大四上课件实验诊断学症状学

1、Symptomatology症状学 (2)黄疸 jaundice腹泻 diarrhoea呕血 hematoemesisJaundice黄疸Accumulation of yellow pigment in the skin and other tissues (Bilirubin)血清胆红素升高使皮肤 黏膜 巩膜黄染Bilirubin Metabolism胆红素的代谢Bilirubin formationTransport of bilirubin in plasmaHepatic bilirubin transport hepatic uptake conjugation biliary e

2、xcretionEnterohepatic circulation胆红素形成胆红素在血浆转运肝内胆红素转运 肝细胞摄取 结合胆红素 胆道排泄肝肠循环BilirubinRBCs Senecent RBCsironhemoglobinglobinbilirubin biliverdin heme Hepatic hemoproteins nonhemoglobin hemenonhemoglobin hemoproteinPremature destruction of newly formed RBCs CMHO RCBR1-5%chiefly70+%20%120dsBilirubin Form

3、ation胆红素形成Albumin + UB UB Albumin ComplexMolarRatioBilirubinBilirubinPlasma proteinAlbuminH affinity binding sitesL affinity binding sitescan be replaced byOther organic anionsPHUB2:12:1Transport of Bilirubin in Plasma胆红素在血浆中的转运 CB1. Hepatic uptake of BilirubinUCBAlbumin Complex SeparatedBilirubin P

4、lasma membrane of the liver(be) taken upMTA (receptor ?) Transfer acrossMicrovillar membrane3.Biliary Excretion of BilirubinBile canaliculus2.Conjugation of BilirubinUCB carrier proteinERCBGACB(be) bound totransferConjugation(catalized by UDPGT)Z proteinligation (Y protein)(lipid soluble)(water solu

5、ble)Hepatic Bilirubin Transport肝细胞内胆红素转运CBB and IUrobilinogens (coloress) be degradedBacterial Enzymesfeces (feceal urobilinogens)Reabsorbedplasmacirculationkidneys50-200 mg/dmostlyurine urobilinogen4 mg/dTliverBilefecesre-excretedexcreted90%trace20% The direct fraction is usually 0.2 mg/100 mlThe i

6、ndirect fraction is usually 200g/d)排便次数增加伴大便性状改变Intestines Function肠道功能Classify of Diarrhea腹泻的分类Causes: digestive system diseases and general diseases 病因: 消化系统疾病和全身疾病Pathophysiological: secretory, osmotic, malabsorptional, hyperperistaltic, rapid transit 病理生理: 分泌性 高渗性 吸收障碍 渗透性 运动性Course: acute (dura

7、tion less than 2 weeks) and chronic (duration more than 2 months) 病程: 急性腹泻 慢性腹泻Causes of Diarrhea病因分类Digestive system diseases 消化系统病变Intestinal tract diseases 肠道病变Hypohydrochloria 胃酸缺乏 Diseases of the pancreas 胰腺病变Diseases of the liver and the gallbladder 肝胆疾病General diseases 全身病变Disturbance of endo

8、crine and metabolism 内分泌代谢障碍Side effect of the drugs 药物副作用Disturbance of the nervous system 神经功能紊乱Allergic diarrhea 变态反应疾病Pathophysiological Classification病理生理分类Secretory diarrhea (increased intestinal secretion) 分泌性腹泻 Osmotic diarrhea 高渗性腹泻Malabsorptional diarrhea (decreased intestinal surface area

9、 and/or intestinal absorption) 吸收功能障碍 Hyperperistaltic diarrhea 渗透性腹泻Rapid transit of intestinal contents (shortened transit time) 运动性腹泻Secretory Diarrhea分泌性腹泻infections (cholera toxin, E-colli, salmonella, staphylococcal)Hormonal (Gut Hormones, ZES, VIP), cancer (calcitonin, Prostaglandins)Miscella

