Icterul mecanic

Definitie ICTER
 Acumulare de pigment galben (bilirubina) in
tegumente si mucoase
 1. Carotenoderma: pigment
Dg. Diferential al ingalbenirii concentrat palmar, tegumentul
tegumentului f limitat plantar, frunte si nasolabial.
1. Carotenoderma
2. Folosire in exces de Quinacrine 2. Dg diferential: nu sunt colorate
3. Expunere la fenoli sclerele

ICTERUL
ICTER nu este o boala ci un sindrom
Coloratie galbena a tegumentelor
si mucoaselor prin exces de
bilirubina Normal
<1.2 mg/dl

Clinic devine
decelabil
2.5mg/dl
Etiologie
Clasificare fiziopatologica

 Prehepatic (hemolitic)
 Hepatic

 Posthepatic (obstructiv/mecanic)

 Congenital
 Clasificare - biochimic

 Predominant – bilirubina
NECONJUGATA
 Predominant bilirubina
CONJUGATA
 Icter hemolitic - fiziopatologie
Supraproductie
Hemoliza (intra- and extra vascular)
 Boli genetice sau dobindite
 Anemia hemolitica autoimuna

 Anemia hemolitica non-imuna

(hemoglobinuria paroxistica nocturna)

Determina supraincarcarea ficatului cu

bilirubina neconjugata
 Icter hemolitic
Simptome
- fatigabilitate, urini hipercrome, anemie
- icter
- splenomegalie
Lab
  bilirubina indirecta,
  urobilinogen fecal si urina
 Anemie hemolitica
 hemoglobinurie (in hemoliza acuta
intravasculara)
 Reticulocitoza
 Icter hemolitic
Profil biochimic sanguin
 Bilirubina crescuta (neconjugata)

 TGP, TGO normale

 gamma GT normal
 Albumina – normal

 reticulocite(%) 10-30% (Normal

<1)
 TP normal
 Icter hemolitic

 Bilirubina urinara: absent

 urobilinogen: normal sau
crescut
Stercobilinogen fecal: normal
 Icter mecanic
Fiziopatologie
Obstructie a ductelor biliare intra- sau
extra hepatic
 Obstructie Intra hepatic: hepatita, ciroza
biliara primitiva, medicamentos
 Obstructie Extra hepatica: litiaza CBP,
stenoze, inflamatie, tumori, etc
 Icter mecanic - etiologie
Intrahepatic – blocare a canaliculilor biliari
cu/fara leziune a hepatocitului
 Medicamente sau toxine
 Sdr. Dubin-Johnson
 Trat cu estrogeni, graviditate
 Hepatita-virala,chimica
 Tumori hepatice
 Hipoplazia sau atrezia biliara intrahepatica
 Ciroza biliara primitiva
 Icter mecanic - etiologie
Extrahepatic- obstructia ductelor biliare
 Compresiune/obstructie prin tumori

 Chist coledoc

 Atrezia biliara extrahepatica

 Litiaza CBP

 Stenoze-postoperatorii/inflamatorii
 Icter mecanic - clinic

 Durere – datorita patologiei

biliare, malignitate avansata
sau distensia capsulei hepatice
 Febra – colangita septica
ascendenta
 Vezicula palpabila
 Hepatomegalie – de regula
neteda sau MTS
 xantoame: depuneri de colesterol
datorita cresterii nivelului de
colesterol pe o durata de citeva
luni (palmar, trunchi, git)
 xanthelasma pleoape
 leziuni de grataj
 scaune decolorate
 urini hipercrome
 Icter mecanic - laborator
 Bilirubina serica 
 Urobilinogen fecal  (obstructie incompleta)
sau absent (completa)
 Urobilinogenurie absenta
 bilirubinurie 
 Fosfataza alcalina 
 colesterol 
 Icter mecanic – profil biochimic
SANGE
 Bilirubina creste f mult

