Guide
Jaundice is a common presentation in patients with hepatobiliary disease, and it is important to correctly identify the cause.
Jaundice is an increase in the concentration of bilirubin in the serum, causing symptoms and signs of yellowing of the sclera, skin, mucous membranes, and other tissues and body fluids. Clinically, there are many causes of jaundice, including excessive bilirubin production, disorders of bilirubin metabolism by hepatocytes, and disorders of bilirubin excretion in the biliary system.
Jaundice can be classified in a variety of ways: according to the etiology, it can be divided into hemolytic jaundice, hepatocellular jaundice, cholestatic jaundice and congenital non-hemolytic jaundice; According to the anatomical site, it can be divided into prehepatic, hepatic and posthepatic jaundice; According to the nature of bilirubin, it can be divided into jaundice with increased unconjugated bilirubin and increased conjugated bilirubin.
Jaundice predominantly unconjugated bilirubin
1. Hemolytic jaundice
Hemolytic jaundice is jaundice caused by hemolysis caused by various etiologies, and its clinical manifestations are complex and diverse, mainly indirect bilirubin increases, total bilirubin is mostly mildly increased, and a small number of total bilirubin can also be significantly increased to 340 μmol/L or more.
There are many causes of hemolysis, and according to the presence or absence of genetic factors, hemolytic anemia is divided into congenital hemolytic diseases and acquired hemolytic diseases. The former include erythrocyte membrane disease, erythrocyte enzyme disease, and hemoglobinopathy; The latter is further divided into immune (such as autoimmune hemolysis, hemolysis after transfusion of blood group incompatibility, neonatal hemolysis, etc.) and non-immune hemolytic anemia (such as microvascular hemolytic anemia, infection, direct trauma and drug-induced hemolysis).
2. Congenital non-hemolytic jaundice
Congenital non-hemolytic jaundice mostly refers to jaundice caused by congenital defects in the uptake, binding and excretion of bilirubin by hepatocytes, which is relatively rare in clinical practice. These include constitutional hepatic dysfunction jaundice (Gilbert's syndrome), congenital glucuronosyltransferase deficiency (Crigler-Najjar syndrome), congenital abnormal bilirubin metabolism (Lucey-Driscoll syndrome), etc.
Jaundice predominantly with elevated conjugated bilirubin
1. Hepatocellular jaundice
Hepatocellular jaundice is the most common type of jaundice and is caused by hepatocellular lesions that reduce the ability to uptake, convert, and excrete bilirubin. Hepatocellular jaundice is elevated in both conjugated and unconjugated bilirubin, tends to be evenly distributed, golden yellow, and is also known as "red jaundice" due to the red telangiectasia of the face in such patients.
Hepatocellular jaundice is common in various liver parenchymal diseases, such as viral hepatitis, autoimmune liver disease, drug-induced liver injury, toxic hepatitis, alcoholic liver disease, hereditary metabolic liver disease, liver damage caused by systemic infectious diseases (such as sepsis, malaria, leptospirosis, typhoid, etc.), and liver cirrhosis and liver tumors caused by various reasons.
2. Cholestatic jaundice
Cholestatic jaundice can be divided into two categories: intrahepatic cholestasis and extrahepatic cholestasis, of which extrahepatic cholestasis is the most common. Cholestatic jaundice is predominantly characterized by a direct increase in bilirubin, accompanied by a significant increase in alkaline phosphatase, much higher than that of transaminases.
Intrahepatic cholestasis can be caused by viral hepatitis (cholestatic type), drug-induced liver damage (cholestatic type), primary biliary cirrhosis, alcoholic hepatitis, Epstein-Barr virus, cytomegalovirus (CMV) hepatitis and other diseases; Causes of extrahepatic cholestasis include common bile duct stones, pancreatic head cancer, periampullary cancer, primary bile duct cancer, acute cholecystitis, etc.
Flowchart for jaundice diagnosis
The general approach to the diagnosis of jaundice should be combined with a detailed history, a careful clinical examination, and appropriate laboratory and imaging studies. Figure 1 summarizes the diagnostic algorithm for jaundice.
Fig.1 Flowchart of jaundice diagnosis
Note: RCP, cholangiopancreatography
Bibliography:
1. Yin Qiuyan, Liu Fengkui, Wang Guoxing. Clinical diagnosis of jaundice[J]. Chinese Journal of Clinical Doctors, 2017,45(12):9-13.
2. Liu Yulan, Chen Guodong. Clinical thinking in the diagnosis of jaundice[J]. Chinese Journal of Practical Internal Medicine, 2009,29(12):1077-1079.
3. Zhang Jie, Zheng Sujun. Clinical features and differential diagnosis of hemolytic jaundice[J]. Journal of Clinical Hepatobiliary Diseases, 2020,36(06):1423-1427.
4. Lu Jie, Li Wu, Liu Ye. Research progress on congenital non-hemolytic jaundice[J]. Journal of Clinical Hepatobiliary Diseases, 2021,37(01):216-220.
5. Yang Min, Lu Mingqin. Diagnosis and treatment of hepatocellular jaundice[J]. Journal of Practical Hepatology, 2018,21(02):160-162.
6. Pavlovic Markovic A, Stojkovic Lalosevic M, Mijac DD, et al. Jaundice as a Diagnostic and Therapeutic Problem: A General Practitioner's Approach[J]. Dig Dis. 2022; 40(3):362-369. doi: 10.1159/000517301.
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