Pseudo-jaundice.
It is seen in excessive consumption of carrots, pumpkin, tomatoes, citrus and other foods containing carotene. Carotene only causes yellowish skin staining with normal sclera; in elderly people, there is a slight yellow fat accumulation in the bulbar conjunctiva, uneven yellow sclera staining, more pronounced in the inner canthus, and no yellow skin staining. The blood bilirubin concentration is normal in pseudo-jaundice.
Pathological jaundice.
Also known as yellow bile, commonly known as yellow disease, is a symptom and sign of yellowing of the skin, mucous membranes and sclera due to elevated bilirubin in the serum. Certain liver diseases, gallbladder disease and blood disorders often cause symptoms of jaundice. When the serum bilirubin concentration is 17.1 to 34.2 umol/L, and the jaundice is not visible to the naked eye, it is called occult jaundice. If the serum bilirubin concentration is higher than 34.2umol/L, then the jaundice is overt.
Basic symptoms
1, yellow staining of the skin, sclera and other tissues. When jaundice deepens, urine, sputum, tears and sweat are also stained yellow.
2.Change in the color of urine and feces.
3, Gastrointestinal symptoms, often with abdominal distension, abdominal pain, loss of appetite, nausea, vomiting, abdominal discharge or constipation.
4, manifestations of bile saltemia, the main symptoms are: itching of skin, bradycardia, abdominal distension, fatty discharge, night blindness, weakness, mental depression and headache.
Accompanying symptoms
1. Jaundice with fever Seen in acute cholangitis, liver abscess, leptospirosis, septicemia, lobar pneumonia. Viral hepatitis or acute hemolysis may be preceded by fever and followed by jaundice.
2, jaundice with abdominal pain Epigastric pain. It can be seen in biliary stones, liver abscess or biliary ascariasis; severe pain in the right upper abdomen, chills and high fever and jaundice as charcot triad, suggesting acute purulent cholangitis; persistent dull pain or distension in the right upper abdomen can be seen in chronic cholecystitis, viral hepatitis, liver abscess or primary liver cancer.
3, if mild to moderate enlargement, soft or medium hard texture and smooth surface, seen in viral hepatitis acute biliary tract infection or biliary tract obstruction. Obvious enlargement with hard texture and uneven surface with nodules is seen in primary or secondary hepatocellular carcinoma. An inconspicuous hepatomegaly with hard edges and small nodules on the surface is seen in liver cirrhosis.
Etiology and pathology
When the red blood cells in the blood die, hemoglobin (Heme) from the hemoglobin in the red blood cells is pooled in the Coover’s cells of the liver and the spleen to be converted into bilirubin. After processing by the liver, bilirubin is secreted with bile into the duodenum and finally excreted with feces through the digestive system.
Jaundice can be divided into three categories according to the above-mentioned heme metabolism process.
1. Prehepatic jaundice/hemolytic jaundice: a jaundice condition that occurs when a large number of red blood cells are broken down. Hemolytic jaundice caused by increased red blood cell destruction and excessive bilirubin production. Jaundice dominated by an increase in unconjugated bilirubin. Such as congenital hemolytic jaundice, acquired hemolytic jaundice, bypass hyperbilirubinemia caused by ineffective hematopoiesis, etc.
2, hepatogenic jaundice: jaundice that occurs when the liver is unable to process bilirubin properly. Hepatocellular jaundice caused by hepatocellular lesions resulting in malfunction of bilirubin metabolism. Such as post-hepatitis hyperbilirubinemia, Gilbert syndrome, jaundice caused by certain drugs and examination reagents (such as cholecystography), etc.
3, post-hepatic jaundice: jaundice that occurs when the liver is unable to eliminate bilirubin normally. Mechanical obstruction of the intrahepatic or extrahepatic biliary system occurs, affecting the excretion of bilirubin, resulting in obstructive (obstructive) jaundice. Jaundice dominated by an increase in conjugated bilirubin.
(1) Extrahepatic bile duct obstruction such as gallstones, cancer of the head of the pancreas, cancer of the bile duct or common bile duct, cancer of the jugular abdomen, bile duct atresia, etc.
(2) Intrahepatic bile duct obstruction such as intrahepatic bile duct stones, schistosomiasis of the Chinese branch, etc.
(3) Intrahepatic cholestasis such as hepatitis, drug-related liver disease, recurrent jaundice during pregnancy, Dubin-Johnson syndrome, etc.