 TGP si TGO la valori mari (nu ca in HVA)

 gamma GT crescut (marker de

colestaza)
 Albumina – normal sau usor scazuta

 Reticulocite normal
 TP – prelungit (lipsa de resorbtie a
vitaminei K)
 Icter mecanic – profil
biochimic
URINAR
 bilirubina: creste

 urobilinogen: scazut sau absent

FECAL
stercobilinogen: redus sau absent
 Icter hepatic

Afectarea hepatocitara: congenitala,

dobindita
 Icter hepatic – fiziopatologie
 Afectarea conjugarii bilirubinei
 Scaderea activitatii glucuronil transferazei (sdr Gilbert)
 Absenta ereditara sau deficienta Uridine Diphosphate
Glucuronosyltransferase (sdr Grigler-Najjar)
 Boli familiare sau ereditare
 Sdr Dubin-Johnson
 Sdr Rotor
• Dobindite
 Necroza (citoliza)
 Colestaza (hepatita, ciroza, medicamente)
 Icter hepatic
 Simptome
 Fatigabilitate
 Inapetenta
 Hepatomegalie
 Eritem palmar
 Angioame cutanate
 Lab
• Citoliza hepatica
• Creste bilirubina neconjugata dar si conjugata 
• Bilirubinurie 
 Icter hepatic
Profil
 Bilirubina creste (neconjugata
predominant)
 TGP si TGO la valori foarte mari

 gamma GT normal

 Albumina scazuta usor sau normal

 Reticulocite normale
 TP usor prelungit
 Icter hepatic

Urinar
 bilirubina: normala sau crescuta

 urobilinogen: normal sau scazut

Fecal
 stercobilinogen: normal sau
scazut
ICTER - Diagnostic

 Anamneza si examen clinic

 Aspect urina si scaun

 Biochimie
 bilirubina
 transaminaze - AST, ALT

 albumina

 fosfataza alcalina
 Diagnostic
Hematologie
 hemoglobina
 Numaratoare completa celulara
 Trombocite
 TP si TPP
IMAGISTICA
echo abdomina;
CT, RMN, etc

 Investigatii etiologice
 Bilirubina
Testarea bilirubinei totale si conjugate
CRESTE

Bilirubina conjugata Bilirubina neconjugata

 Hiperbilirubinemia
NECONJUGATA
 Hemoliza
 Deficit Glucose-6-
phosphate dehidrogenaza
 Deficienta Piruvate kinaza
 Medicamentos
 Eritropoeza ineficienta
 Neonatal
 Hepatita acuta
 Deficit de Uridine
diphosphate
glucuronosyltransferaza
 Gilbert syndrome
 Crigler-Najjar syndromes
 Diverse
 Medicamentos
 Hipotiroidism
 Tirotoxicosa
 Infarct pulmonar
 Infometare
 Hiperbilirubinemia

CONJUGATA
 Congenital
 Sdr Rotor
 Sdr Dubin-Johnson
 Icter colestatic
 Chist coledoc  Ciroza biliara primitiva
 Boli familiare  Colangita sclerozanta
 Colestaza recurenta  Obstrictii biliare
benigna  Boli pancreatice
 Colestaza din sarcina
 Leziuni infiltrative
 Deficit hepatocelular
 Alcohool  Complicatii postop.
 Viral  Medicamente
 Sepsis
 Intrebari initiale

1. Creste bilirubina conjugate sau neconjugata?

2. Creste bilirubina neconjugata: Cauza
 Creste productia de bilirubina neconjuugata?
 Scade preluarea hepatica?
 Conjugare deficitara?
3. Creste bilirubina conjugata: Cauza
 Intra?
 extrahepatic?
4. Proces acut sau cronic?
 EVALUARE

 Istoricul bolii
 Medicatie folosita
 Antecedente personale
 Examen clinic
 Teste de evaluare a functiei hepatice
 ISTORIC
 Expunere
 Istoric familial de  Toxice din mediu
boala hepatica  Coontact cu alte
persoane cu icter
 Abuz de alcool sau  Medicamente
droguri
 Situatii epidemiologice
 Activitate sexuala in societate

