黄疸

JaundiceDefinitionAccumulationofyellowpigmentintheskinandothertissues(Bilirubin)BilirubinMetabolismBilirubinformationTransportofbilirubininplasmaHepaticbilirubintransportHepaticuptakeConjugationBiliaryexcretionEnterohepaticcirculationBilirubinformation120dsCBTransferacrossMicrovillarmembrane3.BiliaryExcretionofBilirubinBilecanaliculusHepaticBilirubinTransport(lipidsoluble)(watersoluble)Entero-hepaticcirculationCBBandIUrobilinogens(coloress)bedegradedBacterialEnzymesfeces(fecealurobilinogens)Reabsorbedplasmacirculationkidneys50-200mg/dmostlyurineurobilinogen4mg/dTtrace20% Theserumofnormaladultscontains1mgofbilirubinper100ml. InhealthyadultsThedirectfractionisusually<0.2mg/100mlTheindirectfractionisusually<0.8mg/100mlPathophysiologicclassificationofJaundiceHemolyticJaundiceHepaticJaundice CholestaticJaundice Congenitalnon-hemolyticjaundiceHemolyticJaundicePathogenesisOverproductionHemolysis(intraandextravascular)inheritedorgeneticdisordersacquiredimmunehemolyticanemia(Autoimmunehemolyticanemia)nonimmunehemolyticanemia(paroxysmalnocturnalHemoglobinuria)Ineffectiveerythropoiesis OverproductionmayoverloadtheliverwithUBHemolyticJaundiceSymptomslightyellowskincolor,darkurine,darkstool,nopruitus,anemia,fever,splenomegalyLabUCBandurobilirubin↓fecalandurineurobilinogenhemolyticanemiaALT/AST(-),ALP/GGThemoglobinuria(inacuteintravascularhemolysis)ReticulocytecountsCholestaticJaundicePathogenesisitisduetointra-andextrahepaticobstructionofbileductsintrahepaticJaundice:Hepatitis,PBC,DrugsExtraHepaticBiliaryObstruction:Stones,,Inflammation,Tumors,(AmpullaofVater)CholestaticJaundicesymptomsdarkyellowtodarkgreen(skincolor)Pruritusdarkurineandlighterstoolabdominalpain,feverChill+fever+gallbladderenlargementstone+cholangitisCholestaticJaundiceLabFindingsSerumBilirubin(CB)Fecesurobilinogen(incompleteobstruction)Fecesurobilinogenabsence(completeobstruction)urobilirubin,urobilinogenALT/ASTALP,GGTHepatocellularJaundiceDuetoadiseaseaffectivehepatictissueeithercongenitaloracquireddiffusehepatocellularinjuryHepatocellularJaundice liverfunctiontestsareabnormal bothCBandUCB urobilirubin urobilinogen ALT/AST,ALP,GGT Congenitalnon-hemolyticJaundice herediarydisorders,rare inabilityofthelivertoperformbilirubinuptake,conjugationandexcretion. include:1.Gilbert'ssyndrome2.Crigler-Najiarsyndrome3.Rotor'ssyndrome4.Dubin-JohnsonsyndromeJaundice---DiagnosticProceduresHistoryP.E.FamiliaroccurrenceofJaundiceLabfindingsImagetechniquesUltrasonographyCTMRIERCP(EndoscopicRetrogradecholangiopancreatography)PTCX-ray(GI,Angiography) Ultrasonography：evaluatingorganlesionssuchasliver,gallbladder,pancreas,spleen. CT:identifythejaundicederivedfromdifferentleisions MRI:displaythediameterofthebileductandpancreaticduct. ERCPprovidedirectobservationoflesionsintheampullaandpapilla,detectpancreaticlesions. PTCdisplaythewholebiliarysystem,distinguishbetweenextra-andintrahepaticobstructionofthebileduct.Jaundice-Differentialdiagnosis1.OnceJaundiceisrecognized,itisimportanttodeterminewhetherhyperbilirubinemiaispredominantlyCBorUCB?2.Differentiationofhemolyticfromothertypeofjaundiceisusuallynotdifficult.3.Thelaboratoryfindingsareinconstantinpartialbiliaryobstructionanddifferentiationfromintrahepaticcholestesisisparticularlydifficult.Jaundice-DifferentialdiagnosisDifferentialDiagnosis UCBorCB ExcludeUCB(e.g.hemolysisorGilbertSynd.) Distinguishhepatocellularfromobstructive Distinguishintrahepaticfromextrahepaticcholestasiskeywords HemolyticJaundice HepaticJaundiceCholestaticJaundice