Clinical examination
In case of jaundice, total serum 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.Indirect bilirubin is mainly elevated. It is mainly seen in various types of hemolytic diseases and neonatal jaundice. In addition, some auxiliary tests related to hemolytic diseases should be performed, such as red blood cell fragility test, acid hemolysis test, autohemolysis test, blood routine, urinary occult blood, serum free hemoglobin, urinary iron-containing hemoglobin glucose-6-phosphate dehydrogenase, etc.
2. Elevated direct bilirubin is the main cause. It is seen in various types of intrahepatic and extrahepatic obstruction to make bile excretion poor. In addition to routine examination, further examination of alkaline phosphatase, γ-glutamyl transpeptidase, total cholesterol, lipoprotein-X, etc. is required.
3.Hepatocellular injury mixed jaundice
It is seen in all kinds of liver diseases, manifested as direct bilirubin and indirect bilirubin are elevated, and abnormal results can be obtained by checking liver function.
Auxiliary examination
1.Blood routine, urine routine.
2.Jaundice index, quantitative serum bilirubin test.
3.Urine bilirubin, urobilinogen and urobilin in urine.
4.Serum enzymology examination.
5.Blood cholesterol and cholesterol ester determination.
6.Immunological examination.
7.X-ray examination.
8.B-type ultrasound examination.
9.Radionuclide examination.
10.Liver biopsy.
11.Laparoscopy.
Bile Duct Cancer
Bile duct cancer is divided into intrahepatic and extrahepatic bile duct cancer. Extrahepatic cholangiocarcinoma is divided into suprahepatic cholangiocarcinoma, which is located from the primary bile duct to the opening of the cystic duct; middle cholangiocarcinoma, which is located below the opening of the cystic duct to the upper edge of the pancreas; and lower cholangiocarcinoma, which is located from the upper edge of the pancreas to the wall of the duodenum.
Pathophysiology
When carcinoma occurs in the bile duct system, the cancerous tissue may grow into the lumen of the duct and take the shape of polyps or papillae or infiltrate into the duct wall, resulting in significant thickening of the duct wall, and sometimes it is difficult to palpate the mass. In histopathology, more than 95% of cholangiocarcinoma are adenocarcinoma, and others include squamous epithelial carcinoma and adenosquamous carcinoma. Early cholangiocarcinoma has less metastasis and mainly grows slowly infiltrating upward and downward along the cholangiocarcinoma. Cholangiocarcinoma can infiltrate surrounding tissues and lymph node metastasis, but rarely metastasizes distantly. Therefore, the blood vessels in the hilar region, the liver and adjacent organs are often invaded.
Causes
The etiology of bile duct cancer is still unknown, but the following factors may play a role in the development of bile duct cancer.
Bile duct stones and biliary tract infection: about 1/3 of bile duct cancer patients are combined with bile duct stones, and 5%-10% of bile duct stone patients will develop bile duct cancer. It is generally believed that the long-term mechanical stimulation of bile duct wall by hepatic bile duct stones and the resulting chronic biliary tract infection and bile stasis lead to chronic proliferative inflammation of bile duct wall, which then causes atypical proliferation of bile duct mucosal epithelium and can gradually migrate into adenocarcinoma.
2.Testicular schistosomiasis: those who are infected with liver fluke by eating raw fish and eating nitrite-rich food may increase the possibility of inducing cancer.
3.Cystic dilatation of bile ducts: stone formation and bacterial infection in the cyst, especially the reflux of pancreatic juice due to abnormal development of the confluence, are the main causes of carcinogenesis.
4.Primary sclerosing cholangitis: an autoimmune disease. It is characterized by diffuse inflammation, narrowing and fibrosis of bile ducts inside and outside the liver and progressive destruction of bile ducts, which eventually leads to cirrhosis, portal hypertension and liver failure. It is generally considered to be a precancerous lesion of bile duct cancer, and most patients are found to have bile duct cancer within 2.5 years after the diagnosis.
5.Carcinogenic agents: radionuclides, chemicals such as asbestos, amyl nitrite, drugs such as isoniazid, methyldopa hydrazide, birth control pills, etc. may be the source of cholangiocarcinoma.
6.Other: It has been reported that post-colon and rectal resection, colitis and chronic typhoid fever carriers are related to the development of bile duct cancer. In addition, intrahepatic cholangiocarcinoma may also be related to viral hepatitis.
Clinical manifestations
The clinical manifestations of intrahepatic and extrahepatic cholangiocarcinoma are different because of the different sites of occurrence.
Intrahepatic cholangiocarcinoma has no obvious clinical symptoms in early stage. Generally, there are abdominal discomfort, weakness, nausea, jaundice and other symptoms such as fever. At the time of consultation, it is mostly in advanced stage, abdominal pain, weight loss, abdominal masses may appear, and jaundice is less common.
Jaundice: 90-98% of patients with extrahepatic cholangiocarcinoma can develop jaundice, most of which is gradually deepening continuous painless jaundice with grayish stools and dark yellow urine. While common bile duct stones are often accompanied by the characteristic triad of cholangitis (jaundice, abdominal pain and high fever), jaundice in extrahepatic cholangiocarcinoma is often not accompanied by abdominal pain, so it is called painless jaundice; it is accompanied by pruritus and weight loss (51%). Sometimes it is accompanied by fever (20%) and abdominal mass (10%). Other symptoms include loss of appetite, nausea and vomiting, weakness, weight loss, and weight loss;
Gallbladder enlargement: Patients with middle and lower bile duct cancer present with enlarged gallbladder, which can be palpated clinically, but Murphy’s sign may be negative, while gallbladder is not palpable in hilar bile duct cancer despite deep yellow staining of the skin;
Large liver: the liver can be palpated under the rib cage. Patients with longer jaundice may develop ascites due to liver damage and liver function loss, or even bilateral lower limb edema. Tumor invasion or compression of portal vein may cause gastrointestinal bleeding due to portal hypertension; advanced patients may have complications of hepatorenal syndrome, resulting in oliguria and anuria.
Biliary tract infection: 36% of patients may be combined with biliary tract infection. There are typical manifestations of cholangitis, such as right upper abdominal pain, chills and high fever, jaundice, and even biliary shock; biliary bleeding If the cancer breaks down and causes upper gastrointestinal bleeding, it is manifested as black stool, fecal occult blood (+) and anemia.
Auxiliary examination
I. Laboratory tests
Serum CAl9-9 is helpful for diagnosis, especially for intrahepatic cholangiocarcinoma evolving from primary sclerosing cholangitis. Total bilirubin (TBIL), direct bilirubin (DBIL), alkaline phosphatase (ALP) and γ-glutamyl transferase (γ-GT) are significantly elevated in the blood of the vast majority of patients with extrahepatic cholangiocarcinoma, which is the most important laboratory manifestation, while transaminases ALT and AST generally appear only mildly abnormal, and this imbalance of elevated bilirubin and transaminases helps to differentiate them from viral hepatitis. Prolonged prothrombin time.
Second, imaging examination
Ultrasound is preferred, which is easy, fast, accurate and less expensive. Ultrasonography can be used to obtain: (i) the dilatation of intrahepatic bile ducts and prove the obstruction of bile ducts; (ii) the site of obstruction is in bile ducts; and (iii) the nature of bile duct obstruction lesions. Color Doppler ultrasonography can also provide information about the invasion of portal vein and hepatic artery, which can help to assess the resectability of the tumor.
Endoscopic ultrasound: The ultrasound probe it uses has a high frequency and can avoid the interference of intestinal gas, which can show extrahepatic bile duct tumors more clearly and accurately. It can reach 82.8% and 85% accuracy in determining the depth of infiltration of middle and lower bile duct cancer and hilar bile duct cancer, respectively. Under ultrasound guidance, it can also perform exfoliative cytological examination of bile at the site of obstruction and histological examination by direct puncture of diseased tissue.
CT and MRI can show the site of biliary obstruction and the nature of lesions, among which three-dimensional spiral CT biliary imaging and magnetic resonance cholangiopancreatography (MRCP) have a tendency to replace PTC and ERCP examination.
Disease treatment
Treatment principle: surgical resection is the main treatment for resectable cases, and postoperative radiotherapy and chemotherapy are used to consolidate and improve the effect of surgical treatment. For advanced cases that cannot be resected, biliary drainage surgery should be performed to relieve biliary obstruction, control biliary infection, improve liver function, reduce comorbidities, prolong life and improve quality of life.
Bile duct cancer surgery is the most challenging surgery in abdominal surgery because of its complexity and high difficulty, and the surgical method mainly depends on the site of bile duct cancer.