 Istoric de transfuzii  Exista modificari

anterioare ale functiei
 Istoric nutritional hepatice

 Istoric de patologie
biliara sau pancreatica
 Elemente importante de anamneza

 Febra si/sau frisoane: pledeaza in favoarea

colangitei si infectiei bacteriene
 Durrea abdominala: poate indica o patologie
pancreatica, in mod particular iradierea
posterioara in coloana
 Durerea difuza in cadranul superior drept:
sugereaza hepatita virala
 Scadere in greutate, anorexia, greata si voma:
confuzii – marea majoritate a bolilor
hepatobiliare sau obstructii au anorexia si
scadere in greutate
 Pruritus: orice forma de colestaza cronica
 VIRSTA

< 30 ani ——› afectare acuta

parenchimatoasa
 > 65 ani ——› litiaza sau cancer
 30 - 50 years ——› boala hepatica cronica
 Apartenenta la un grup

 BARBATII mai frecvent  FEMEILE mai frecvent

 Cirozasecundara  Ciroza biliara primitiva
alcoolului  Litiaza
 Cancer pancreatic  Hepatita cronica
 HCC,

 Hemocromatoza
 EXAMEN CLINIC
 Ficatul
 Splina
 Stigmate de ciroza hepatica
 Ficat dur, nodular——› ciroza
 Masa palpabila——› abces sau malignitate
 Splenomegalie ——› congestive, HTP, malignitate
 Loja hepatica dureroasa ——› boala acuta, dar frecvent confuzii
 EXAMEN CLINIC

 Spider angioma
 Eritem palmar
 Circulatie venoasa colaterala ciroza
 Icter
 Ascita
Hepatita acuta
 Icter Ciroza
 Ascita
Malignitate
 EXAMEN CLINIC

Infectii
 Splenomegalie
Maladii infiltrative

 Vezicula palpabila ——› obstructie maligna

 Asterixis Hepatita fulminanta

Insuficienta hepatica terminala
 Febra Colica biliara
Colangita
 ICTER

HEPATOCELULAR COLESTAZA

Bilirubina Variaza Mare

Tipic < 5mg/dL tipic > 5 mg/dL
TGP Variabil in functie de Valori moderate
activitatea bolii tipic < 400 IU/mL
FAlc Normal Mare
Tipic> x3 VN
 CRESTEREA FOSFATAZEI ALCALINE

 VN→ obstructia extrahepatica este putin probabila

 x3 VN→ colestaza intra sau extrahepatica

 Valori mari asociate cu icter – obstructiv: litiaza sau

cancer

 Valori mari cu bilirubina normala - obstructie partiala

 DIAGNOSTIC
 gamaGT
 Crescuta la pacientii cu afectare hepatica cronica si abuz
alcool

 Proteine
 Boala hepatica acuta versus cronica
 Cresteri globuline si hipoalbuminemie - ciroza

 TP – sinteza factorilor de coagulare din complexul

protrombinic

 Hipercolesterolemia colestaza

 Urina – bilirubina, urobilinogen

 Common Drugs Associated With
Hyperbilirubinemia
HEPATOCELLULAR CAUSES

 Acetominophen  Niacin
 Alcohol  Nifedipine
 Amiodarone  NSAIDs
 Azulfidine  Propylthiouracil
 Carbenicillin  Pyridium
 Clindamycin  Pyrazinamide
 Colchicine  Quinidine
 Cyclophosphamide  Rifampicin
 Diltiazem  Salicylates
 Ketoconazole  Verapamil
 Methyldopa
 Common Drugs Associated With
Hyperbilirubinemia
CHOLESTATIC CAUSES
 Amitriptyline  5-Flucytosine
 Androgenic steroids (B)  Fluoroquinolones
 Atenolol  Griseofulvin
 Augmentin  Haloperidol (D)
 Azathioprine  Labetolol
 Bactrim (D)  Nicotinic acid
 Benzodiazeprines  NSAIDs
 Captopril  Penicillins
 Carbamazole  Phenobarbital
 Chlordiazepoxide (D))  Phenothiazines (D)
 Clofibrate  Phenytoin
 Coumadin  Tamoxifen
 Cyclosporine  Tegretol
 Danazol (B)  Thiabendazole (D)
 Dapsone  Thiazides
 Disopyramide  Thiouracil
 Erythromycin  Tolbutamide (D)
 Estrogens (B)  Tricyclics (D)
 Ethambutol  Verapamil
 Floxuridine  Zidovudine
B. bland or noninflammatory cholestasis: D. ductopenic cholestasis or vanishing bile duct syndrome.
Common Drugs Associated With
Hyperbilirubinemia

