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首页 张顺财-黄疸鉴别

张顺财-黄疸鉴别.ppt

张顺财-黄疸鉴别

一山之中
2010-07-12 0人阅读 举报 0 0 暂无简介

简介:本文档为《张顺财-黄疸鉴别ppt》,可适用于医药卫生领域

DifferencialDiagnosisofJaundiceDifferencialDiagnosisofJaundiceZhangshuncaiDepartmentofGastroenterology,ZhongshanHospitalSummarizationSummarizationDefinition:serumtotalbilirubin(STB)>µmolL,causingayellowcolorofskin,scleraandtissuefluidLatenticterus:anincreaseofSTBbutnotmorethanµmolL,withoutcolorchangesofskinandscleraFalsejaundice:yellowskinandsclerabutwithouthyperbilirubinemia,duetoingestionofsomedrugsandfoodsMetabolismofBilirubinMetabolismofBilirubinSourceofbilirubinTransportofbilirubinAbsorbedbyhepatocytesConjugationofbilirubinExcretionofbilirubinSourceofBilirubinSourceofBilirubinSenileredbloodcell(RBC)~RBC’slifetime:aboutdaysImmatureRBC~Others~,likefreehemeinliverandsomeproteinscontaininghemeTransportofBilirubinTransportofBilirubinCharacteristicoffreebilirubin:UnconjugatedwithglucuronatetransferaseUndissolvablePoisonoustobioticmembranewhichcontainsphospholidTransportformation:Conjugatedwithalbuminformingalbuminbilirubincomplex,andtransporttohepatocyteAbsorptionofBilirubinAbsorptionofBilirubinIntakeofunconjugatedbilirubinbySeparationofalbuminfrombilirubinBilirubinentersthehepaticcellTothemicrosomebyY,ZproteinConjugationofBilirubinConjugationofBilirubinConjugatedwithglucuronate,byglucuronidetransferaseOthers,conjugatedwithglucose,glycineCharacteristicofconjugatedbilirubinDissolvableNonpoisonoustobiomembranewhichcontainsphospholipidEliminationthroughurineExcretionofBilirubinExcretionofBilirubinCBGolgibilecapillarybiletubulebileductintestineUrobilinogenfecalbilinogenexcretionlowerileum,colonreabsorptionportalveinliverbilirubinbilesintestineClassificationofBilirubin()ClassificationofBilirubin()Byetiology:HemolyticjaundiceHepaticjaundiceObstructivejaundiceCongenitaljaundiceClassificationofBilirubin()ClassificationofBilirubin()BythetypeofbilirubinHyperbilirubinemiamainlybyunconjugatedbilirubinOverproducedbilirubin:hemolyticjaundiceBilirubinabsorptionblocked:GilbertsyndromeBilirubinconjugationblocked:GilbertsyndromeHyperbilirubinemiamainlybyconjugatedbilirubinPosthepaticobstruction:cholelithiasis,canceroftheheadofthepancreasIntrahepaticobstruction:hepatolithiasisIntrahepaticchlolestasis:hepatitis,drugs,infectionMechanismandCharacterofJaundice()MechanismandCharacterofJaundice()HemolyticjaundiceEitherkindofhemolysiscouldmakeanoverproductionofbilirubinoncethecapacityofthebilirubinmetabolismbyhepatocytesisexceeded,theserumunconjugatedbilirubinincreasedandthejaundiceforms:suchascongenitalandacquiredhemolyticjaundiceCharacterofHemolyticJaundiceCharacterofHemolyticJaundiceAlightlylemoncolorofscleraFever,backpain,paleskinWithoutitchSplenomegalyCompensativelyactivebonemarrowproliferationHyperbilirubinemiamainlybyunconjugatedbilirubin:<µmolLUrobilinogen↑,urobilin()Hemoglobinurine,urinarysiderosisHepaticJaundice()HepaticJaundice()Etiologyandmechanism:hepatocytesmaybeinjuredinanyliverdiseasesDisorderintheabsorption,conjugationandexcretion:UCB↑Bilirubindrainingdisorder:CB↑HepaticJaundice()HepaticJaundice()AlightyelloworgoldencolorofskinandscleraTheremaybeskinitchCB↑UCB↑urobilin(),urobilinogen↑ImpairedliverfunctionLiverbiopsyCholestaticJaundice()CholestaticJaundice()EtiologyandMechanismExtrahepaticobstuctivecholestasis:Intrahepaticbiliaryobstruction:cholelithiasis,carcinomaofbileductExtrahepaticbiliaryobstruction:canceroftheheadofthepancreas,carcinomaofampullaIntrahepaticobstructivecholestasis:Intrahepaticmuddystone,ClonorchissinesisdiseaseBileductobstructed→cholanjiectasis→ruptureofbileduct→bileretroflowstotheblood→conjugatedbilirubinincreasedCholestaticJaundice()CholestaticJaundice()Intrahepaticcholestasis:bileproductionandexcretion↓infection,drugsChangesinthestructureandfunctionofthehepaticcellmembraneDysfunctionofmicrotubuleandmicrofilamentThepermeabilityofbilecapillarymembraneandtightjunction↑DisorderinthebileacidmetabolismCharacterofCholestaticJaundiceCharacterofCholestaticJaundiceDarkyellowskinObviousskinitchHyperbilirubinemiamainlybyconjugatedbilirubinUrobilin()Urobilinogen↓or()Fecal:lightgrayorpotter’sclaycolorCholesterol,γGTandALP↑↑↑CongenitalNonhemolyticJaundice()CongenitalNonhemolyticJaundice()Gilbertsyndromedisorderinabsorptionandconjugationofbilirubin(innateinadequateofglucuronidetransferase)Character:HyperbilirubinemiamainlybyunconjugatedbilirubinSTB<µmolLNohemolysisNormalliverfunctionNormalcholecystographyCongenitalNonhemolyticJaundice()CongenitalNonhemolyticJaundice()DubinJohnsonsyndromeDisorderinexcretionofconjugatedbilirubinandorganicnegativeionCharacterHyperbilirubinemiamainlybyconjugatedbilirubinICGtest↓Cholecystomy:BlackmegalohepatiaCongenitalNonhemolyticJaundice()CongenitalNonhemolyticJaundice()Rotorsyndromeintakeorexcretiondisordercharacter:HyperbilirubinemiamainlybyconjugatedbilirubinICGtest↓Cholecystomy:normalorLiverbiopsy:normal,withoutmegalohepetiaCriglerNajjarsyndromelackofglucuronidetransferaseusuallydiedofnuclearjaundiceDifferntiationDiagnosisofJaundiceDifferntiationDiagnosisofJaundiceDiagnosisSTB>µmolLClassificationHistory,signsandmajorlaboratoryexaminationsSomespecialexaminationsmaybekeypointLiverFunction,UrobilinogenandUrobilinLiverFunction,UrobilinogenandUrobilinTheimportanceofhistory,symptomsandsigns()historyTheimportanceofhistory,symptomsandsigns()historyhistoryagesnewbornsphysicaljaundice、neonataljaundice、congenitalatresiaofbiliaryductsenilecarcinomaContacthistorydrugs、poisons、bloodtransfusedandothercontagiousdiseaseFamilyhistorycongenitaljaundice、hemolytichistoryPasthistorybiliaryoperationorliverdiseasePregnanthistoryacutefattyliverofpregnancy、severehepatitis、recurrentjaundiceofpregnantClinicalcoursehepatitis:monthcholelithiasis:mightrecurTheimportanceofhistory,symptomsandsigns()symptomsTheimportanceofhistory,symptomsandsigns()symptomsfeverbiliarydiseasecholangitis:hyperpyrexiaabdominalpainbiliarycolic,upperabdominalandbackpaindyspepsiaviralhepatitis、canceroftheheadofthepancreasskinitchcholestaticjaundiceandhepaticjaundiceweightobviouslyreduceinpatientswithmalignantdiseasecolorofurineandfecalcholestaticjaundice:lightgrayorpotter’sclaycolorfecalTheimportanceofhistory,symptomsandsigns()signsTheimportanceofhistory,symptomsandsigns()signsSkinhemolytic:palehepatic:hepaticpalm,spidernevus,hepaticfaceobstructic:skinitch,pigmentation,eyelidsxanthomaHepatomegalyacutehepatitis:megaloheptia、softtouchhepatocarcinoma:swelling,hardtouchwithtuberclecirrhosis:shrink,hardtouchbloodflowdisorder:megalohepetia,palpationpainSplenomegalycirrhosis:megalospleniaCholecystomegalyextrahepaticobstruction:Courvoisier`ssignOthersascites、breastdevelopmentinmalecirrhosis,hematoascitestumorOtherLaboratoryExaminationsOtherLaboratoryExaminationsDifferencialDiagnosisofJaundiceDifferencialDiagnosisofJaundiceClinicalexaminationMultiplebiochemicalexaminationabnormalsinglebiochemicalexaminationabnormalultrasoundHemolytictestBileacidhighnormalDubinJohnsonGilbertCholangiectasisERCPorPTCNocholangiectasisAccorddifferentOtherexaminationsbiopsyCTorandERCP,PTCdiagnosis

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