《黄疸》-09级一系-老年-麻醉-救援-心理-陶小红-12-04-181.ppt

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Jaundice(黄疸),Department of Gastroenterology,First Affiliated Hospital of Chongqing Medical University,XIAOHONG TAO(陶小红),Jaundice or icterus:,What is jaundice?,Clinically it is the yellow discoloration of the,Sclera,(巩膜),Skin,Mucous membrane,due to deposition of bile pigment,(,bilirubin胆红素),Serum total bilirubin(normal 1.7-17.1 umol/lit),Conjugated bilirubin:0-3.42mol/l，,Unconjugated bilirubin:1.7-13.68mol/l.,1.DEFINITION,2.BILIRUBIN METABNISM,Heme Degradation,HEME,BILIVERDIN,O,2,Fe,+3,NADPH,NADP,+,(opens the porphyrin ring),BILIRUBIN,NADPH,NADP,+,BILIRUBIN diglucuronide,BILE,The Fate of Bilirubin,Alb=albuminB=bilirubinGST=glutathione-S-transferase,UDPGA=uridine diphosphoglucuronic acid;CB=conjugated bilirubin,UGT1A1=UDP-glucuronosyltransferase 1A1,MRP2=Multi-drug Resistance Protein 2,Adapted from Harrisons 15,th,Ed.“Principles of Internal Medicine”,2001.,MRP2,B,+GST,CB,Plasma,Hepatic Cell,Bile,Alb,B,Alb,?,:GST,B,sER,B,+,UDPGA,UGT1A1,Bilirubin Excretion,Intestines,Liver,B,CB,CB,B,Urobilinogen,B-glucoronidase,bacteria,bacteria,Bile,Enterohepatic circulation,Kidney,Urobilin,ox,Urobilinogen,Urobilin,Stercobilin,Stercobilingogen,feces,Urine,ox,Liver,Albunin,Heme,Ferroheme,transferase,Bilirubin,Conjugated bilirubin,Kidney,Urobilin,Stercobilinogen,Urobilinogen,Intestines,Albumin,Bilirubin,reductase,Heme,Globin,Hemoglobin,oxidase,Biliverdin,Marrow,Infantility Erythrocyte,Ferroheme Enzyme,15%20%,Bilirubin,|,Albumin,Erythrocyte,80%85%,UDP,UDPGA,Bilirubin glucuronolactone,urobilinogen,Enterohepatic circulation,Y/Z protein,cathepsin,Erythrocyte,Biochemical change of Normal bilirubin metabolism,3.CLASSFICATION,1.Depending on Etiology,Hemolytic Jaundice,（溶血性黄疸）,Hepatocellular Jaundice（肝细胞性黄疸）,Cholestatic Jaundice（胆汁淤积性黄疸）,Congenital jaundice,（先天性黄疸）,2.Depending on bilirubin,Unconjungated bilirubin increased jaundice,Conjungated bilirubin increased jaundice,Etiology,1.Congenital hemolytic anemia(,thalassemia(海洋性贫血),hereditary spherocytosis(遗传性球形红细胞增多症).,2.P,osteriority acquired hemolytic anemia(autoimmunity hemolytic anemia,hemolytic disease of newborn,posttransfusion hemolytic,Favism(蚕豆病),.,Mechanism,A large number of erythrocyte destroyed rapidly,Anemia,hypoxia and toxity of erythocyte metabolism products,3.1.Hemolytic Jaundice,Hemolytic Jaundice mechanism,Clinical Manifestation,Mild jaundice,light lemon,no skin itch(痒).,Acute hemolysis:fever,chill,headache,vomit,backache,anemia,hemoglobinuria(血红蛋白尿),acute renal failure.,Chronic hemolysis:anemia and splenomegaly(脾大).,Laboratory Examination,1.Serum TB,UCB,CB normal.,2.UCBintestinal CBfaecal color deepen.,3.Intestinal Urobilinogen(尿胆原)urinary Urobilinogen.,4.Acute hemolytis,occult blood test(+).,5.Blood test:anemia,reticulocyte(网织红细胞),erythrocyte proliferation.,3.2.Hepatocellular Jaundice,Etiology,Hepatocyte damage.,Mechanism,Impair