrome disorder in absorption and conjugation of bilirubin (innate inadequate of glucuronide transferase) Character: Hyperbilirubinemia mainly by unconjugated bilirubin STB < 80 µmol/L No hemolysis Normal liver function Normal cholecystographyCongenital Nonhemolytic Jaundice (2)Congenital Nonhemolytic Jaundice (2)Dubin-Johnson syndrome Disorder in excretion of conjugated bilirubin and organic negative ion Character Hyperbilirubinemia mainly by conjugated bilirubin ICG test ↓ Cholecystomy: Black megalohepatiaCongenital Nonhemolytic Jaundice (3)Congenital Nonhemolytic Jaundice (3) Rotor syndrome intake or excretion disorder character: 1. Hyperbilirubinemia mainly by conjugated bilirubin 2. ICG test ↓ 3. Cholecystomy: normal or ? 4. Liver biopsy: normal, without megalohepetia Crigler-Najjar syndrome lack of glucuronide transferase ,usually died of nuclear jaundiceDifferntiation Diagnosis of JaundiceDifferntiation Diagnosis of JaundiceDiagnosis STB>17.1 µmol/L Classification History, signs and major laboratory examinations Some special examinations may be key pointLiver Function, Urobilinogen and UrobilinLiver Function, Urobilinogen and UrobilinThe importance of history, symptoms and signs (1) historyThe importance of history, symptoms and signs (1) historyhistory ages newborns---physical jaundice、neonatal jaundice、congenital atresia of biliary duct senile-----carcinoma Contact history drugs、poisons、blood transfused and other contagious disease Family history congenital jaundice、hemolytic history Past history biliary operation or liver disease Pregnant history acute fatty liver of pregnancy、severe hepatitis、recurrent jaundice of pregnant Clinical course hepatitis: 1 month cholelithiasis: might recurThe importance of history, symptoms and signs (2) symptomsThe importance of history, symptoms and signs (2) symptoms fever biliary disease---cholangitis: hyperpyrexia abdominal pain biliary colic,upper abdominal and back pain. dyspepsia viral hepatitis、cancer of the head of the pancreas. skin itch cholestatic jaundice and hepatic jaundice. weight obviously reduce in patients with malignant disease. color of urine and fecal cholestatic jaundice: light gray or potter’s clay color fecalThe importance of history, symptoms and signs (3) signsThe importance of history, symptoms and signs (3) signs Skin hemolytic:pale hepatic:hepatic palm,spider nevus,hepatic face obstructic:skin itch,pigmentation, eyelids xanthoma Hepatomegaly acute hepatitis: megaloheptia、soft touch hepatocarcinoma:swelling,hard touch with tubercle cirrhosis:shrink, hard touch blood flow disorder:megalohepetia, palpation pain Splenomegaly cirrhosis:megalosplenia Cholecystomegaly extra-hepatic obstruction: Courvoisier`s sign Others ascites、breast development in male---cirrhosis, hematoascites---tumor Other Laboratory ExaminationsOther Laboratory ExaminationsDifferencial Diagnosis of JaundiceDifferencial Diagnosis of JaundiceClinical examinationMultiple biochemical examination abnormalsingle biochemical examination abnormalultrasoundHemolytic test+-Bile acidhighnormalDubin-Johnson Gilbert Cholangi-ectasisERCP or PTCNo cholangiectasisAccord differentOther examinationsbiopsyCT or/and ERCP,PTCdiagnosis
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