Diet and precautions
1.Patients with cystic dilatation of bile ducts, primary sclerosing cholangitis and other diseases closely related to bile duct cancer should have regular follow-up checkups;
2.Eat more vegetables and fruits rich in vitA and vitC, fish and seafood.
It is also very important to have a regular life, pay attention to the combination of work and rest, often participate in sports activities, eat breakfast on time, avoid gaining weight and reduce the number of pregnancy.
4. A reasonable diet for bile duct cancer is an important guarantee for treatment and recovery. It is important to choose foods that can be easily digested and absorbed, eat more fresh vegetables and fruits, eat no or less oil and high-fat foods, ensure adequate fiber intake every day, prohibit alcohol and quit smoking, adjust total calories to make them balanced depending on physical activities, and consciously choose some foods with auxiliary anti-cancer effects, such as purple cabbage, carrot, shiitake mushroom, asparagus, cauliflower and tomato. The diet of bile duct cancer means to improve eating habits and cooking methods, and to keep a happy mood when eating.
Pancreatic cancer
It is more common in men than in women, and 90% of patients die within one year of diagnosis.
It includes cancer of the head of the pancreas and the tail of the pancreas. Among them, pancreatic head cancer accounts for 70-80%.
The risk of pancreatic cancer among smokers is more than 3 times that of non-smokers.
The “three highs” diet, i.e. high protein, high fat and high calorie foods, can also have a bad effect on the development of pancreatic cancer.
Diagnosis
Early clinical manifestations are often atypical.
Among the first symptoms of pancreatic cancer, jaundice and abdominal pain are the most common, followed by emaciation, upper abdominal fullness, low back pain, weakness, and individual fever.
Pain The pain is related to the location and size of the tumor, which may be abdominal pain or low back pain.
Jaundice Jaundice is more commonly seen in tumors of the jugular abdomen and lower bile duct. In addition, the presence of jaundice does not mean that the tumor is advanced, but in some cases it is the jaundice that allows the tumor to be detected at an earlier stage.
Some patients may experience indigestion, poor appetite, or unexplained significant weight loss over a period of time.
Imaging.
Ultrasound is the method of choice for screening and diagnosis. It is non-invasive, non-radioactive, and can show the internal structure of the pancreas, the presence or absence of obstruction in the bile duct and the site of obstruction. Limitations are small field of view and easily influenced by gas in the stomach and intestinal tract as well as body size. There is a certain degree of subjectivity.
CT is currently the best non-invasive imaging method for examining the pancreas and is mainly used for the diagnosis and staging of pancreatic cancer. Plain scan can roughly show the size and location of the lesion, while enhanced scan can further describe the morphology, internal structure and the relationship with surrounding structures. It can determine the presence of liver metastases and enlarged lymph nodes more accurately.
PET-CT is of high value for the staging diagnosis of malignant tumors and the selection of appropriate treatment plans. However, it is more expensive and self-paying.
Magnetic resonance cholangiopancreatography (MRCP) examination: currently not used as the preferred method for diagnosing pancreatic cancer has obvious advantages in determining the presence or absence of biliary tract obstruction, the site of obstruction and the cause of obstruction, and is safe compared with invasive examination means such as endoscopic retrograde cholangiopancreatography (ERCP) and transhepatic percutaneous cholangiography (PTC).
Blood biochemical immunological examination.
1. Tumor obstruction of bile ducts can cause elevated blood bilirubin, accompanied by enzymatic changes such as alanine transaminase (ALT) and glutathione transaminase (AST). Forty percent of patients with pancreatic cancer will have elevated blood glucose and abnormal glucose tolerance.
2. Tumor markers such as CEA and CA199 may be elevated in the serum of pancreatic cancer, but such changes are not absolute.
Puncture pathology examination.
Under the guidance of body surface ultrasound or ultrasound endoscopy, puncture biopsy of the lesion and specimen for pathology or cytology can help to determine the diagnosis of pancreatic cancer. However, a negative needle aspiration test does not completely negate the diagnosis of malignancy; it needs to be combined with imaging and laboratory tests for comprehensive consideration, and repeat puncture may be required if necessary. It should be emphasized here that a diagnosis of needle aspiration pathology is not always required preoperatively for patients who are ready to undergo surgical treatment.
