What Are the Causes of Jaundice with Fever?

Jaundice is a common symptom and sign, and its occurrence is caused by an increase in serum bilirubin concentration due to bilirubin metabolism disorders. Clinically, the sclera, mucosa, skin and other tissues are stained yellow. Because the sclera contains more elastin and has a strong affinity for bilirubin, the yellow stain of the sclera in jaundice patients is often detected first before the mucosa and skin. When the total serum bilirubin is 17.1 ~ 34.2 mol / L, but no jaundice is visible to the naked eye, it is called recessive jaundice or subclinical jaundice; when the total serum bilirubin concentration exceeds 34.2 mol / L, it can be found clinically. Jaundice, also known as dominant jaundice.

Basic Information

English name: jaundice

Visiting department: Internal medicine
Common symptoms: In addition to yellow sclera, it can be accompanied by abdominal pain, itching, and fever

Causes of jaundice

There are many reasons for jaundice, and the mechanism can be divided into five categories:

1. Excessive bilirubin production

This is because after the destruction of red blood cells (hemolysis), the formation of unbound bilirubin increases, and a large amount of unbound bilirubin is transported to the liver, which will inevitably increase the burden on the liver (hepatocytes). When it takes up and binds, it increases the concentration of unbound bilirubin in the blood. In addition, anemia caused by a large amount of hemolysis makes liver cells in a state of hypoxia and ischemia, and its ability to uptake and bind unbound bilirubin will inevitably be further reduced, resulting in a higher concentration of unbound bilirubin in the blood. Jaundice appears to increase.

2. Hepatocyte function is low or the amount of functional liver cells is reduced

This is because the liver's liver enzyme function is low, or due to advanced liver cirrhosis, or fulminant hepatitis, liver failure, the amount of functional liver cells remaining in the liver is very small, and non-binding bilirubin in the blood cannot be taken, resulting in non- In combination with bilirubin, the concentration in the blood is even higher and jaundice occurs. Neonatal physiological jaundice is also due to this reason.

3. Hepatocyte destruction combined with bilirubin spillover

In hepatitis patients, due to extensive damage (degeneration, necrosis) of hepatocytes, the uptake and binding of unbound bilirubin by hepatocytes are impaired, so the concentration of unbound bilirubin in the serum is increased, and some are not affected. Damaged hepatocytes can still continue to take up and bind unbound bilirubin, turning it into conjugated bilirubin, but some of the conjugated bilirubin fails to excrete into the capillary bile ducts, but instead reacts through the necrotic hepatocyte space. Flow into liver lymph fluid and blood, resulting in increased serum bilirubin concentration and jaundice. At this time, the patient's transaminase will increase.

4. Intrahepatic cholestasis jaundice

In some patients, due to hepatocyte degeneration, swelling, inflammatory lesions in the manifold area, and formation of bile ducts in the bile ducts and small bile ducts, the excretion of bound bilirubin is blocked. As a result, the combined bilirubin overflows through the small bile ducts (small bile ducts). Internal pressure rises and ruptures) and flows back into the liver lymphatic flow and blood. In some patients, the excretion of conjugated bilirubin is blocked due to pathological changes in the capillary bile duct, the small bile duct itself, the formation of bile plugs in the small bile duct, or the abnormal structure of the capillary bile duct. As a result, the combined bilirubin overflows through the small bile duct (or The internal pressure of the small bile duct is increased and ruptured), and it flows into the liver lymphatic flow and blood. Some patients are not entirely caused by mechanical factors such as bile duct rupture (such as cholestasis caused by drugs), but also due to reduced bile secretion (dysfunction of secretion), increased capillary bile duct permeability, bile concentration, and stasis. Reduced flow eventually leads to bile salt deposition and bile embolism in the bile ducts.

5. Jaundice due to obstruction of the bile ducts

Obstruction or cholestasis occurs in any part of the liver, extrahepatic hepatobiliary ducts, common hepatic duct, common bile duct, and ampulla. The pressure in the upper bile ducts of the obstruction or stagnation increases continuously, and the bile ducts continue to expand. Rupture of the inner small bile duct or micro bile duct and capillary bile duct causes the combined bilirubin to overflow from the ruptured bile duct and flow back into the blood to cause jaundice.

