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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