hepatocyte uptakeing,conjugating and excreting bilirubin,UCB,CB reflux into blood,serum CBjaundice.,Hepatocellular Jaundice mechanism,Clinical Manifestation,Skin and mucosa:light to deep yellow,mild skin itch,(痒),Tired,loss of appetite,hemorrhagic tendency,ascites,coma.,Primary disease manifestation,Laboratory Examination,CB,UCB,Icteric,hepatitis:CB UCB,Urine:,CB(+),urobilinogen,Blood test:liver damaged,3.3.Cholestatic Jaundice,Etiology,Obstruction in liver:virus hepatitis,drug caused,drug hepatitis,primary biliary cirrhosis.,Obstruction of Extrahepatic bile duct:narrow,obstruction,stone,inflammtory,tumor.,Mechanism,Obstruction causes small bile duct and bile capillary broken,conjugated bilirubin reflux to blood.,Failure of hepatocyte excreting CB,bilirubin deposit and bile thrombus(胆栓)formation.,Cholestatic Jaundice mechanism,Clinical Manifestation,Skin dark yellow,yellow green.,Skin itch,(痒),bradycardia(心动过缓),dark yellow of urine,faecal light yellow or clay color.,Courvoisiers sign.,Laboratory Examination,Serum CB,Urine bilirubin(+),Urobilinogen,stercobilin(粪胆原)or absence,Serum alkaline phosphatase and Cholesterol(胆固醇),A.Hemolytic anemia,excess,hemolysis,unconjugated bilirubin,(in blood),conjugated bilirubin,(released to bile duct),UB,Urobilinogen,B.Hepatitis,unconjugated bilirubin,(in blood),conjugated bilirubin,(in blood),UB,Urobilinogen,C.Biliary duct stone,unconjugated bilirubin,(in blood),conjugated bilirubin,(in blood),UB,Urobilinogen,5.Genetic Disorders of Bilirubin Metabolism,Condition,Defect,Bilirubin,Clinical,Findings,Crigler-Najjar syndrome,severely defective,UDP-glucuronyl transferase,Unconjugated bilirubin,Profound jaundice,Gilberts syndrome,reduced activity of,UDP-glucuronyl transferase,Unconjugated bilirubin,Very mild jaundice during illnesses,Dubin-Johnson syndrome,abnormal transport of conjugated bilirubin into the biliary system,Conjugated bilirubin,Moderate jaundice,Rotors syndrome,deficiency of uptaking UCB,and excreting CB,CB,jaundice.,Crigler-Najjar syndrome,Gilberts syndrome,Three kinds of jaundice laborotory examination indentification,Class Hemolytic Hepatocellular Cholestatic,TB increased increased increased,CB normal increased markedly increased,CB/TB 15一20 30一40 50一60,urine bilirubin 十 十十,urobilinogen increased slight increased decreased or absence,ALT、AST normal markedly increased may increased,ALP normal increased markedly increased,r-GT normal increased markedly increased,PT normal delayed delayed,Vit K respond no poor good,Cholesterol normal slight increased or decreased markedly increased,Serum protein normal Alb decreased,Glob increased normal,Accessory Examination,1.Ultrosound,2.X ray,3.ERCP,(Endoscopic retrograde cholangiopancreatography,逆行胰胆管造影),4.PTC,(Percutaneous transheptic cholangiography,经皮肝穿刺胆管造影),5.CT,(Computed tomography,),6.MRI,(Magnetic resonance cholangiopancreatography),7.Liver Biopsy and