黄疸-09级一系-老年-麻醉-救援-心理-课件

Jaundice(黄疸)

DepartmentofGastroenterology,FirstAffiliatedHospitalofChongqingMedicalUniversityXIAOHONGTAO(陶小红)Jaundice(黄疸)DepartmentofGa1Jaundiceoricterus:Whatisjaundice?ClinicallyitistheyellowdiscolorationoftheSclera(巩膜)SkinMucousmembraneduetodepositionofbilepigment(bilirubin胆红素)

Serumtotalbilirubin(normal1.7-17.1umol/lit)Conjugatedbilirubin:0-3.42μmol/l，Unconjugatedbilirubin:1.7-13.68μmol/l.1.DEFINITIONJaundiceoricterus:Whatis22.BILIRUBINMETABNISM2.BILIRUBINMETABNISM3HemeDegradationHEMEBILIVERDINO2Fe+3NADPHNADP+(openstheporphyrinring)BILIRUBINNADPHNADP+BILIRUBINdiglucuronideBILEHemeDegradationHEMEBILIVERDIN4TheFateofBilirubin…Alb=albumin B=bilirubin GST=glutathione-S-transferaseUDPGA=uridinediphosphoglucuronicacid; CB=conjugatedbilirubinUGT1A1=UDP-glucuronosyltransferase1A1MRP2=Multi-drugResistanceProtein2AdaptedfromHarrison’s15thEd.“PrinciplesofInternalMedicine”,2001.MRP2B+GSTCBPlasmaHepaticCellBileAlbBAlb?:GSTBsERB+UDPGAUGT1A1TheFateofBilirubin…Alb=al5BilirubinExcretionIntestinesLiverBCBCBBUrobilinogenB-glucoronidasebacteriabacteriaBileEnterohepaticcirculationKidneyUrobilinoxUrobilinogenUrobilinStercobilinStercobilingogenfecesUrineoxBilirubinExcretionIntestinesL6LiverAlbuninHemeFerrohemetransferaseBilirubinConjugatedbilirubinKidneyUrobilinStercobilinogenUrobilinogenIntestinesAlbuminBilirubinreductaseHemeGlobinHemoglobinoxidaseBiliverdinMarrowInfantilityErythrocyteFerrohemeEnzyme15%~20%Bilirubin|AlbuminErythrocyte80%~85%UDPUDPGABilirubinglucuronolactoneurobilinogenEnterohepaticcirculationY/ZproteincathepsinErythrocyteBiochemicalchangeofNormalbilirubinmetabolismLiverAlbuninHemeFerrohemetrans73.CLASSFICATION1.DependingonEtiologyHemolyticJaundice（溶血性黄疸）HepatocellularJaundice（肝细胞性黄疸）CholestaticJaundice（胆汁淤积性黄疸）Congenitaljaundice（先天性黄疸）

2.DependingonbilirubinUnconjungatedbilirubinincreasedjaundiceConjungatedbilirubinincreasedjaundice3.CLASSFICATION1.Dependingo8Etiology1.Congenitalhemolyticanemia(thalassemia(海洋性贫血),hereditaryspherocytosis(遗传性球形红细胞增多症)).2.Posteriorityacquiredhemolyticanemia(autoimmunityhemolyticanemia,hemolyticdiseaseofnewborn,

posttransfusionhemolytic,Favism(蚕豆病).MechanismAlargenumberoferythrocytedestroyedrapidlyAnemia,hypoxiaandtoxityoferythocytemetabolismproducts3.1.HemolyticJaundiceEtiology3.1.HemolyticJaundi9HemolyticJaundicemechanismHemolyticJaundicemechanism10ClinicalManifestation

Mildjaundice,lightlemon,noskinitch(痒).Acutehemolysis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(血红蛋白尿),acuterenalfailure.Chronichemolysis:anemiaandsplenomegaly(脾大).ClinicalManifestation11LaboratoryExamination