Treatment
The main treatment includes surgery, radiotherapy, chemotherapy, and interventional therapy. Surgical resection is an effective treatment method. Pancreatic cancer lacks obvious symptoms in the early stage, and the opportunity for radical surgery is lost in most cases when the diagnosis is made. Surgical treatment requires different surgical approaches depending on the stage of the disease and the degree of local invasion of the tumor lesion.
Surgical treatment
(1) Preoperative preparation
For those who have severe jaundice and abnormal liver function and cannot receive surgery in time, biliary drainage can be done first to reduce jaundice and improve liver function. In the past, cholecystostomy was performed first, followed by second-stage surgery. Nowadays, percutaneous transhepatic choledochotomy and drainage (PTCD) can be performed first, and depending on the improvement of liver function, radical surgery can be performed in a limited time. For those who have a large amount of bile drained daily, patients should be encouraged to drink the drained bile in small portions and supplemented with a highly nutritious diet to better improve their nutritional status and prepare for further treatment.
Surgical methods
(1) Radical surgery
Depending on the tumor site, it can be broadly divided into pancreaticoduodenectomy, pancreatic tail resection and total pancreatectomy. They should be performed in hospitals with a large volume of pancreatic surgery. Surgery for pancreatic cancer with vascular resection
(2) In the past, tumor invasion of portal vein and superior mesenteric vein was considered as a contraindication to surgical resection, resulting in a low surgical resection rate. In recent years, complete resection of the tumor can be achieved through vascular resection and reconstruction. The results of surgical treatment for these patients are the same as those for patients without vascular involvement.
(3) Surgical treatment of unresectable pancreatic cancer
In patients who are not suitable for radical surgical resection due to tumor or physical reasons, appropriate surgical interventions may have a significant effect on prolonging the patient’s survival and improving the quality of survival. Common surgical interventions in such cases include gastrointestinal anastomosis and biliary-intestinal anastomosis. It should be emphasized that with the development of medicine and the increasingly widespread use of ductal stenting techniques, the number of patients undergoing open palliative bile-intestinal anastomosis solely due to biliary obstruction has decreased significantly compared to the previous period.
Other treatments
1.Chemotherapy
(1) The purpose of chemotherapy is to prolong the survival, improve the quality of life and enhance the effect of other treatments such as surgery, including adjuvant chemotherapy after surgery and palliative chemotherapy for patients who do not receive radical treatment. The commonly used chemotherapy drugs are gemcitabine or tegeo (S1) based regimens.
(2) Targeted drug therapy has become a new approach to treat pancreatic cancer. However, the efficacy is far from satisfactory and still needs further exploration.
(3) Chinese medicine treatment
(4) Radiotherapy is mainly used for the comprehensive treatment of inoperable locally progressive pancreatic cancer, the comprehensive treatment of residual or recurrent tumor cases after surgery, and the palliative reduction treatment of advanced pancreatic cancer. In recent years, preoperative neoadjuvant radiotherapy, which aims to improve the effect of surgical treatment or increase the rate of surgical resection, has also been used more often.
2.Supportive treatment
The purpose of supportive treatment is to reduce the symptoms and improve the quality of life.
(1) Pain control
Pain is one of the most common symptoms of pancreatic cancer. The drugs are administered according to the WHO three-step principle of pain control, and attention is paid to timely management of adverse effects of oral pain medications such as nausea and vomiting, constipation, dizziness and headache in the process of drug administration. Pain management departments are available in large oncology centers, where doctors can provide professional pain relief help.
(2) Improve cachexia
Methylhydroxyprogesterone or megestrol can be used to improve appetite, pay attention to nutritional support, timely detection and correction of liver and kidney insufficiency and water and electrolyte disorders. For patients with nutritional absorption disorders, give elemental diet, and for patients who cannot eat, give parenteral nutrition support treatment.
3.Disease prevention
Everyone should pay attention to their health, and those over 30 years old should insist on routine physical examination at least once a year. Once there is abdominal distension, abdominal pain, fever, or even symptoms of diabetes, pancreatitis, weight loss, etc., you should immediately go to a specialist hospital for examination. Strive for early detection and early treatment. In addition, one should try to quit bad lifestyle, promote healthy eating habits and physical exercise, and maintain a positive and optimistic attitude, all of which can significantly reduce the occurrence of many tumorigenic and non-tumorigenic diseases, including pancreatic cancer.