LC,(Laparoscopy，腹腔镜),Accompanying Symptoms,Fever:acute,cholangitis,liver abscess,leptospirosis,(,钩端螺旋体病,),septicemia(,败血症,),lobar pneumonia(,大叶性肺炎,).Fever then jaundice:virus hepatitis,acute,hemolysis,.,Upper abdominal sharp pain:,biliary,calculi(,胆道结石,),liver abscess,biliary,ascariasis,(,胆道蛔虫病,),Right upper,abdom,sharp pain,chill,high fever,jaundice,Charcot triad sign:acute,pyogenic,cholangitis,(,急性化脓性胆管炎,),Sustained right upper abdominal blur or swell pain:virus hepatitis,liver abscess,primary carcinoma of liver,Hepatomegaly,(,肝大,),Mild or moderate,soft or moderate hard,smooth surface:Virus hepatitis,acute infection of,biliary,tract.obstruction of,biliary,tract,Obvious enlargement,hard,ragged surface:primary or secondary carcinoma of liver.,Not obvious enlargement,hard,edge not tidy,nodule on the surface:cirrhosis.,Gallbladder enlargement:common bile duct obstruction,pancreatic head carcinoma,common bile duct carcinoma,carcinoma of,ampulla,.,Splenomegaly,:virus hepatitis,leptospirosis,(,钩端螺旋体病,),septicemia(,败血症,),Malaria(,疟疾,),cirrhosis,hemolytic anemia,lymphoma,(,淋巴瘤,).,Acites,:serious hepatitis,decompensation,of,cirrosis,(,肝硬化失化偿期,),carcinoma of liver.,Inquisition,Points（问诊要点）,1.Assure jaundice,2.Etiology and onset,3.Accompany syndrome,4.Time and fluctuation of jaundice,5.Influnce to the overall health,In one word:make sure the type of jaundice,and then find the pathogeny,Recognise jaundice,Position：sclera,skin and,tongue sleeves,Pseudojaundice(假性黄疸):,eat,Carotene(胡罗卜素)food(Carotene,pumpkin(南瓜),tomato,orange)also can cause skin stained yellow,but bilirubin is not increased.,Old people fat,accumulation at bulbar conjunctiva(球结膜),yellow,uneven distribution,Questions,1)Unconjugated hyperbilirubinemia usually results from a intra-or extrahepatic biliary obstruction.,A.True,B.False,2)Clinical features of cholecystitis include all of the following except:,A.RUQ abdominal pain,B.Radiation to R upper back,C.Nausea,Vomiting,D.+Murphys sign,E.Fever,3)A marker of acute hepatocyte injury is:,A.PT,B.ALT,C.Albumin,D.Direct bilirubin,E.Ammonia,1.A 13 years old male,chief complaints“Finding skin and sclera yellow and feeling right upper abdomen swell pain for 1 week”,Blood test:TBil:80mol/L,DBil:50mol/L,ALT:1200U/L.,B Ultrasound:normal.,What are the possible diagnoses and your suggested examinations.,Hepatocellular and Cholestetic jaundice.,Hepatitis virus test,Urine test,or MRCP.,Question,Reference books,Cecil mecidine 23,rd,edition.,Davidson principles and practice of medicine.,Harrisons principles of internal medicine.16,th,edition.,1,、字体安装与设置,如果您对PPT模板中的字体风格不满意，可进行批量替换，一次性更改各页面字体。,在,“,开始”,选,项卡,中,，点击“,替,换”按,钮右,侧箭,头,，,选,择“,替,换,字,体,”。（如下,图）,在图“替换”下拉列表中选择要更改字体。（如下图）,在“替换为”下拉列表中选择替换字体。,点击“替换”按钮，完成。,37,2,、替换模板中的图片,模板中的图片展示页面，您可以根据需要替换这些图片，下面介绍两种替换方法。,方法一：更改图片,选中模版中的图,片,（,有些图片与其他,对象,进行了组合，,选,择,时,一定要选中图,片 本身，而不是组合）。,单击鼠标右键，选择“更改图片”，选择要替换的图片。（如下图）,注意：,为防止替换图片发生变形，请使用与原图长宽比例相同的图片。,37,赠送精美图标,