1.SerumTB↑,UCB↑,CBnormal.2.UCB↑→intestinalCB↑→faecalcolordeepen.3.IntestinalUrobilinogen(尿胆原)↑→urinaryUrobilinogen↑.4.Acutehemolytis,occultbloodtest(+).5.Bloodtest:anemia,reticulocyte(网织红细胞)↑,erythrocyteproliferation↑.LaboratoryExamination123.2.HepatocellularJaundiceEtiologyHepatocytedamage.MechanismImpairhepatocyteuptakeing,conjugatingandexcretingbilirubin,UCB↑CBrefluxintoblood,serumCB↑→jaundice.3.2.HepatocellularJaundiceE13HepatocellularJaundicemechanismHepatocellularJaundicemechan14ClinicalManifestation

Skinandmucosa:lighttodeepyellow,mildskinitch(痒)Tired,lossofappetitehemorrhagictendency,ascites,coma.PrimarydiseasemanifestationClinicalManifestation15LaboratoryExamination

CB↑,UCB↑Icterichepatitis:CB↑↑UCB↑Urine:CB(+),urobilinogen↑Bloodtest:liverdamagedLaboratoryExamination163.3.CholestaticJaundiceEtiologyObstructioninliver:virushepatitis,drugcaused,drughepatitis,primarybiliarycirrhosis.ObstructionofExtrahepaticbileduct:narrow,obstruction,stone,inflammtory,tumor.MechanismObstructioncausessmallbileductandbilecapillarybroken,conjugatedbilirubinrefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombus(胆栓)formation.3.3.CholestaticJaundic17CholestaticJaundicemechanismCholestaticJaundicemechanism18ClinicalManifestationSkindarkyellow,yellowgreen.Skinitch(痒),bradycardia(心动过缓),darkyellowofurine,faecallightyelloworclaycolor.Courvoisier’ssign.ClinicalManifestation19LaboratoryExamination

SerumCB↑Urinebilirubin(+)Urobilinogen,stercobilin(粪胆原)↓orabsenceSerumalkalinephosphataseandCholesterol(胆固醇)↑LaboratoryExamination20A.Hemolyticanemiaexcesshemolysis

unconjugatedbilirubin(inblood)conjugatedbilirubin(releasedtobileduct)UB

UrobilinogenB.Hepatitisunconjugatedbilirubin(inblood)conjugatedbilirubin(inblood)

UB

UrobilinogenC.Biliaryductstoneunconjugatedbilirubin(inblood)conjugatedbilirubin(inblood)

UBUrobilinogen

A.Hemolyticanemiaexcess21黄疸》-09级一系-老年-麻醉-救援-心理-课件225.GeneticDisordersofBilirubinMetabolismConditionDefectBilirubinClinical

FindingsCrigler-NajjarsyndromeseverelydefectiveUDP-glucuronyltransferaseUnconjugatedbilirubin

ProfoundjaundiceGilbertssyndromereducedactivityofUDP-glucuronyltransferaseUnconjugatedbilirubin

VerymildjaundiceduringillnessesDubin-JohnsonsyndromeabnormaltransportofconjugatedbilirubinintothebiliarysystemConjugatedbilirubin

ModeratejaundiceRotorssyndromedeficiencyofuptakingUCBandexcretingCB,CB↑jaundice.5.GeneticDisordersofBiliru23Crigler-NajjarsyndromeGilbertssyndromeCrigler-Najjarsyndrome24Threekindsofjaundicelaborotoryexaminationindentification

ClassHemolyticHepatocellularCholestatic

TBincreasedincreasedincreasedCBnormalincreasedmarkedlyincreasedCB/TB＜15％一20％＞30％一40％＞50％一60％urinebilirubin—十十十urobilinogenincreasedslightincreaseddecreasedorabsenceALT、ASTnormalmarkedlyincreasedmayincreasedALPnormalincreasedmarkedlyincreasedr-GTnormalincreasedmarkedlyincreasedPTnormaldelayeddelayedVitKrespondnopoorgoodCholesterolnormalslightincreasedordecreasedmarkedlyincreasedSerumproteinnormalAlbdecreased,Globincreasednormal

Threekindsofjaundicelaboro25AccessoryExamination

1.Ultrosound2.Xray3.ERCP(Endoscopicretrogradecholangiopancreatography,逆行胰胆管造影)4.PTC(Percutaneoustranshepticcholangiography,经皮肝穿刺胆管造影)5.CT(Computedtomography)6.MRI(Magneticresonancecholangiopancreatography)7.LiverBiopsyandLC(Laparoscopy，腹腔镜)AccessoryExamination1.Ultro26AccompanyingSymptoms