MIXED CAUSES

 Acetohexamide  Hydralazine
 Allopurinol  Lovostatin
 Ampicillin  Nitrofurantoin
 Augmentin  NSAIDs
 Cimetidine  Phenytoin
 Dapsone  Rifampicin
 Disulfiram  Thiouracil
 Gold  Tetracycline
Identificarea cauzei

 Cai biliare intrahepatice dilatate

(Echo) – colangiografie (MRI,
percutana transhepatica)
 Ducte nedilatate (Echo)- MRI
 Biopsie hepatica
Semnul Courvoisier
Carcinom hepatocelular
Colangita sclerozanta
 Simptome asociate
 Febra
 Durere (Charcot: febra, durere, frison)
 Hepatomegalie
 Splenomegalie
 Ascita
 HDS
 prurit
Diagnostic diferential
 Dg diferential - pasi
1. Bilirubina DIRECTA sau INDIRECTA?
2. Hemoliza este usor de exclus.
3. Dificultati in obstructii partiale si colestaza
intrahepatica.
 Bilirubina neconjugata
 ↑productiei
 Hemoliza extravasculara
 Extravazare singe

 Hemoliza intravasculara

 Accidente posttransfuzionale

 Afectarea preluarii hepatice a bilirubinei

 Ciroza
 Shunt portosistemic

 Inhibitie medic.: rifampin, probenecid

 Bilirubina neconjugata
 Deficit de conjugare a bilirubinei
 Gilbert
 Crigler-Najarr

 Icter neonatal

 Hipertiroidism

 Estrogeni

 Hepatopatii: ciroza, Wilson , hepatita cronica

 Bilirubina neconjugata
 Colestaza intrahepatica/afectarea excretiei
 Hepatita (viral, alcool, etc)
 Ciroza biliara primitiva

 Sepsis

 TPN

 Sarcina

 Maladii infiltrative: TB, amloidoza, sarcoidoza,

limfom
 Intoxicatie cu arsenic
 Bilirubina conjugata
 Colestaza extrahepatica
 Litiaza CBP
 Cancer (oriunde)
 Stenoze CBP
 Pancreatita acuta sau cronica
 Colangita sclerozanta
 Parazitoze (ascaridioza)

 Primele 5 cele mai importante cauze

 Screening biochimic
 Probe hepatice normale: traumatism sau
boala genetica/hemoliza
 ↑FAlc – colestaza
 ↑si in sarcoidoza, TB
 GGT este specifica pentru leziunea biliara

 ↑TGO/TGP citoliza
 ↓albumina sau ↑INR hepatopatie cronica
grava
 Laborator - continuare
 Daca nu exista dubii legate de obstructie:
 Antigene virale B si C
 Anticorpi antimitocondriali (ciroza hepatica
primitiva)
 Anticorpi anti-fibra musculara neteda (leziune
autoimuna)
 Hemocromatoza

 Ceruloplasmina (Wilson’s)
 Imagistica
 Echo
 Litiaza si calibrul cailor biliare
 CT scan
 Tipul si localizarea obstructiei
 RMN – gold standard
 ERCP
 Vizualizare si tratament
 Mai ales in coledoco-litiaza
 Colangio percutana – abord mai ales pentru
leziunile proximale de confluent
 EUS