Печень

“DIFFERENTIAL DIAGNOSIS AT THE
JAUNDICE. MODES OF THE
GENERAL PRACTITIONER”
PREVENTION
LECTOR: DOCENT NURILLAEVA N.M.
Anatomy
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Jaundice
Someone with jaundice is likely to have a yellow look to
their skin and the whites of the eyes.
Many newborn babies develop jaundice, but the
condition can affect people of all ages. This article
looks at older children and adults.
Jaundice is caused by a build-up of bilirubin in the
blood and body tissue. That build-up is often due to
conditions affecting the liver, such as cirrhosis,
hepatitis or gallstones.
If someone shows signs of jaundice, doctors will look to
treat the condition that's causing it rather than jaundice
itself.
If you have signs of jaundice, seek medical advice.
Symptoms of jaundice
 As well as the classic yellow tinge to the skin
and whites of the eyes, someone with jaundice
may also have yellowing of mucous
membranes in the mouth and nose.
Stools (faeces or poo) can be pale in colour
and urine dark in colour.
Some underlying conditions, which lead to
jaundice, may feel like flu, and may also result
in fever, chills, stomach pain, itching or weightloss or be without an explanation such as a
diet.
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Causes of jaundice
When red blood cells break down naturally in a 120day cycle, bilirubin is produced as a waste by-product.
The journey bilirubin takes out of the body's waste
disposal systems takes it carried by blood to the liver.
There is it combined with bile (digestive fluid) from the
gallbladder.
Infections or damage can disrupt this process, leading
to jaundice.
This mixture exits the body through faeces
and urine. If everything is working well,
faeces should be brown and urine light
yellow.
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Pre-hepatic jaundice
If an infection or medical condition makes the red blood cells break down
sooner than usual, bilirubin levels rise. This is known as pre-hepatic jaundice.
Conditions which may trigger this include malaria, sickle cell anaemia,
thalassaemia, Gilbert's syndrome, hereditary spherocytosis and Crigler-Najjar
syndrome.
Intra-hepatic jaundice
If the liver is damaged, it may be less able to process bilirubin. This causes
what doctors call intra-hepatic jaundice.
The liver damage may be a result of causes that include hepatitis, alcoholic
liver disease, glandular fever, liver cancer, illegal drug use including ecstasy,
and paracetamol overdose.
Obesity and non-alcoholic fatty liver disease can be a cause of cirrhosis of the
liver and jaundice. Eating a high-fat diet can raise your cholesterol levels and
increase the risk of having gallstones.
Post-hepatic jaundice
 Gallstones, pancreatitis, pancreatic cancer and
cancers of the gallbladder or bile duct may also
disrupt the bilirubin removal process leading to
jaundice. This is called post-hepatic jaundice.
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В
ЗАВИСИМОСТИ ОТ ЭТИОЛОГИЧЕСКИХ
ФАКТОРОВ РАЗЛИЧАЮТ
Гемолитическую
(надпеченочная)
Печеночная
Подпеченоч
ная
Конституциональная
Чрезмерное разрушение
эритроцитов и
повышенная выработка
билирубина
Нарушения улавливания
клетками печени
билирубина и связывания
его с глюкуроновой
кислотой
Наличия препятствия к
выделению билирубина с
желчью в кишечник и
обратного всасывания
связанного билирубина в
кровь
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Jaundice diagnosis
The yellowing of skin and eyes are likely to be the main clues a
doctor will use before confirming a jaundice diagnosis.
A person will be asked about other symptoms and risks, such
as foreign travel or illegal drug use.
A physical examination will be carried out to look for signs of
swelling of the liver and legs, ankles or feet which might
indicate cirrhosis of the liver.
Urine can be tested for urobilinogen, which is produced when
bilirubin is broken down. Finding high or low levels can help
pinpoint the type of jaundice.
Blood tests may be used to check for conditions like malaria or
hepatitis.
Существуют два основных вида рака печени.
Опухоли, исходящие из
клеток самой печени,
называются гепатомами
Опухоли, образующиеся в
желчных протоках
Холангиокарцинома
Локализуются внутри печени
Карцинома желчных
протоков
Локализуются в части протока за
пределами печени
Проявления рака печени
При первичном и вторичном раке печени
наблюдаются одинаковые симптомы
Диагностика в
начальных
стадиях очень
трудна
Важный симптом
Длительные боли
(неприятные
ощущения) в правом
подреберье
Быстрое похудание
Часто первым признаком бывают ощущение
дискомфорта и, возможно, вздутие в
верхней части живота, вызванные
увеличением печени.