Fever:acutecholangitis,liverabscess,leptospirosis(钩端螺旋体病),septicemia(败血症),lobarpneumonia(大叶性肺炎).Feverthenjaundice:virushepatitis,acutehemolysis.Upperabdominalsharppain:biliarycalculi(胆道结石),liverabscess,biliaryascariasis(胆道蛔虫病),Rightupperabdomsharppain,chill,highfever,jaundice,Charcottriadsign:acutepyogeniccholangitis(急性化脓性胆管炎),Sustainedrightupperabdominalblurorswellpain:virushepatitis,liverabscess,primarycarcinomaofliverAccompanyingSymptomsFever:a27Hepatomegaly(肝大)①Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytract②Obviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.③Notobviousenlargement,hard,edgenottidy,noduleonthesurface:cirrhosis.Hepatomegaly(肝大)28Gallbladderenlargement:commonbileductobstruction,pancreaticheadcarcinoma,commonbileductcarcinoma,carcinomaofampulla.Splenomegaly:virushepatitis,leptospirosis(钩端螺旋体病),septicemia(败血症),Malaria(疟疾),cirrhosis,hemolyticanemia,lymphoma(淋巴瘤).Acites:serioushepatitis,decompensationofcirrosis(肝硬化失化偿期),carcinomaofliver.Gallbladderenlargement:commo29InquisitionPoints（问诊要点）1.Assurejaundice2.Etiologyandonset3.Accompanysyndrome4.Timeandfluctuationofjaundice5.InfluncetotheoverallhealthInoneword:makesurethetypeofjaundice,andthenfindthepathogenyInquisitionPoints（问诊要点）1.Ass30RecognisejaundicePosition：sclera,skinandtonguesleeves

Pseudojaundice(假性黄疸):eatCarotene(胡罗卜素)food(Carotene,pumpkin(南瓜),tomato,orange)alsocancauseskinstainedyellow,butbilirubinisnotincreased.Oldpeoplefataccumulationatbulbarconjunctiva(球结膜),yellow,unevendistributionRecognisejaundice31Questions1)Unconjugatedhyperbilirubinemiausuallyresultsfromaintra-orextrahepaticbiliaryobstruction.A.TrueB.FalseQuestions1)Unconjugatedhype322)Clinicalfeaturesofcholecystitisincludeallofthefollowingexcept:A.RUQabdominalpainB.RadiationtoRupperbackC.Nausea,VomitingD.+Murphy’ssignE.Fever2)Clinicalfeaturesofchole333)Amarkerofacutehepatocyteinjuryis:A.PTB.ALTC.AlbuminD.DirectbilirubinE.Ammonia3)Amarkerofacutehepatocy341.A13yearsoldmale,chiefcomplaints“Findingskinandsclerayellowandfeelingrightupperabdomenswellpainfor1week”Bloodtest:TBil:80μmol/L,DBil:50μmol/L,ALT:1200U/L.BUltrasound:normal.Whatarethepossiblediagnosesandyoursuggestedexaminations.HepatocellularandCholesteticjaundice.Hepatitisvirustest,Urinetest,orMRCP.QuestionQuestion35ReferencebooksCecilmecidine23rdedition.Davidson’principlesandpracticeofmedicine.Harrison'sprinciplesofinternalmedicine.16thedition.ReferencebooksCecilmecidine36Jaundice(黄疸)

DepartmentofGastroenterology,FirstAffiliatedHospitalofChongqingMedicalUniversityXIAOHONGTAO(陶小红)Jaundice(黄疸)DepartmentofGa37Jaundiceoricterus:Whatisjaundice?ClinicallyitistheyellowdiscolorationoftheSclera(巩膜)SkinMucousmembraneduetodepositionofbilepigment(bilirubin胆红素)

