黄疸(诊断学第9版,2学时 )

,石国庆,主任医师,诊断学,消化系统疾病,诊断学,第,9,版,黄 疸,J,aundice,第十七节 黄疸（,P36,）,jaundice,3,?,jaundice,什 么 是 黄 疸,?,jaundice,?,jaundic,4,黄疸,是由于血清中胆红素升高致使皮肤、粘膜和巩膜发黄的症状和体征。,Jaundice is due to elevated serum bilirubin, resulting in skin, mucous membranes and sclera yellowing symptoms and signs.,若血中胆红素浓度升高，而临床上尚未出现肉眼可见的黄疸者，称为,隐性黄疸,。,I,f the concentration of bilirubin in the blood is elevated, but there is no visible jaundice in clinic, it is called recessive jaundice.,定 义,Definition,5,血清中胆红素的浓度,Serum bilirubin concentration,正 常 人：,1.7,17.1mol/L,Normal persons,隐性黄疸,: 17.1,34.2mol/L,Recessive jaundice,黄 疸,:,34.2mol/L,Jaundice,胆红素的来源,Sources of bilirubin,胆红素在血液中的转运,Transport of bilirubin in blood,胆红素在肝内的代谢,Bilirubin metabolism in the liver,胆红素的排泄,Excretion of bilirubin,胆红素的代谢,Bilirubin metabolism,正常人每日生成胆红素约,200250mg,Normal people produce bilirubin about 200250mg per day.,“旁路”胆红素,衰老的红细胞,1.,骨髓幼稚红细胞的血红蛋白,2.,肝内含,亚铁血,红素的,蛋白质,过氧化氢酶,过氧化物酶,细胞色素氧化酶,肌红蛋白,8085%,1520%,其他物质,（一）,胆红素的来源,Sources of bilirubin,衰老红细胞,血红素加氧酶,胆绿素还原酶,单核巨噬系统分解,血红蛋白,。,胆绿素,胆红素,非结合胆红素,（,unconjugated Bilirubin,UCB,）,（一）,胆红素的来源,Sources of bilirubin,血红素,9,血浆,胆红素,清蛋白,血 管,与血清中的清蛋白结合，形成胆红素,-,清蛋白复合物,清蛋白,胆红素,（二）,胆红素在血液中的转运,Transport of bilirubin in blood,（三）,胆红素在肝内的代谢,Bilirubin metabolism in the liver,葡萄糖醛酸,Alb,胆红素,胆红素,Y,Z,胆红素,-,葡萄糖醛酸,酯,Alb,胆红素,结合胆红素（,CB,）,conjugated Bilirubin,H,+,O,2+,CB,UCB,UBG,胆红素,肠肝循环,UBG,UBG,CB,非结合,胆红素,结合,胆红素,尿胆原,粪,胆原,（四）,胆红素的排泄,Excretion of bilirubin,非结合胆红素,UCB,Unconjugated Bilirubin,结合胆红素,CB,Conjugated Bilirubin,脂溶性，不溶于水，不能从尿中排出,血中与清蛋白结合,水溶性，可从尿中排出,肝中与葡萄糖醛酸结合,总胆红素（,Total,bilirubin,TB,）,UCB 与 CB 的比较,13,胆红素正常代谢示意图,门静脉,肝脏,肠,循环系统,红细胞,(RBC),单核,-,巨噬细胞系统,血红蛋白,肾,尿胆原,与葡萄糖醛酸结合,肠肝循环,尿胆原,粪胆原,结合胆红素,(CB),非结合胆红素,(UCB),10-20%,黄疸的分类,C,lassification of jaundice,(,一,),按病因学分类,Classification by etiology,(,二,),按胆红素性质分类,Classification according to the nature of bilirubin,15,门静脉,肠,肝脏,循环系统,红细胞,(RBC),单核,-,巨噬细胞系统,血红蛋白,尿胆素,与葡萄糖醛酸结合,肠肝循环,尿胆原,粪胆素,结合胆红素,(CB),非结合胆红素,(UCB),1.,溶血性黄疸,2.,肝细胞性黄疸,3.,胆汁淤积性黄疸,(,阻塞性黄疸,),4.,先天性非溶,血性黄疸,按病因分类示意图,按胆红素性质分类：,Classification according to the nature of bilirubin,1,、以,UCB,增高为主的黄疸,Jaundice with increased UCB,2,、以,CB,增高为主的黄疸,Jaundice with increased CB,溶血性黄疸,Hemolytic jaundice,肝细胞性黄疸,Hepatocyte jaundice,胆汁淤积性黄疸,C,holestatic jaundice,先天性非溶血性黄疸,(,了解）,Congenital