Часто характеризуется
лихорадкой неясной этиологии
Признаки общего недомогания - чувство усталости,
утрата аппетита, тошнота, снижение массы тела
Увеличение печени; она становится довольно плотной и
при надавливании болезненной
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A liver function blood test may indicate
hepatitis, cirrhosis or alcoholic liver disease.
Sometimes a liver biopsy - removal of small
tissue sample - is needed to confirm or rule out
conditions such as cirrhosis or liver cancer.

Doctors may also need to
look inside the body for
problems with the liver or
bile duct using
ultrasound, X-ray with
contrast, MRI or CT scans.
Объективный осмотр
Общие симптомы
желтуха
выпадение волос на
туловище
лихорадка
Ангина
инфекционный
мононуклеоз
Увеличение лимфоузлов
инфекционный
мононуклеоз
Печень
увеличение или
уменьшение
Увеличенный желчный
пузырь
рак головки поджелудочной
железы
Тремор
болезнь Вильсона
алкогольный цирроз печени
Покраснение,
одутловатость лица
алкоголизм
Увеличение
околоушных желез
Сосудистые звездочки
Расчесы холеостаз
Гинекомастия
Спленомегалия
Расширение вен
передней брюшной
стенки
цирроз печени
Покраснение ладоней
ТАКТИКА ВОП ПРИ ЖЕЛТУХЕ
Ранняя диагностика
основной причины
Консультация узкого
специалиста согласно
квалификационной
характеристики ВОП
(I или II категория)
Осуществление
профилактических мер, а
также при необходимости
медикаментозное
лечение совместно с
узкими специалистами
Диспансерное
наблюдение и
реабилитация
(IV категория)
ЛАБОРАТОРНО-ИНСТРУМЕНТАЛЬНОЕ ИССЛЕДОВАНИЕ
При подозрении:
3.2.
категория
Вирусные
гепатиты
Для исключения
вирусной этиологии
хронического
гепатита или
цирроза печени
Хронические
гепатиты
Цирроз печени
-маркеры вирусов гепатита,
-АСТ
--фракции билирубина
- необходимо обследование на
маркеры вирусов гепатита В (НВs Ag,
HВe Ag, анти HBS Ag, анти Hbe Ag) и С
(анти - НСА).
- АСТ, ЛДГ и фракции
билирубина
- кровь на белковый спектр
- коагулаграмма
- УЗИ печени, желчного пузыря и
селезенки
-Сулемовая и тимоловая пробы
-Щелочная фосфатаза
3.1.
категория
- общий анализ
крови, мочи и кала
- АЛТ
ЛАБОРАТОРНО-ИНСТРУМЕНТАЛЬНОЕ ИССЛЕДОВАНИЕ
При подозрении:
3.2.
категория
Холедохолитиаз
Рак поджелудочной
железы
Гемолитические
анемии
Рак печени
-УЗИ
-холангиография или
радиоизотопное исследование
- УЗИ поджелудочной железы
- КТ или МРТ
- АСТ, ЛДГ и фракции
билирубина
- УЗИ печени и селезенки
- УЗИ печени
-КТ или МРТ
-Пункционная биопсия
3.1.
категория
- общий анализ
крови, мочи и кала
- АЛТ
Консультация
гематолога
Спленоэктомия
(при наследственном
микросфероцитозе )
Гемолитические
анемии
дезинтоксикационная
терапия
Глюкокортикостероиды
(аутоиммунная
гемолитическая анемия)
витамин Е
(наследственный
стомацитоз )
Консультация
инфекциониста
изоляция
Острые гепатиты
дезинтоксикационная
терапия
Глюкокортикостероиды
(при тяжелых течениях –
гепатиты В, Д)
Диета
Консультация
гепатолога
гепатопротекторы
Хроинические
гепатиты
дезинтоксикационная
терапия
Противовирусные
препараты
Глюкокортикостероиды
Диета
Консультация
гепатолога
гепатопротекторы
Цирроз печени
дезинтоксикационная
терапия
Глюкокортикостероиды
Диета
Консультация
онколога
химиотерапия
Рак головки
поджелудочной
железы
Оперативное лечение
Лучевая терапия
Принципы ведения и диспансерного наблюдения больных
с ЖЕЛТУХОЙ в условиях СВП или семейной поликлиники
Консультация по ведению здорового образа жизни
Обучение больного принципам самоконтроля
Мониторинг уровня БИЛУРУБИНА, ТРАНСАМИНАЗ (гепатиты)
УЗИ мониторинг
Мониторинг уровня гемоглобина (гемолитические анемии)
Мониторинг индекса массы/тела
Психологическая поддержка (опухоли)
Своевременная диагностика и профилактика осложнений
Контроль над последствиями фармакотерапии
Периодические клинические осмотры
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Preventing jaundice
Due to the wide range of potential causes, it's not possible to prevent all
cases of jaundice. However, there are four main precautions that you can
take to minimise your risk of developing jaundice. They are:
ensuring that you stick to the recommended daily amount (RDA) for alcohol
consumption
maintaining a healthy weight for your height and build
if appropriate, ensuring that you're vaccinated against a hepatitis A or B
infection, which are more common in certain parts of the world compared to
England; therefore, vaccination would usually only be recommended
depending on where in the world you're travelling (see below)
minimising your risk of exposure to hepatitis C because there's currently no
vaccine for the condition; in England, the most effective way of preventing
hepatitis C is by not injecting illegal drugs, such as heroin, or making sure
that you don't share drug injecting equipment if you do
More information about each precaution is provided below.