Clinical manifestations of jaundice

Basic symptoms

(1) When the skin, sclera and other tissues are yellowed, itchy, and jaundice deepened, urine, sputum, tears, and sweat are also yellowed, and saliva generally does not change color.

(2) Strong tea-like urine, clay-like stool.

(3) Gastrointestinal symptoms, often with abdominal distension, abdominal pain, loss of appetite, nausea, vomiting, diarrhea or constipation.

(4) The manifestations of bile saltemia, the main symptoms are: itching of the skin, bradycardia, abdominal distension, steatosis, night blindness, fatigue, malaise and headache.

2. Accompanying symptoms

(1) Jaundice with fever is seen in acute cholangitis, liver abscess, leptospirosis, sepsis, and lobar pneumonia. Viral hepatitis or acute hemolysis may be followed by fever and jaundice.

(2) Jaundice with severe epigastric pain can be seen in biliary stones, liver abscess, or biliary tsutsugamushi disease; severe right upper quadrant pain, chills, fever, and jaundice are triads of charcot, suggesting acute suppurative cholangitis. Persistent dull or tenderness of the right upper abdomen can be seen in viral hepatitis, liver abscess, or primary liver cancer.

(3) Jaundice with hepatomegaly, if mild to moderate swelling, soft or medium hardness, and smooth surface, it is found in acute hepatitis with viral hepatitis or biliary obstruction. Significantly swollen texture and uneven surface with nodules are found in primary or secondary liver cancer. Hepatomegaly is not obvious and the texture is harder and the edges are irregular and there are small nodules on the surface.

3. Abdominal signs

(1) Abdominal appearance Hepatic space occupying lesions, giant spleen, retroperitoneal tumors, and pelvic tumors all have local swellings at the corresponding locations. When a large amount of ascites appears frog-like, and the umbilicus protrudes, abdominal wall hernia and umbilical hernia can also occur. Varicose veins of the abdominal wall are seen in portal hypertension, obstruction of the portal vein or inferior vena cava.

(2) Liver conditions Jaundice and hepatomegaly coexist in acute viral hepatitis or toxic hepatitis. The liver is soft, tenderness and throbbing pain are more obvious. In acute and subacute liver necrosis, jaundice rapidly deepens, but liver enlargement does not occur or shrinks. In chronic hepatitis and liver cirrhosis, liver enlargement is not as obvious as acute hepatitis, and the texture is increased, without tenderness; also in liver cirrhosis Irregular edges and nodules can be involved. In liver cancer, hepatomegaly may lose its normal form, be firm, and may be associated with large masses or small nodules. The tenderness may not be significant, but the smooth liver surface cannot rule out deep cancer or subclinical "small liver cancer". . When liver abscesses approach the liver surface, local skin may show signs of inflammation such as redness, swelling, tenderness, etc. When liver abscesses, hepatic hydatidosis, polycystic liver and cavernous hemangiomas are present, the liver area may have a cystic or fluctuating sensation.

(3) Splenomegaly and jaundice accompanied by splenomegaly are more common in the decompensated period of various types of liver cirrhosis, chronic active hepatitis, acute hepatitis, hemolytic jaundice, systemic infectious diseases and invasive diseases, cancer invasion When it is related to portal vein and splenic vein, it can cause splenomegaly, and rare spleen infarction and spleen abscess are similar to splenomegaly and have signs such as tenderness.

(4) Gallbladder enlargement Jaundice accompanied by gallbladder enlargement are extrahepatic obstructions, and should be considered: Cancerous jaundice is found in common bile duct cancer, pancreatic head cancer, lack of ampulla and rare primary duodenum cancer. The gallbladder is smooth, non-tender, and movable, the so-called Cour-voisier gallbladder. Gallbladder cancer is firm and often tender. Once the primary common bile duct stones are obstructed, the gallbladder can be enlarged without tenderness. Gallbladder stones and chronic cholecystitis, the gallbladder atrophy can not be reached, chronic obstructive cholecystitis, due to the presence of stones in the gallbladder duct, the chance of gallbladder enlargement is greater than acute cholecystitis, tenderness is not obvious. In chronic pancreatitis, inflammatory fibrous tissue hyperplasia can compress the common bile duct and make the gallbladder swollen, and the tenderness is not significant. Huge stones at the bottom of the gallbladder, congenital bile duct dilatation, or biliary ascariasis can also cause gallbladder enlargement and tenderness. Gallbladder atrophy during intrahepatic cholestasis, whether the gallbladder is swollen is helpful for the differential diagnosis of jaundice.