non hemolytic jaundice,病因、发生机制和临床表现,Etiology, pathogenesis and clinical manifestations,（一）发病机制：,1,、大量,RBC,破坏,UCB,超过肝脏处理,能力,UCB,2,、贫血、缺氧等削弱正常肝细胞代谢,能力,UCB,溶血性黄疸,Hemolytic jaundice,19,门静脉,肝脏,肠,循环系统,红细胞,(RBC),单核,-,巨噬细胞系统,血红蛋白,肾,尿胆原,与葡萄糖醛酸结合,肠肝循环,尿胆原,粪胆原,结合胆红素,(CB),非结合胆红素,(UCB),10-20%,溶血性黄疸发生机制示意图,胆红素正常代谢示意图,UCB,（二）病因,Pathogeny,：,1,、先天性溶血性贫血：海洋性贫血、遗传性球形红细胞增多症。,Congenital hemolytic anemia: thalassemia and hereditary spherocytosis,2,、后天性获得性溶血性贫血：自身免疫性溶血性贫血、不同血型输血后的溶血、蚕豆病、蛇毒等。,Acquired hemolytic anemia: autoimmune hemolytic anemia, hemolysis after blood,transfusion of different blood groups, broad bean disease, snake venom, etc.,溶血性黄疸,Hemolytic jaundice,（三）临床表现,Clinical manifestation,皮肤黏膜颜色：浅柠檬色,。,Skin and mucosa color: light lemon.,1,、急性溶血时：发热、寒战、头痛、呕吐，严重者有急性肾功能衰竭。,Acute hemolysis: fever, chills, headache, vomiting, severe cases of acute renal failure.,2,、慢性溶血时；贫血、脾肿大。,Chronic hemolysis, anemia and splenomegaly.,溶血性黄疸,Hemolytic jaundice,溶血性黄疸,Hemolytic jaundice,血清：,UCB,CB TB,（四）实验室检查特点,Laboratory examination characteristics,尿：尿胆原,尿胆红素,大便：粪胆素,大便：粪色加深,(,),正常,大便：粪胆素,大便：粪色加深,（一）发病机制,1,、肝细胞受损不能将,UCB,完全转化为,CBUCB,2,、合成的,CB,经,损害和坏死肝细胞入血,CB,水肿致肝内胆管阻塞排,泌困难反流入血,CB,肝细胞性黄疸,Hepatocyte jaundice,24,肠,门静脉,肝脏,循环系统,红细胞,(RBC),单核,-,巨噬细胞系统,血红蛋白,肾,尿胆原,与葡萄糖醛酸结合,肠肝循环,尿胆原,粪胆原,结合胆红素,(CB),非结合胆红素,(UCB),10-20%,尿胆红素,(+),各种肝病,肝细胞性黄疸发生机制示意图,胆红素正常代谢示意图,UCB,CB,（二）病因,Pathogeny,病毒性肝炎、肝硬化、中毒性肝炎、钩端螺旋体病、败血症等。,Viral hepatitis, cirrhosis, toxic hepatitis, leptospirosis, septicemia, etc.,（三）临床表现,Clinical manifestation,皮肤、黏膜浅黄至深黄色,。原发病表现：疲乏、食欲减退、严重者有出血倾向,。,The skin and mucous membrane are pale yellow to deep yellow. Primary symptoms include fatigue, loss of appetite, and bleeding tendency in severe cases.,肝细胞性黄疸,Hepatocyte jaundice,血清：,UCB,CB,TB,尿：尿胆原 尿胆红素,大便：粪胆素,大便：粪色变浅或无明显变化,（,+,）,（四）实验室检查特点,Laboratory examination characteristics,肝细胞性黄疸,Hepatocyte jaundice,（一）发病机制,阻塞上方压力小胆管、毛细胆管破裂,CB,反流入血,CB,毛细胆管通透性胆汁浓缩 、,流量减少 胆道内胆盐沉淀、,胆栓形成,CB,肝内外阻塞,胆汁淤积性黄疸,Cholestatic jaundice,肠,门静脉,肝脏,循环系统,红细胞,(RBC),单核,-,巨噬细胞系统,血红蛋白,肾,尿胆原,肠肝循环,尿胆原,粪胆原,非结合胆红素,(UCB),与葡萄糖醛酸结合,结合胆红素,(CB),胆汁淤积性黄疸发生机制示意图,各种梗阻因素,尿胆红素,(+),胆红素正常代谢示意图,CB,（二）病因,Pathogeny,1、肝内胆汁淤积：药物性胆汁淤积、原发性胆汁性肝硬化。,Intrahepatic cholestasis: drug cholestasis and primary biliary cirrhosis.,2、肝外胆汁淤积：胆总管结石、蛔虫、肿瘤等。