阻塞性黄疸-课件

1、病例摘要患者女性，75岁，主因“皮肤黄染伴搔痒1个月”门诊入院。1个月前无明显诱因出现皮肤发黄伴搔痒，大便颜色变浅，尿色深如茶水，就诊于中医院，考虑为老年搔痒症，予以中药口服治疗。1个月来皮肤搔痒无缓解，并逐渐出现皮肤巩膜重度黄染，上腹饱胀，进食差，大便为白陶土色，体重下降15公斤。现来我院就诊。既往冠心病10年、高血压13年查体：皮肤巩膜重度黄染，右上腹可触及胆囊肿大，无压痛。1化验改变指标血清总胆红素322 umol/L(5.1-19)结合胆红素221 umol/L(0-7.0)谷氨酰转肽酶碱性磷酸酶465IU/L365IU/L(7-50)(40-150)尿三胆 尿胆红素+尿胆素原 +尿胆

2、素 +粪胆素原 -21、诊断学方面作何考虑？（黄疸类型、部位、可能的疾病）2、进一步作何检查？3阻塞性黄疸(obstructive jaundice)各种原因引起的胆汁排泄通道受阻，使胆小管和毛细胆管内压力增大破裂，致使结合胆红素逆流入血, 造成血清胆红素升高所致。4临床表现黄疸：暗黄色甚至黄绿色心动过缓皮肤搔痒（因胆盐和其胆汁成分反流入体循环内，刺激皮肤周围神经末梢所致）粪色浅甚至白陶土色尿色深5实验室检查血清TB升高，以CB升高为主CB/TB 50-60%尿胆红素试验阳性尿胆原及粪胆素减少或缺如血清碱性磷酸酶及总胆固醇增高6各种黄疸时血、尿、粪胆色素的改变指标正常溶血性黄疸肝细胞性黄疸阻塞

3、性黄疸血清胆红素浓度1mg/dl1mg/dl1mg/dl1mg/dl结合胆红素极少未结合胆红素00.7mg/dl尿三胆 尿胆红素尿胆素原少量不一定尿胆素少量不一定粪胆素原40280mg/24h或正常或粪便颜色正常深变浅或正常完全阻塞时白陶土色7Etiology of Obstructive JaundiceIntrahepatic-Liver cell Damage/Blockage of Bile CanaliculiDrugs or chemical toxinsHepatitis-viral,chemicalInfiltrative tumorsIntrahepatic biliary

4、hypoplasia or atresiaPrimary biliary cirrhosis8Etiology of Obstructive JaundiceExtrahepatic-Obstructive of bile Ducts Choledocholithiasis Gallblader stones（Mirrizzi syndrome）Cancer/Neoplasm: Pancreatic CACholangiocarcinoma (rare)Gallbladder CAAmpullary adenoma/adenocarcinomaDuodenal adenoma/adenocar

5、cinomaMetastatic CA Strictures after invasive proceduresAcute and chronic pancreatitisPrimary sclerosing cholangitis (PSC)9Imaging for Obstructive JaundiceBUS: identification of stonesEndoscopic Ultrasound (EUS): visualization of the common bile duct without the hindrance of overlying bowel gasCT sc

6、an: identification and description of obstructionERCPDirect visualization of biliary tree & pancreatic ductsDiagnostic & therapeutic MRCPPTCInjection of contrast media provides close to 100 percent sensitivity and specificity for the diagnosis of biliary tract obstruction Useful when the obstruction is proximal to the common hepatic duct1011121314151617181、诊断、诊断依据？2、如何治疗？191、进行性“无痛”性黄疸2、化验：阻塞性黄疸3、胆囊增大4、影像学检查示胆总管下端梗阻20治疗目标解除黄疸去除病灶减少复发21治疗选择引