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PREVENTING JAUNDICE
Alcohol
Giving up drinking alcohol altogether is the most effective way of reducing
your risk of developing jaundice, particularly if you've been drinking for many
years.
As a minimum preventative measure, stick to the recommended daily
amounts for alcohol consumption. The recommended daily amounts are:
3-4 units a day for men
2-3 units a day for women
A unit of alcohol is approximately equal to half a pint of normal-strength
lager, a small glass of wine or a single measure (25ml) of spirits.
Many experts would recommend that as well as sticking to the
recommendation daily amounts, you also spend 2-3 days not drinking any
alcohol.
Visit your GP if you're finding it difficult to moderate your alcohol
consumption. Counselling services and medication are available to help you
reduce your alcohol intake.
See Alcohol misuse - treatment and Alcohol for more information and
advice.
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Preventing jaundice Maintaining a healthy weight
Obesity and the resulting damage it can sometimes cause to the
liver (non-alcoholic fatty liver disease) is an often-overlooked
cause of cirrhosis (scarring of the liver) and jaundice. Therefore,
achieving and maintaining a healthy weight is an effective way of
preventing jaundice.
In addition, a diet that's high in fat can increase your blood
cholesterol level, which in turn will also raise your risk of
developing gallstones.
The most successful weight loss programmes include at least
150 minutes (2 hours and 30 minutes) of moderate-intensity
aerobic activity (i.e. cycling or fast walking) every week, eating
smaller portions and only having healthy snacks in between
meals. A gradual weight loss of around 0.5kg (1.1lbs) a week is
usually recommended.
Read more about the treatment of obesity and losing weight
safely.
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Preventing jaundice Hepatitis A and Hepatitis B
As both hepatitis A and hepatitis B are relatively uncommon conditions in
England, vaccination is usually only recommended if you're travelling to parts of
the world that are known to have high levels of both conditions. You may also be
advised to have a vaccination if your job or lifestyle increases your risk of
exposure to either type of virus.
For example, vaccination for hepatitis A is recommended for: people who are
travelling to places where the virus is common, such as the Indian subcontinent,
Africa, central and south America, the Far East and eastern Europe
people who work in laboratories
people who work with primates, such as monkeys and chimpanzees
Vaccination for hepatitis B is recommended for: visitors to parts of the world
where hepatitis B is widespread, such as south-east Asia, sub-Saharan Africa
and the Pacific Islands, such as the Hawaiian Islands
those who regularly inject drugs; men who have sex with men; sex workers
See the topics about Hepatitis A - Prevention and Hepatitis B - Prevention for
more information and advice.
Preventing jaundice
Hepatitis C
If you regularly inject drugs, such as heroin, the best way to avoid getting a
hepatitis C infection is to not share any of your drug-injecting equipment with
others. This doesn't just apply to needles but also to anything that could come
into contact with other people's blood, such as: mixing spoons; filters; water used
to dissolve drugs; tourniquets – the belt that drug users sometimes tie around
their arm to make their veins easier to inject
As hepatitis C doesn't cause any noticeable symptoms for many years, many
people may not realise that they're infected. It's therefore safer to assume that
anyone may have the infection.
Even if you're not a drug user, it's important to take some common sense
precautions to minimise your exposure to other people’s blood, such as avoiding
sharing any object that could be contaminated with blood, such as razors and
toothbrushes.
PREVENTING JAUNDICE
There's less risk of developing hepatitis C by
having sex with someone who is infected, but as a
precaution it's recommended that you use a
barrier method of contraception, such as a
condom.
It may also be possible to get hepatitis C by
sharing banknotes or ‘snorting tubes’ with an
infected person to snort drugs, such as cocaine or
amphetamine. These types of drugs can irritate
the lining of the nose, and small particles of
contaminated blood could be passed on to the
note or tube, which you could then inhale.