,Extrahepatic cholestasis: choledocholithiasis, Ascaris, tumor and so on.,胆汁淤积性黄疸,Cholestatic jaundice,（三）临床表现,Clinical manifestation,皮肤呈暗黄色、甚至黄绿色,。,The skin is dark yellow and even yellowish green.,尿色深、白陶土大便。,Deep urine and white clay stools.,皮肤瘙痒。,Skin Itch.,胆汁淤积性黄疸,Cholestatic jaundice,胆汁淤积性黄疸,Cholestatic jaundice,血清：,UCB,CB,TB,尿：尿胆原 尿胆红素,( ),大便：粪胆素,大便：粪色变浅或呈白陶土色,(,),(,),（四）实验室检查特点,Laboratory examination characteristics,1.Gilbert,综合征,3.Rotor,综合征,2.Crigler-Najjar,综合征,4.Dubin-Johnson,综合征,肝细胞对,CB,向毛细胆管排泄障碍致血中,CB,增加,肝细胞对摄取,UCB,及排泄,CB,存在先天性障碍,葡萄糖醛酸转移酶缺乏血中,UCB,增多,肝细胞摄取,UCB,障碍及葡萄糖醛酸转移酶不足致血中,UCB,增加,先天性非溶血性黄疸,Congenital non hemolytic jaundice,33,溶血性、肝细胞性、胆汁淤积性黄疸的鉴别,溶血性黄疸,肝细胞性黄疸,胆汁淤积性黄疸,病因,临床表现,总胆红素,(TB),结合胆红素,(CB),非结合胆红素,(UCB),CB/TB,转氨酶,尿胆原,尿胆红素,粪便颜色,肝内外性,胆汁淤积,先天性或后天性,溶血性贫血,溶血表现,各种肝病,肝原发病表现,胆道阻塞表现,正常,正常或轻度,50%,正常,深黄色,正常或稍浅,浅黄或白陶土色,1,、伴发热：急性胆管炎、肝脓肿等。,Accompanied by fever: acute cholangitis, liver abscess, etc.,2,、伴上腹剧痛：胆道结石、蛔虫等。,Accompanied by epigastric pain: biliary calculi, Ascaris and so on.,伴上腹钝痛或胀痛：肝炎、肝脓肿、肝癌。,Accompanied by upper abdominal pain or pain: hepatitis, liver abscess, liver cancer.,伴随症状,Concomitant symptoms,右上腹剧,痛,伴发,热,、,黄,疸者，称,Charcot,三联征，提示急性化脓性胆管炎。,Patients with severe pain in the right upper quadrant with fever and jaundice are referred to as Charcot triad, suggesting acute suppurative cholangitis.,3,、伴肝肿大,Accompanied by hepatomegaly,：,轻中度肿大：病毒性肝炎、急性胆道感染；,Mild to moderate enlargement: viral hepatitis and acute biliary tract infection.,明显肿大：原发性肝癌；,Obvious enlargement: primary liver cancer.,4,、伴胆囊肿大：胆总管梗阻。,Gallbladder enlargement: obstruction of common bile duct.,伴随症状,Concomitant symptoms,5,、,伴脾肿大：病毒性肝炎、肝硬化、淋巴瘤等。,With splenomegaly: viral hepatitis, cirrhosis, lymphoma, etc.,6,、,伴腹腔积液：重症肝炎、肝硬化失 代偿期、肝癌等。,With ascites: severe hepatitis, decompensated cirrhosis, liver cancer and so on.,伴随症状,Concomitant symptoms,辅助检查,A,ccessory examination,1,、影像学检查,B,超,CT MRI,胆 管 造 影,诊断结石、占位性病变，提示梗阻的部位和病因。,辅助检查,A,ccessory examination,针对疑难黄疸病例,2,、肝穿刺活检,1,、,黄疸的定义；何谓隐性黄疸？,Definition of jaundice; what is recessive jaundice?,2,、,黄疸的分类。,Classification of jaundice.,3,、,三种黄疸的特点与鉴别。,The characteristics and differential diagnosis of three kinds of jaundice.,4,、,何谓,Charcot,三联征？提示什么疾病？,W,hat is Charcot triad? What diseases do you suggest?,复习思考题,Review questions,SEE,you,