Serumtotalbilirubin(normal1.7-17.1umol/lit)Conjugatedbilirubin:0-3.42μmol/l，Unconjugatedbilirubin:1.7-13.68μmol/l.1.DEFINITIONJaundiceoricterus:Whatis382.BILIRUBINMETABNISM2.BILIRUBINMETABNISM39HemeDegradationHEMEBILIVERDINO2Fe+3NADPHNADP+(openstheporphyrinring)BILIRUBINNADPHNADP+BILIRUBINdiglucuronideBILEHemeDegradationHEMEBILIVERDIN40TheFateofBilirubin…Alb=albumin B=bilirubin GST=glutathione-S-transferaseUDPGA=uridinediphosphoglucuronicacid; CB=conjugatedbilirubinUGT1A1=UDP-glucuronosyltransferase1A1MRP2=Multi-drugResistanceProtein2AdaptedfromHarrison’s15thEd.“PrinciplesofInternalMedicine”,2001.MRP2B+GSTCBPlasmaHepaticCellBileAlbBAlb?:GSTBsERB+UDPGAUGT1A1TheFateofBilirubin…Alb=al41BilirubinExcretionIntestinesLiverBCBCBBUrobilinogenB-glucoronidasebacteriabacteriaBileEnterohepaticcirculationKidneyUrobilinoxUrobilinogenUrobilinStercobilinStercobilingogenfecesUrineoxBilirubinExcretionIntestinesL42LiverAlbuninHemeFerrohemetransferaseBilirubinConjugatedbilirubinKidneyUrobilinStercobilinogenUrobilinogenIntestinesAlbuminBilirubinreductaseHemeGlobinHemoglobinoxidaseBiliverdinMarrowInfantilityErythrocyteFerrohemeEnzyme15%~20%Bilirubin|AlbuminErythrocyte80%~85%UDPUDPGABilirubinglucuronolactoneurobilinogenEnterohepaticcirculationY/ZproteincathepsinErythrocyteBiochemicalchangeofNormalbilirubinmetabolismLiverAlbuninHemeFerrohemetrans433.CLASSFICATION1.DependingonEtiologyHemolyticJaundice（溶血性黄疸）HepatocellularJaundice（肝细胞性黄疸）CholestaticJaundice（胆汁淤积性黄疸）Congenitaljaundice（先天性黄疸）

2.DependingonbilirubinUnconjungatedbilirubinincreasedjaundiceConjungatedbilirubinincreasedjaundice3.CLASSFICATION1.Dependingo44Etiology1.Congenitalhemolyticanemia(thalassemia(海洋性贫血),hereditaryspherocytosis(遗传性球形红细胞增多症)).2.Posteriorityacquiredhemolyticanemia(autoimmunityhemolyticanemia,hemolyticdiseaseofnewborn,

posttransfusionhemolytic,Favism(蚕豆病).MechanismAlargenumberoferythrocytedestroyedrapidlyAnemia,hypoxiaandtoxityoferythocytemetabolismproducts3.1.HemolyticJaundiceEtiology3.1.HemolyticJaundi45HemolyticJaundicemechanismHemolyticJaundicemechanism46ClinicalManifestation

Mildjaundice,lightlemon,noskinitch(痒).Acutehemolysis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(血红蛋白尿),acuterenalfailure.Chronichemolysis:anemiaandsplenomegaly(脾大).ClinicalManifestation47LaboratoryExamination

1.SerumTB↑,UCB↑,CBnormal.2.UCB↑→intestinalCB↑→faecalcolordeepen.3.IntestinalUrobilinogen(尿胆原)↑→urinaryUrobilinogen↑.4.Acutehemolytis,occultbloodtest(+).5.Bloodtest:anemia,reticulocyte(网织红细胞)↑,erythrocyteproliferation↑.LaboratoryExamination483.2.HepatocellularJaundiceEtiologyHepatocytedamage.MechanismImpairhepatocyteuptakeing,conjugatingandexcretingbilirubin,UCB↑CBrefluxintoblood,serumCB↑→jaundice.3.2.HepatocellularJaundiceE49HepatocellularJaundicemechanismHepatocellularJaundicemechan50ClinicalManifestation

Skinandmucosa:lighttodeepyellow,mildskinitch(痒)Tired,lossofappetitehemorrhagictendency,ascites,coma.PrimarydiseasemanifestationClinicalManifestation51LaboratoryExamination