10、neous (laxatives abuse, villous adenoma of the rectum)agentsAdenylate cyclasecAMP systemsecretory diarrheaactiveNaClOsmotic Diarrhea高渗性腹泻It caused by accumulation of the followings in the gut lumenwatersaltspoorly absorble solutesmaldigestion of ingested foodfailure to transport an osmotically activ

11、e dietary non electrolyte(E: glucose)intestinal Lumenbeing osmotically activediarrheaCourse of Diarrhea病程分类Acute diarrhea 急性腹泻intestinal disorders 肠道疾病 digestive systemic disease 消化系统病变 acute poisoning 急性中毒 general disorders 全身病变 general infection 全身性感染incretion and metabolic impediment 内分泌代谢障碍Chron

12、ic diarrhea 慢性腹泻other systemic disorders 其他系统疾病 nervous dysfunction 神经功能紊乱drugs side-effect 药物副作用Etiology of Acute Diarrhea急性腹泻常见病因Intestinal infection 肠道感染 Food poisoning: bacterial, plants, chemical poison (arsenic,.) 食物中毒: 细菌 植物 化学毒物如砒霜等Systematic diseases: influenza, sepsis, measles, etc 全身性感染:

13、流感 败血症 Miscellaneous: allergic diseases (allergic purpura, enteropathy.), endocrinal diseases (ZES, etc.), drugs (laxatives, 5-Fu, etc). 其他疾病: 过敏性疾病如过敏性紫癜 内分泌疾病 药物如肌松剂 Intestinal Infection肠道感染病原微生物Viral 病毒Bacterial: campylobacteria, Shigella, E. Coli, Salmoneila etc 细菌: 大肠杆菌 Fungal 真菌Parasitic: amoe

14、bic trophozoites, Giardia 寄生虫: 阿米巴滋养体 Etiology of Chronic Diarrhea慢性腹泻常见病因Intestinal 肠原性Gastric: chronic gastritis,subtotal gastrectomy, etc. 胃原性: 慢性胃炎 胃次全切除等Pancreatic: chronic pancreatitis, pancreatic cancer, etc. 胰原性: 慢性胰腺炎 胰腺癌等Hepatobiliary: liver cirrhosis, obstructive jaundice 肝胆性: 肝硬化 阻塞性黄疸En

15、docronic: hyperthyroids crisis, ZES, carcinoids 内分泌性: 甲亢危象 类癌Drugs: reserpin, ismelin, laxatives, etc. 药物性: 利血平，胍乙啶，泻药Others: uremia, hypogammaglobulemia, etc. 其他: 尿毒症 低丙种球蛋白血症等Intestinal Disease肠原性病变Infections: T.B., chronic bacteria dysentery, etc. 感染: 肠结核 慢性细菌性痢疾等Parasities: amoebic dysentery, gi

16、ardiasis, etc. 寄生虫感染: 阿米巴痢疾 贾第鞭毛虫病等IBD: ulcerative colitis, Crohns diseases, etc. 炎性肠病: 溃疡性结肠炎 克隆病malabsorption synd: lactase deficiency, etc. 吸收不良: 乳糖酶缺乏等Tumors 肿瘤Inquiry Point of Diarrhea腹泻的问诊要点Rise and course of disease 起病及病程Times and stool character 腹泻次数与大便性状Relation between diarrhea and pain 腹泻

17、与腹痛的关系 panied Symptoms 伴随症状Rise and Course of Disease起病及病程Rise rapidly and freshly: intestinal infection, food poisoning 起病急 新近出现: 肠道感染 食物中毒Long course: chronic infection, inflammation, malabsorption, intestinal tumor 慢性腹泻: 慢性感染 炎症 吸收不良 肠道肿瘤Times and Stool Character腹泻次数与大便性状Watery and large amount:

18、intestinal diseases 稀水便 量大: 小肠疾病 Bloody and pus, time more and amount less: bacteria dysentery, colon cancer 脓血便 次多量少: 细菌性痢疾 结肠癌Hogwash like: cholera 米泔水样: 霍乱 Jam like: amoeba dysentery 果酱样: 阿米巴痢疾 Asphalt like: upper digestive tract bleeding 柏油样: 上消化道出血Relation between Diarrhea and Pain腹泻与腹痛的关系Pain

19、around umbilicus and no relieve after defecation: intestinal diseases 脐周痛 便后不缓解: 小肠疾病Pain in supra-pubic region and relieve after defecation: colon diseases 下腹痛 便后缓解: 结肠疾病No abdominal pain and large volume of stool like hogwash: cholera 无腹痛 大量米泔水样便: 霍乱 panied Symptoms伴随症状Severe dehydration: cholera,

20、 pancreatic cholera-WDHA 严重脱水: 霍乱 胰原性Fever: acute bacteria dysentery, TB enteritis 发热: 急性细菌性痢疾 结核性肠炎Tenesmus: acute dysentery, proctitis 下坠感: 急性痢疾 直肠炎Markedly weight loss: cancer of gut, malabsorption 消瘦: 肠癌 吸收不良Arthralgia/arthritis: IBD, connective tissue diseases 关节病变: 炎性肠病 结缔组织病Masses: malignant

21、tumor of GI, TB, peritonitis 包块: 消化道恶性肿瘤 结核 腹膜炎 Diarrhea Caused by Enteritis小肠炎性腹泻Paste-like or water-like stool 大便呈稀糊状或水样Excessive loss of water may result in dehydration 量多 易出现脱水Pain around the umbilicus and cant be relieved by defecation 腹痛多位脐周 便后痛多不缓解Acute onset, usually caused by unsanitary mea

22、l 急性起病 多与饮食不洁有关Abrupt onset of painless watery diarrhea suggests cholera 无痛性腹泻 米泔水样便应疑及霍乱Diarrhea Caused by Colonitis结肠炎性腹泻Mucus, pus, and blood appear in the stool 大便常混粘液脓血 量少Frequent defecation (10-15/d or more) 排便次数每天可达1015次或更多Lower abdominal pain, relievable by defecation 痛多位于下腹 便后痛可减轻Tenesmus s

23、uggests the lesion is at the end of the colon 里急后重 下坠提示病变在结肠末端Long-lasting diarrhea, weight loss without fever may induce by carcinoma. 长期腹泻 消瘦 不发热注意肿瘤可能Endoscopic Image: Infectious Colitis感染性结肠炎内镜下改变Hematemesis呕血Efflux of blood from the GI tract, usually bright red or “coffee-ground” material is vo

24、mited上消化道出血经胃从口呕出Common Cause of Hematemesis常见病因Peptic ulcer 消化性溃疡Gastropathy: alcohol, aspirin, NSAIDs, stress 胃黏膜病变: 酒精 阿司匹林 非甾体消炎药 应激GE varices 胃食管静脉曲张Gastric cancer 胃癌Less Common Cause of GI Bleeding其他消化道出血病因Esophageal or intestinal neoplasm 食管和肠管肿瘤Esophagitis, malloy-weiss tear 食管炎 食管息室Anticoag

25、ulant fibrinoloytic therapy 抗凝治疗Telangiectases: aneurysm, vasculitis, dieulafoy ulcer, AV malformation 动脉瘤 脉管炎 动静脉畸形Connective tissue disease 结缔组织病Hemabilia: biliary origin, Crohns disease, amyloidosis, hematological diseases 胆管出血 克隆病 淀粉样变性 血液病Clinical Manifestation 临床表现Abdominal fort and nausea: blood stimulating in stomach 上腹部不适与恶心: 胃内血液刺激Color and volume of blood rejected: wine, coffee, turkey red 呕出血液的颜色和量: 暗红色 咖啡色 鲜红色Circulation failure: bleeding volume ratio to circulating 周围循环衰竭: 出血量占循环血量 in 1015% with syncope and chill; 头晕 畏寒 20% with sweating, limb cold and t