The occurrence of jaundice is always associated with hyperbilirubinemia and occurs in a number of diseases, but with damage to the liver and biliary tract - this is one of the most important and typical symptoms.
Yellow staining appears first in the serum. If you suspect jaundice (for example, if epidemic hepatitis is suspected), take 10 ml of blood from a vein and leave it in a test tube. After some time, a yellow-colored liquid layer will be visible above the clot of clotted blood. As the pathological process develops, yellow color is noted on the sclera, in the frenulum of the tongue and on the soft palate , then the entire skin becomes yellow, and the intensity of jaundice may be different for the same degree and duration of bilirubin in the body. The latter is associated with the thickness of the subcutaneous fat layer, the development of muscles. With artificial light (with the exception of "daylight" lamps) jaundice can not be detected.
With a uniform icteric staining of the skin, various shades of jaundice can be observed. It can be lemon yellow, reddish, greenish (as a result of the transition of bilirubin deposited in the skin to biliverdin), gray-green, turning into black. The so-called black jaundice is characteristic of a long bile retention, most often on the basis of cancer in the biliary tract. The simplest method to determine the degree and partly the type of jaundice is a laboratory method for the determination of bilirubin in the blood (see Ehrlich diazoreaction ). Differential diagnosis of jaundice requires the use of a number of laboratory, radiological, radiotracer, and other techniques (see Liver, research methods).Go
There are hemolytic, hepatic and mechanical jaundice (Fig. 9-11).
Fig. 9. Obstructive jaundice (pancreatic head cancer). Fig. 10. Parenchymal jaundice. Fig. 11. Hemolytic jaundice. Under each figure, the color of urine (a) and feces (b) is indicated, respectively.
Hemolytic jaundice (synonym: suprahepatic, urobilinic) is the result of excessive formation of bilirubin with increased blood destruction in the body.
Occurs with hemolytic anemia (see), as well as with sepsis , lobar pneumonia, Addison's disease - Birmera, malaria, prolonged septic endocarditis , with intoxication with poisons that cause hemolysis (see Hemolytic poisons).
Skin color with hemolytic jaundice lemon-yellow color. Patients are more pale than yellow. The numbers of free bilirubin (see) in the blood are moderately elevated. Jaundice is not accompanied by pruritus. It may be wave-like. Bradycardia is usually absent. With severe anemia, systolic murmur can be heard. The liver is usually not palpated, sometimes it can be enlarged. Functional tests are not changed. The spleen is usually enlarged. Pigment stones can form, and the clinical picture of gallstone disease joins (see). In the study of urine detect a high content of urobilin, and bilirubin is absent. In feces - high content of stercobilin. In the study of blood - the hypochromic type of anemia, a decrease in the osmotic resistance of red blood cells and a positive Coombs reaction (see Coombs reaction).Go
Hepatic jaundice (synonym: parenchymal, hepatocellular) is observed with lesions of the infectious or toxic hepatic tissue. If the liver cell is damaged, the functional ability to excrete bilirubin from the blood to the biliary tract is reduced.
In the study of blood serum , an increased content of bound and free bilirubin is found. Bilirubin and bile acids appear in the urine, their number gradually increases. The amount of stercobilin in feces decreases. At the height of hepatic jaundice, there is no urobilin in the urine and stercobilin in the feces. Duodenal content is discolored. As jaundice decreases in the urine, urobilin appears, the amount of bilirubin in the blood begins to decrease; duodenal contents and feces acquire normal color. A characteristic feature of this type of jaundice is the change in all functional liver samples. The most sensitive test for the diagnosis of hepatic jaundice is the bromsulfalein test.
The most typical clinical manifestation of hepatic jaundice is jaundice in epidemic hepatitis (see epidemic hepatitis).
Mechanical jaundice (synonym: subhepatic, congestive, obstructive) occurs as a result of the closure of the hepatic or common bile duct (stone, tumor, squeezed from the outside, such as a tumor of the pancreatic head). Due to the presence of a mechanical obstruction in the bile ducts, the pressure in the overlying biliary tract rises, the excretion of bound bilirubin into the bile canaliculi is disturbed. Bile capillaries expand, rupture. The liver cells are filled with bile, and it enters the lymphatic crevices and blood.
With mechanical jaundice, the icteric coloration of the skin increases gradually. With complete obstruction of the biliary tract, feces are discolored, stercobilin is absent, urine is the color of black beer , contains large amounts of bilirubin, and urobilin is absent. An increased content of bound bilirubin, cholesterol , bile acids is detected in the serum and the activity of alkaline phosphatase increases. Jaundice is accompanied by itching, bradycardia. The liver is enlarged. Sometimes a positive symptom of Courvosier - Terrier is found (a distended gallbladder is palpated). Pronounced violations of functional liver samples are usually not observed.
With prolonged mechanical jaundice, the skin acquires a gray-green color, sometimes hemorrhagic rashes appear, associated with a lack of vitamin K and changes in the vascular wall. Absorption of fat-soluble vitamins (A, D, K), calcium decreases, and the ability of digestion of meat and fats in the intestine is impaired.