(5) Other conditions include hepatitis, flutter tremor, hepatic encephalopathy and other neuropsychiatric disorders, scarcity of axillary hair, testicular atrophy, clubbing fingers, hyperkeratosis of the skin, spoon-shaped nails, multiple venous embolism, and bradycardia. Patients with advanced cancerous jaundice can still show signs of cancer metastasis. Liver failure can manifest encephalopathy and intracranial hemorrhage. Bloody abdomen, biliary peritonitis, biliary nephropathy, and shock can also be seen in patients with cancerous jaundice.

Jaundice check

Laboratory inspection

When jaundice occurs, serum total bilirubin and direct bilirubin should be checked to distinguish the type of bilirubin elevation. In addition, urinary bilirubin, urobilinogen, and liver function are also essential.

(1) Jaundice dominated by indirect elevation of bilirubin It is mainly found in various hemolytic diseases, neonatal jaundice and other diseases. The ratio of direct bilirubin to total bilirubin is less than 35%.

In addition to the above examinations, some auxiliary examinations about hemolytic diseases should be performed, such as red blood cell fragility test, acid hemolysis test, autohemolysis test, anti-human globulin test, blood routine, occult blood in urine, serum free hemoglobin, urine hemoglobin yellow Hormone, serum lactate dehydrogenase, glucose-6-phosphate dehydrogenase, etc.

(2) Jaundice with direct elevation of bilirubin Seen in various types of intrahepatic and extrahepatic obstructions that make bile excretion unsatisfactory. The ratio of direct bilirubin to the total is greater than 55%.

In addition to some routine checks, further checks are needed for alkaline phosphatase, -glutamyl transpeptidase, leucine aminopeptidase, 5-nucleotidase, total cholesterol, lipoprotein-X, etc.

(3) Mixed jaundice of liver cell damage is found in various types of liver diseases, which are manifested in the increase of direct bilirubin and indirect bilirubin, and the ratio of direct bilirubin to total bilirubin is 35% to 55%. Get abnormal results.

2. Other inspections

(1) Blood routine and urine routine.

(2) Quantitative test of jaundice index and serum bilirubin.

(3) Examination of bilirubin, urobilinogen and urobilin in urine

(4) Serum enzyme test.

(5) Determination of blood cholesterol and cholesterol ester.

(6) Immunological examination.

(7) X-ray inspection.

(8) Type B ultrasonic inspection.

(9) Radionuclide inspection.

(10) Liver biopsy.

(11) Laparoscopy.

Jaundice diagnosis

Jaundice is just a symptom / sign, not a disease. The diagnosis of jaundice is not difficult, but differential diagnosis is important. As long as the serum bilirubin concentration is 17.1 to 34.2umol / L (1 to 2mg / dl), those who do not see jaundice to the naked eye are called cryptic jaundice. If the serum bilirubin concentration is higher than 34.2umol / L (2mg / dl), yellow staining of the sclera, skin, mucous membranes and other tissues and body fluids is obvious jaundice.

Differential diagnosis of jaundice

Need to be distinguished from pseudo jaundice. Pseudo jaundice is seen in overeating foods such as carrots, pumpkins, tomatoes, and oranges that contain carotene. Carotene only causes yellowing of the skin, and the sclera is normal; the bulbar conjunctiva of the elderly has a slight yellow fat accumulation, the yellowing of the sclera is uneven, and the inner lining is more obvious, and the skin is not yellowing. The blood bilirubin concentration was normal during pseudojaundice.

Jaundice treatment

The treatment principle of jaundice is to treat the cause on the basis of clarifying the primary disease, and to treat the symptoms such as itching and yellowing.