CB↑,UCB↑Icterichepatitis:CB↑↑UCB↑Urine:CB(+),urobilinogen↑Bloodtest:liverdamagedLaboratoryExamination523.3.CholestaticJaundiceEtiologyObstructioninliver:virushepatitis,drugcaused,drughepatitis,primarybiliarycirrhosis.ObstructionofExtrahepaticbileduct:narrow,obstruction,stone,inflammtory,tumor.MechanismObstructioncausessmallbileductandbilecapillarybroken,conjugatedbilirubinrefluxtoblood.FailureofhepatocyteexcretingCB,bilirubindepositandbilethrombus(胆栓)formation.3.3.CholestaticJaundic53CholestaticJaundicemechanismCholestaticJaundicemechanism54ClinicalManifestationSkindarkyellow,yellowgreen.Skinitch(痒),bradycardia(心动过缓),darkyellowofurine,faecallightyelloworclaycolor.Courvoisier’ssign.ClinicalManifestation55LaboratoryExamination

SerumCB↑Urinebilirubin(+)Urobilinogen,stercobilin(粪胆原)↓orabsenceSerumalkalinephosphataseandCholesterol(胆固醇)↑LaboratoryExamination56A.Hemolyticanemiaexcesshemolysis

unconjugatedbilirubin(inblood)conjugatedbilirubin(releasedtobileduct)UB

UrobilinogenB.Hepatitisunconjugatedbilirubin(inblood)conjugatedbilirubin(inblood)

UB

UrobilinogenC.Biliaryductstoneunconjugatedbilirubin(inblood)conjugatedbilirubin(inblood)

UBUrobilinogen

A.Hemolyticanemiaexcess57黄疸》-09级一系-老年-麻醉-救援-心理-课件585.GeneticDisordersofBilirubinMetabolismConditionDefectBilirubinClinical

FindingsCrigler-NajjarsyndromeseverelydefectiveUDP-glucuronyltransferaseUnconjugatedbilirubin

ProfoundjaundiceGilbertssyndromereducedactivityofUDP-glucuronyltransferaseUnconjugatedbilirubin

VerymildjaundiceduringillnessesDubin-JohnsonsyndromeabnormaltransportofconjugatedbilirubinintothebiliarysystemConjugatedbilirubin

ModeratejaundiceRotorssyndromedeficiencyofuptakingUCBandexcretingCB,CB↑jaundice.5.GeneticDisordersofBiliru59Crigler-NajjarsyndromeGilbertssyndromeCrigler-Najjarsyndrome60Threekindsofjaundicelaborotoryexaminationindentification

ClassHemolyticHepatocellularCholestatic

TBincreasedincreasedincreasedCBnormalincreasedmarkedlyincreasedCB/TB＜15％一20％＞30％一40％＞50％一60％urinebilirubin—十十十urobilinogenincreasedslightincreaseddecreasedorabsenceALT、ASTnormalmarkedlyincreasedmayincreasedALPnormalincreasedmarkedlyincreasedr-GTnormalincreasedmarkedlyincreasedPTnormaldelayeddelayedVitKrespondnopoorgoodCholesterolnormalslightincreasedordecreasedmarkedlyincreasedSerumproteinnormalAlbdecreased,Globincreasednormal

Threekindsofjaundicelaboro61AccessoryExamination

1.Ultrosound2.Xray3.ERCP(Endoscopicretrogradecholangiopancreatography,逆行胰胆管造影)4.PTC(Percutaneoustranshepticcholangiography,经皮肝穿刺胆管造影)5.CT(Computedtomography)6.MRI(Magneticresonancecholangiopancreatography)7.LiverBiopsyandLC(Laparoscopy，腹腔镜)AccessoryExamination1.Ultro62AccompanyingSymptoms

Fever:acutecholangitis,liverabscess,leptospirosis(钩端螺旋体病),septicemia(败血症),lobarpneumonia(大叶性肺炎).Feverthenjaundice:virushepatitis,acutehemolysis.Upperabdominalsharppain:biliarycalculi(胆道结石),liverabscess,biliaryascariasis(胆道蛔虫病),Rightupperabdomsharppain,chill,highfever,jaundice,Charcottriadsign:acutepyogeniccholangitis(急性化脓性胆管炎),Sustainedrightupperabdominalblurorswellpain:virushepatitis,liverabscess,primarycarcinomaofliverAccompanyingSymptomsFever:a63Hepatomegaly(肝大)①Mildormoderate,softormoderatehard,smoothsurface:Virushepatitis,acuteinfectionofbiliarytract.obstructionofbiliarytract②Obviousenlargement,hard,raggedsurface:primaryorsecondarycarcinomaofliver.